Prevention of venous thromboembolism in surgical patients with breast cancer

Do bilateral procedures further increase the complications for autologous breast reconstruction in obese patients?

BACKGROUND

Obesity is known to be associated with high complication rates. The aim of this study was to evaluate the effect of bilateral procedures on complication rates in obese patients undergoing autologous breast reconstruction with deep inferior epigastric perforator flaps.

METHODS

Medical records of patients undergoing autologous breast reconstruction between January 2017 and December 2019 were retrospectively reviewed. Patients were divided into two groups according to their body mass index (BMI): Group 1 (BMI > 30) and Group 2 (BMI < 30). Group 1 was further divided into 3 subgroups: Group 1a (bilateral reconstruction), Group 1b (unilateral reconstruction), and Group 1c (unilateral reconstruction and contralateral symmetrization). Outcomes and complication rates were compared between groups.

RESULTS

Ninety-one patients (with 119 free flaps) were followed up between 6 and 12 months. Length of hospital stay, smoking rates, and age were similar in all groups. Group 1 had significantly more rates of wound dehiscence (p = 0.024), mastectomy skin flap necrosis (p = 0.019), and re-operation (p = 0.033). The operation time was significantly higher in group 1 (p = 0.003). There was no significant difference between group 1 and group 2 in terms of hematoma-seroma formation, flap loss, and pulmonary thromboembolism rates. When obese subgroups were compared, no significant difference was observed in terms of complications.

CONCLUSION

In our series, microvascular breast reconstruction was associated with more complication rates in obese patients. However, bilateral procedures in the obese patient group did not significantly increase risk of complications as compared to unilateral procedures. By taking appropriate measures bilateral procedures can be performed in obese patients without additional risks.

Incidence of Venous Thromboembolism Based on Caprini Score in Deep Inferior Epigastric Perforator Flap Breast Reconstruction

BACKGROUND

 Deep inferior epigastric perforator (DIEP) flaps are commonly used for autologous breast reconstruction, but reported rates of venous thromboembolism (VTE) are up to 6.8%. This study aimed to determine the incidence of VTE based on preoperative Caprini score following DIEP breast reconstruction.

METHODS

 This retrospective study included patients who underwent DIEP flaps for breast reconstruction between January 1, 2016 and December 31, 2020 at a tertiary-level, academic institution. Demographics, operative characteristics, and VTE events were recorded. Receiver operating characteristic analysis was performed to determine the area under the curve (AUC) of the Caprini score for VTE. Univariate and multivariate analyses assessed risk factors associated with VTE.

RESULTS

 This study included 524 patients (mean age 51.2 ± 9.6 years). There were 123 (23.5%) patients with the Caprini score of 0 to 4, 366 (69.8%) with scores 5 to 6, 27 (5.2%) with scores 7 to 8, and 8 (1.5%) patients with scores >8. Postoperative VTE occurred in 11 (2.1%) patients, at a median time of 9 days (range 1-30) after surgery. VTE incidence by the Caprini score was 1.9% for scores 3 to 4, 0.8% for scores 5 to 6, 3.3% for scores 7 to 8, and 13% for scores >8. The Caprini score achieved an AUC of 0.70. A Caprini score >8 was significantly predictive of VTE on multivariable analysis relative to scores 5 to 6 (odds ratio = 43.41, 95% confidence interval = 7.46-252.76, p < 0.001).

CONCLUSION

 In patients undergoing DIEP breast reconstruction, VTE incidence was highest (13%) in Caprini scores greater than eight despite chemoprophylaxis. Future studies are needed to assess the role of extended chemoprophylaxis in patients with high Caprini scores.

Enhanced Recovery for Breast Reconstruction Surgery

PURPOSE OF REVIEW

Enhanced recovery pathways are a well-described perioperative healthcare program involving evidence-based interventions. Enhanced recovery is designed to standardize techniques such as drug selection and nerve blocks in order to speed recovery and reduce overall hospital costs.

