1
|
Haddock NT, Ercan A, Teotia SS. Bilateral Simultaneous Lumbar Artery Perforator Flaps in Breast Reconstruction: Perioperative Outcomes Addressing Safety and Feasibility. Plast Reconstr Surg 2024; 153:895e-901e. [PMID: 37335548 DOI: 10.1097/prs.0000000000010830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
BACKGROUND The lumbar artery perforator (LAP) flap has emerged as an excellent option for breast reconstruction, but its steep learning curve makes it less approachable. Furthermore, length of the operation, flap ischemia time, need for composite vascular grafts, complex microsurgery, multiple position changes, and general concern for safety has led experienced surgeons to stage bilateral reconstructions. In the authors' experience, simultaneous bilateral LAP flaps are feasible, but overall perioperative safety has not been fully explored. METHODS Thirty-one patients (62 flaps) underwent simultaneous bilateral LAP flaps and were included in the study (excluding stacked four-flaps and unilateral flaps). Patients underwent two position changes in the operating room: supine to prone and then supine again. A retrospective review of patient demographics, intraoperative details, and complications was performed. RESULTS The overall flap success rate was 96.8%. Five flaps were compromised postoperatively. The intraoperative anastomotic revision rate was 24.1% per flap (4.3% per anastomosis). The significant complication rate was 22.6%. The number of sustained hypothermic episodes and hypotensive episodes correlated with intraoperative arterial thrombosis ( P < 0.05). The number of hypotensive episodes and increased intraoperative fluid correlated with flap compromise ( P < 0.05). High body mass index correlated with overall complications ( P < 0.05). The presence of diabetes correlated with intraoperative arterial thrombosis ( P < 0.05). CONCLUSIONS Simultaneous bilateral LAP flaps can be performed safely with an experienced and trained microsurgical team. Hypothermia and hypotension negatively affect the initial anastomotic success. In this complex operation, a coordinated approach between the anesthesia and nursing team is paramount for patient safety. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
Collapse
Affiliation(s)
- Nicholas T Haddock
- From the Department of Plastic Surgery, University of Texas Southwestern Medical Center
| | - Alp Ercan
- From the Department of Plastic Surgery, University of Texas Southwestern Medical Center
| | - Sumeet S Teotia
- From the Department of Plastic Surgery, University of Texas Southwestern Medical Center
| |
Collapse
|
2
|
Malheiro RM, Peleteiro B, Silva G, Lebre A, Paiva JA, Correia S. Surveillance of surgical site infection after colorectal surgery: comprehensiveness and impact of risk factors. Infect Control Hosp Epidemiol 2023; 44:1601-1606. [PMID: 36945140 DOI: 10.1017/ice.2023.40] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
OBJECTIVE The incidence of surgical site infection (SSI) is highest after colorectal surgery. We assessed the impact of risk factors for SSI using the population attributable fraction (PAF). DESIGN Retrospective cohort study. SETTING Portuguese hospitals performing regular surveillance. PATIENTS We identified patients who underwent colorectal procedures in hospitals that reported colorectal surgeries every year between 2015 and 2019. Among 42 reporting hospitals, 18 hospitals were included. METHODS Risk-factor incidence was estimated using the National Epidemiological Surveillance platform from 2015 to 2019. This platform follows the methodology recommended by the European Centre for Disease Prevention and Control. American Society of Anaesthesiologists (ASA) physical classification, wound classification, open surgery, urgent operation, antibiotic prophylaxis, operation time, and male sex were included as risk factors. Measures of association were retrieved from published meta-analyses. PAFs were calculated using the Levin formula. To account for interaction between risk factors, communality of risk factors was used in a weighted-sum approach, providing a combined value that serves as a measure of the comprehensiveness of surveillance. RESULTS Among 11,219 reported procedures, the cumulative SSI incidence was 16.8%. The proportion of SSI attributed to all risk factors was 61%. Modifiable variables accounted for 31% of procedures; the highest was laparotomy (16.8%), and urgent operations (2.7%) had the lowest value. Nonmodifiable factors accounted for 28.7%; the highest was wound classification (14.3%). CONCLUSIONS A relevant proportion (39%) of SSI remains unaccounted for by current surveillance. Almost one-third of SSI cases have potentially modifiable factors. Interventions focusing on shorter, less invasive procedures may be optimally effective in reducing the SSI incidence.