RECENT FINDINGS

A PubMed literature search was performed for articles that included the terms enhanced recovery and breast reconstruction surgery. The present investigation summarizes enhanced recovery literature related to breast surgery with a focus on breast reconstruction. Enhanced recovery considerations discussed in this review include patient education, preadmission optimization, perforator flap planning, anesthetic techniques, optimized fasting, venous thrombosis prophylaxis, early mobilization, and antimicrobial prophylaxis.

Improved patient outcomes using the enhanced recovery pathway in breast microsurgical reconstruction: a UK experience

Introduction

The enhanced recovery after surgery (ERAS) pathway is a protocol aimed at optimizing patient care by reducing the physiological alterations caused by surgery, thus reducing recovery time, surgical morbidities and length of stay. This study assessed the impact of ERAS on patients undergoing microsurgical breast reconstruction.

Methods

Patients undergoing microsurgical breast reconstruction over an eight-month period were retrospectively examined. LOS, complication rates and perioperative outcomes were analysed. Results were compared between patients admitted on the traditional recovery after surgery (TRAS) and the ERAS pathways.

Results

One hundred and thirty-eight patients were included. Seventy-two patients were admitted on the TRAS pathway and 66 patients on the ERAS pathway. There was no difference in median LOS (4 days) between the two groups, p = 0.48. We noted a significant reduction in the total number of major complications (ERAS 11%, TRAS 24% p = 0.04) as well as significant differences in time to catheter removal, time to independent mobilisation, total opioid usage and time to removal of PCA, all in favour of the ERAS group. There was a non-significant reduction in return to theatre and readmission rate in the ERAS group (11% versus 21% p = 0.1 and 6% versus 11% p = 0.29 respectively). Obesity and complications were predictors of a prolonged LOS.

Conclusion

The ERAS pathway reduced overall and major complication rates in a tertiary centre using an already streamlined service. Adoption of ERAS pathways to reduce surgical morbidities and improve patient care is encouraged. Further work is required to optimise enhanced recovery in breast microsurgical reconstruction.

Consensus Review of Optimal Perioperative Care in Breast Reconstruction: Enhanced Recovery after Surgery (ERAS) Society Recommendations

BACKGROUND

Enhanced recovery following surgery can be achieved through the introduction of evidence-based perioperative maneuvers. This review aims to present a consensus for optimal perioperative management of patients undergoing breast reconstructive surgery and to provide evidence-based recommendations for an enhanced perioperative protocol.

METHODS

A systematic review of meta-analyses, randomized controlled trials, and large prospective cohorts was conducted for each protocol element. Smaller prospective cohorts and retrospective cohorts were considered only when higher level evidence was unavailable. The available literature was graded by an international panel of experts in breast reconstructive surgery and used to form consensus recommendations for each topic. Each recommendation was graded following a consensus discussion among the expert panel. Development of these recommendations was endorsed by the Enhanced Recovery after Surgery Society.

RESULTS

High-quality randomized controlled trial data in patients undergoing breast reconstruction informed some of the recommendations; however, for most items, data from lower level studies in the population of interest were considered along with extrapolated data from high-quality studies in non-breast reconstruction populations. Recommendations were developed for a total of 18 unique enhanced recovery after surgery items and are discussed in the article. Key recommendations support use of opioid-sparing perioperative medications, minimal preoperative fasting and early feeding, use of anesthetic techniques that decrease postoperative nausea and vomiting and pain, use of measures to prevent intraoperative hypothermia, and support of early mobilization after surgery.

CONCLUSION

Based on the best available evidence for each topic, a consensus review of optimal perioperative care for patients undergoing breast reconstruction is presented.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, V.

Cardiac safety of systemic therapy in breast cancer patients with high risk of atherosclerosis complications

Aim: This study was designed to verify the efficacy of breast cancer treatment and its cardiac toxicity in population with significant cardiac comorbidities. Materials & methods: Prospective observational study was conducted in 48 patients. Results: The increase and dependence of echocardiographic parameter early/late were observed on hemoglobin level in all patients, and white blood cells and cholesterol in patients with diabetic were reported. Patients undergo left ventricle diameter change on treatment. Conclusion: Use of potentially cardiotoxic chemo regimens in breast cancer patients with cardiac comorbidities, with optimized cardiac therapy accordingly can save patients from development of early myocardial dysfunction induced by chemotherapy – limiting factor to minimize the risk is optimization of lipid level, red blood cell count and platelets count.

Case report of a definitive autologous reconstruction in a patient requiring immediate postoperative anticoagulation and reduced operative time

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Breast reconstruction in anticoagulated patients is not well described.

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They are at high risk for intra-operative and post-operative bleeding complications.

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They often require abbreviated operative times because of other risk factors.

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Here we make use of a recently described autologous technique to address these issues.

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Extirpation & reconstruction took 2.5 h while minimizing perioperative bleeding risk.

Introduction

The available options for post-mastectomy reconstruction in a patient requiring abbreviated operative times and immediate and sustained post-operative anticoagulation are limited.

Presentation of case

A 50 year old woman with a history of multiple deep venous thromboses (DVTs) and pulmonary embolisms (PEs) requested a bilateral prophylactic mastectomy and immediate reconstruction. She had a history of multiple breast biopsies demonstrating atypia and two sisters with premenopausal breast cancer. Her hematologist requested that her anticoagulation be held for the minimal amount of time and that her theater times be kept as short as possible. As such, we felt that she was not a candidate for traditional implant-based reconstruction nor autologous flap surgery. Instead, we made use of a recently described single-stage autologous modified Goldilocks procedure to complete her bilateral mastectomy and reconstruction in 150 min. She was anticoagulated in the operating room and was restarted on her preoperative regimen twelve hours after surgery. She suffered no post-operative complications.

Discussion

There is minimal published literature discussing immediate post-mastectomy reconstruction in the anticoagulated patient. Most reconstructive surgeons find these patients unsuitable for traditional reconstructive techniques. In the current case, we utilized a recently described single-stage autologous technique which allowed us to avoid the bleeding complications associated with the muscular dissection required with implant and flap-based reconstructive surgery. The extirpation and reconstruction was completed in 150 min which is significantly quicker than traditional reconstructions.

Conclusion

The modified Goldilocks procedure is an excellent option in the patient who requires immediate postoperative anticoagulation and abbreviated operative times.

Tissue factor over-expression by human pancreatic cancer cells BXPC3 is related to higher prothrombotic potential as compared to breast cancer cells MCF7

Cancer histology influences the risk of venous thromboembolism and tissue factor (TF) is the key molecule in cancer-induced hypercoagulability. We investigated the relation between TF expression by pancreatic and breast cancer cells (BXPC3 and MCF7 respectively) and their capacity to trigger in vitro thrombin generation in normal human plasma. Flow cytometry and Western blot analysis for TF expression were performed using murine IgG1 monoclonal antibody against human TF. Real-time PCR for TFmRNA was also performed. Activity of TF expressed by cancer cells was measured with a specific chromogenic assay. Thrombin generation in PPP was assessed using calibrated automated thrombogram. Cancer cells were added to platelet poor plasma from healthy volunteers. In separate experiments cells were incubated with the anti-TF antibody at concentration that completely neutralized the activity of recombinant human TF on thrombin generation. BXPC3 cells expressed significantly higher amounts of functional TF as compared to MCF7 cells. Incubation of BXPC3 and MCF7 cells with PPP resulted in acceleration of the initiation phase of thrombin generation. BXPC3 cells manifested higher procoagulant potential than MCF7 cells. The incubation of BXPC3 or MCF7 cells with the anti-TF monoclonal antibody which resulted in reversal of their effect on thrombin generation. The present study establishes a link between the amount of TF expressed by cancer cells with their procoagulant activity. Both studied types of cancer cells trigger thrombin generation but they have different procoagulant potential. The procoagulant activity of BXPC3 and MCF7 cells is related to the amount of TF expressed. Kinetic parameters of thrombogram are the most relevant for the detection of the TF-dependent procoagulant activity of cancer cells. TF expression is one of the mechanisms by which cancer cells manifest their procoagulant potential but it is not the unique one. The present experimental model will allow the characterization the procoagulant fingerprint of cell lines from the same or different histological types of cancer.