Collapse
Affiliation(s)
- Rui M Malheiro
- EPIUnit, Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal
- Laboratório para a Investigação Integrativa e Translacional em Saúde Populacional (ITR), Porto, Portugal
| | - Bárbara Peleteiro
- EPIUnit, Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal
- Laboratório para a Investigação Integrativa e Translacional em Saúde Populacional (ITR), Porto, Portugal
- Departmento de Saúde Pública, Ciências forenses e Educação Médica, Faculdade de Medicina, Universidade do Porto (University of Porto Medical School), Porto, Portugal
| | - Goreti Silva
- Programa de Prevenção e Controlo de Infeção e Resistência aos Antimicrobianos (PPCIRA), Direção-Geral de Saúde, Lisboa, Portugal
| | - Ana Lebre
- Programa de Prevenção e Controlo de Infeção e Resistência aos Antimicrobianos (PPCIRA), Direção-Geral de Saúde, Lisboa, Portugal
- Instituto Português de Oncologia do Porto Francisco Gentil, E.E., Porto, Portugal
| | - José Artur Paiva
- Programa de Prevenção e Controlo de Infeção e Resistência aos Antimicrobianos (PPCIRA), Direção-Geral de Saúde, Lisboa, Portugal
- Unidade de Cuidados Intensivos, Centro Hospitalar Universitário São João, Porto, Portugal
- Departmento de Medicina, Faculdade de Medicina, Universidade do Porto (University of Porto Medical School), Porto, Portugal
| | - Sofia Correia
- Departmento de Saúde Pública, Ciências forenses e Educação Médica, Faculdade de Medicina, Universidade do Porto (University of Porto Medical School), Porto, Portugal
| |
Collapse
|
3
|
Chen YC, Cherng YG, Romadlon DS, Chang KM, Huang CJ, Tsai PS, Chen CY, Chiu HY. Comparative effects of warming systems applied to different parts of the body on hypothermia in adults undergoing abdominal surgery: A systematic review and network meta-analysis of randomized controlled trials. J Clin Anesth 2023; 89:111190. [PMID: 37390588 DOI: 10.1016/j.jclinane.2023.111190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 05/27/2023] [Accepted: 06/18/2023] [Indexed: 07/02/2023]
Abstract
STUDY OBJECTIVE The prevention of perioperative hypothermia after anesthesia induction is a critical concern in patients undergoing abdominal surgery. The effectiveness of various warming systems for preventing hypothermia and shivering when applied to specific areas of the body remains undetermined. DESIGN Systematic review and network meta-analysis. SETTING Operating room. INTERVENTION Five electronic databases were searched, including only randomized control trials (RCTs) reporting the effects of warming systems applied to specific body sites on the intraoperative core temperature and postoperative risk of shivering in adults undergoing abdominal surgery. A multivariate random-effects network meta-analysis with a frequentist framework was implemented for data analysis. MEASUREMENTS The primary outcome was the core body temperature 60 and 120 min after anesthesia induction for abdominal surgery. The secondary outcome was the incidence of postoperative shivering. RESULTS This review comprised a total of 24 RCTs including 1119 patients. At 60 and 120 min after anesthesia induction, a forced-air warming system applied to the upper body (0.3 °C and 95% confidence intervals = [0.3 to 0.4], 1.0 °C [0.7 to 1.3]), lower body (0.4 °C [0.3 to 0.5], 0.9 °C [0.5 to 1.2]), and underbody (0.5 °C [0.5 to 0.6], 1.2 °C [0.9 to 1.6]) was superior to passive insulation in terms of core body temperature regulation. Compared with passive insulation, the forced-air warming system applied to the lower body (odds ratio = 0.06) or underbody (0.44) and the electric heating blanket to the lower body (0.02) or the whole body (0.07) significantly reduced the risk of shivering. CONCLUSIONS The results of this NMA revealed that forced-air warming with an underbody blanket effectively elevates core body temperatures in 60 and 120 min after induction of anesthesia and prevents shivering in patients recovering from abdominal surgery.