Evidence-based review of enhancing postoperative recovery after breast surgery

BACKGROUND

The introduction of enhanced recovery after surgery (ERAS) protocols has revolutionized preoperative and postoperative care. To date, however, the principles of enhanced recovery have not been applied specifically to patients undergoing breast surgery.

METHODS

Based on the core features of ERAS, individual aspects of postoperative care in breast surgery were defined. A comprehensive search of MEDLINE, PubMed, Embase and the Cochrane Library database was performed from 1980 to 2010 to determine the best evidence for perioperative care in oncological breast surgery. A graded recommendation based on the best level of evidence was then proposed for each feature of ERAS.

RESULTS

Twelve core features of enhanced recovery after breast surgery were identified. Use of the thoracic block, from both analgesic and anaesthetic viewpoints, is well supported by evidence and should be encouraged. Trials specific to breast surgery regarding aspects such as perioperative fasting, preanaesthetic medication, prevention of hypothermia and postdischarge support are scarce, and evidence was extrapolated from non-breast trials. Trials on postoperative analgesia and prevention of postoperative nausea and vomiting in breast surgery are generally of small numbers. In addition, there is heterogeneity between studies.

CONCLUSION

This review suggests that the principles of enhanced recovery can be adopted in breast surgery. A 12-point protocol is proposed for prospective evaluation.

Practice patterns in venous thromboembolism prophylaxis: a survey of 606 reconstructive breast surgeons

Current practice patterns for venous thrombembolism (VTE) prophylaxis in autogenous breast reconstruction are unknown. A web-based survey on VTE prophylaxis was distributed to all American Society of Plastic Surgery members in the United States with a clinical interest in autogenous tissue breast reconstruction (N = 3584). A total of 606 completed surveys were returned for a response rate of 16.9%. Overall compliance with established guidelines was low (25%). High volume surgeons (43% vs. 22%) and surgeons in academic practice (42% vs. 22%) were significantly more likely to report prophylaxis regimens consistent with American College of Chest Physicians guidelines (ACCP) recommendations. Subgroup analysis of 72 surgeons who specifically report conformance to ACCP guidelines demonstrated only 38% actually provided prophylaxis consistent with ACCP recommendations. VTE is a potentially fatal complication of autogenous breast reconstruction. Further research is necessary to create VTE prophylaxis guidelines specific to patients undergoing these procedures. The need for surgeon education on appropriate prophylaxis cannot be overemphasized.

Prophylactic and therapeutic anticoagulation for thrombosis: major issues in oncology

Venous thromboembolism (VTE) is a major cause of morbidity and mortality in patients with cancer. Primary prevention with pharmacologic agents (or mechanical methods, if anticoagulants are contraindicated) is recommended in all cancer patients hospitalized for surgical or medical reasons. The role of prophylaxis in outpatients is less certain because of the diversity of the patient populations and their cancer treatments with respect to the associated risks of VTE and bleeding. Treatment with low-molecular weight heparin is the recommended first-line approach in cancer patients with newly diagnosed VTE, and is usually continued for a minimum of 3-6 months. Other management issues that require further research include the optimum duration of anticoagulant therapy, the treatment of recurrent VTE, the role of vena cava filters, the effects of VTE and its treatment on quality of life, and the impact of anticoagulants on survival. Newer anticoagulants hold promise in providing more-effective and convenient treatment of VTE in this high-risk population, but further studies are awaited.