Collapse
Affiliation(s)
- Yi-Chen Chen
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
| | - Yih-Giun Cherng
- Department of Anaesthesiology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan; Department of Anaesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | | | - Kai-Mei Chang
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
| | - Chun-Jen Huang
- Department of Anaesthesiology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan; Integrative Research Center for Critical Care, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan; Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Pei-Shan Tsai
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan; Department of Nursing, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Chien-Yu Chen
- Department of Anaesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Department of Anaesthesiology, Taipei Medical University Hospital, Taipei, Taiwan
| | - Hsiao-Yean Chiu
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan; Research Center of Sleep Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Department of Nursing, Taipei Medical University, Taipei, Taiwan.
| |
Collapse
|
4
|
Hayek J, Zorrilla-Vaca A, Meyer LA, Mena G, Lasala J, Iniesta MD, Suki T, Huepenbecker S, Cain K, Garcia-Lopez J, Ramirez PT. Patient outcomes and adherence to an enhanced recovery pathway for open gynecologic surgery: a 6-year single-center experience. Int J Gynecol Cancer 2022; 32:ijgc-2022-003840. [PMID: 36202425 DOI: 10.1136/ijgc-2022-003840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
OBJECTIVES To evaluate compliance with an Enhanced Recovery After Surgery (ERAS) protocol for open gynecologic surgery at a tertiary center and the relationship between levels of compliance and peri-operative outcomes. METHODS This retrospective cohort study was conducted between November 2014 and December 2020. Two groups were defined based on compliance level (<80% vs ≥80%). The primary outcome was to analyze overall compliance since implementation of the ERAS protocol. The secondary endpoint was to assess the relationship between compliance and 30-day re-admission, length of stay, re-operation, opioid-free rates, and post-operative complications. We also assessed compliance with each ERAS element over three time periods (P1: 2014-2016, P2: 2017-2018, P3: 2019-2020), categorizing patients according to the date of surgery. Values were compared between P1 and P3. RESULTS A total of 1879 patients were included. Overall compliance over the period of 6 years was 74% (95% CI 71.9% to 78.2%). Mean overall compliance increased from 69.7% to 75.8% between P1 and P3. Compliance with ERAS ≥80% was associated with lower Clavien-Dindo complication rates (grades III (OR 0.55; 95% CI 0.33 to 0.93) and V (OR 0.08, 95% CI 0.01 to 0.60)), 30-day re-admission rates (OR 0.61; 95% CI 0.43 to 0.88), and length of stay (OR 0.59; 95% CI 0.47 to 0.75). No difference in opioid consumption was seen. Pre-operatively, there was increased adherence to counseling by 50% (p=0.01), optimization by 21% (p=0.02), and carbohydrate loading by 74% (p=0.02). Intra-operatively, compliance with use of short-acting anesthetics increased by 37% (p=0.01) and avoidance of abdominal drainage increased by 7% (p=0.04). Use of goal-directed fluid therapy decreased by 16% (p=0.04). Post-operatively, there was increased compliance with avoiding salt and water overload (8%, p=0.02) and multimodal analgesia (5%, p=0.02). CONCLUSIONS Over the time period of the study, overall compliance increased from 69.7% to 75.8%. Compliance (≥80%) with ERAS is associated with lower complication rates, fewer 30-day re-admissions, and shorter length of stay without impacting re-operation rates and post-operative opioid use.
Collapse
Affiliation(s)
- Judy Hayek
- Gynecologic Oncology, SUNY Downstate Medical Center, Brooklyn, New York, USA
| | - Andres Zorrilla-Vaca
- Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Larissa A Meyer
- Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Gabriel Mena
- Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Javier Lasala
- Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Maria D Iniesta
- Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Tina Suki
- Gynecology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sarah Huepenbecker
- Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Katherine Cain
- Division of Pharmacy, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Juan Garcia-Lopez
- Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Pedro T Ramirez
- Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| |
Collapse
|