Anne C. O'Neill

Reconstruction of sarcoma defects following pre-operative radiation: Free tissue transfer is safe and reliable

BACKGROUND Neoadjuvant radiotherapy followed by surgical resection and soft tissue reconstruction provides the best possibility of achieving superior limb function in soft tissue sarcomas. The aim of this study was to report our experience of free flap microsurgical reconstruction of recently irradiated soft tissue sarcoma defects. METHODS A retrospective study of microsurgical outcome in consecutively treated extremity and trunk sarcoma patients undergoing free tissue transfer between 2007 and 2012 was conducted from a prospectively collected database. Outcomes in pre-operatively irradiated patients were compared with non-irradiated patients. Demographic data, operative details, limb salvage rate, post-operative including microsurgical complications, and long-term limb function (Toronto Extremity Salvage score, TESS; Musculoskeletal Tumour Society Rating Scale, MSTS) were recorded and analysed for differences between the two study groups. RESULTS Forty-six patients underwent 46 free flaps (pre-irradiated n = 32, non-irradiated n = 14) over the study period. Microvascular complications (intra-operative revision, flap re-exploration, flap loss) were uncommon and similar between the two groups (4/32 and 2/14 respectively, p > 0.05). Recipient site wound healing complications (i.e. not flap related) occurred more frequently in pre-irradiated patients (16 events) compared with the control group (2 events, p = 0.03). There was no significant difference in limb salvage rate, or TESS/MSTS functional outcome scores between the two patient groups. CONCLUSIONS Free tissue transfer is safe and effective in patients undergoing surgical resection and reconstruction following neoadjuvant radiotherapy.

Can the ACS-NSQIP surgical risk calculator predict post-operative complications in patients undergoing flap reconstruction following soft tissue sarcoma resection?

The ACS‐NSQIP surgical risk calculator is an open‐access on‐line tool that estimates the risk of adverse post‐operative outcomes for a wide range of surgical procedures. Wide surgical resection of soft tissue sarcoma (STS) often requires complex reconstructive procedures that can be associated with relatively high rates of complications. This study evaluates the ability of this calculator to identify patients with STS at risk for post‐operative complications following flap reconstruction.

The influence of dispositional optimism on decision regret to undergo major breast reconstructive surgery

It is not known if optimism influences regret following major reconstructive breast surgery. We examined the relationship between dispositional optimism, major complications and decision regret in patients undergoing microsurgical breast reconstruction.

Usability of the internal mammary recipient vessels in microvascular breast reconstruction

BACKGROUND AND AIM Although the internal mammary vessels are, for many surgeons, the recipient vessels of choice in microvascular breast reconstruction, there continues to be some debate regarding their use. The reliability of these vessels, particularly the vein, has been called into question, with high rates of conversion to alternative vessels being reported. This study investigates the true usability rate of the internal mammary vessels in a large series of consecutive patients without preselection. METHODS A review of all patients who underwent microvascular breast reconstruction at the University Health Network between September 2007 and December 2013 was conducted, and the conversion rate to alternative vessels was determined. RESULTS A total of 759 microvascular breast reconstructions were performed in 515 patients. The internal mammary vessels were explored in all cases and found to be suitable for anastomosis in 756 of 759 reconstructions. Conversion to the thoracodorsal vessels was required in three reconstructions (0.4%) due to unusable internal mammary arteries. There was no significant increase in unusable vessels with timing or laterality of reconstruction or other factors such as smoking, vascular co-morbidities and adjuvant chemotherapy or radiotherapy. Total flap failure occurred in four reconstructions (0.5%), whereas partial flap loss occurred in five (0.6%). CONCLUSION The internal mammary vessels can be safely and reliably used in almost all patients undergoing microsurgical breast reconstruction with low rates of microvascular complications.

A decision-making algorithm for recipient vein selection in bipedicle deep inferior epigastric artery perforator flap autologous breast reconstruction

The bipedicle deep inferior epigastric artery perforator (DIEP) flap allows reliable transfer of the entire lower abdominal flap in patients who have a small pannus or require a large volume breast reconstruction. Selection of recipient vessels for the second pedicle can however, be challenging. We describe our experience with a consecutive series of twenty three bipedicle DIEP flaps with particular focus on selection of the recipient veins. We demonstrate that with judicious selection the internal mammary system can be reliably used as recipients for both pedicles with low complication rates.

Chronic Postsurgical Pain Outcomes in Breast Reconstruction Patients Receiving Perioperative Transversus Abdominis Plane Catheters at the Donor Site: A Prospective Cohort Follow-up Study

Chronic postsurgical pain (CPSP) is a debilitating and costly condition. Risk factors for CPSP after autologous breast reconstruction have not been clearly established. Previously, we demonstrated that transversus abdominis plane (TAP) catheters delivering intermittent local anesthetic reduced postoperative morphine consumption. This prospective follow‐up study aimed to (1) compare the incidence of CPSP after autologous breast reconstruction between patients who received postoperative intermittent TAP catheters with bupivacaine or saline boluses and (2) assess the factors that contribute to the development and maintenance of CPSP in this study cohort.

Development and testing of a decision aid for women considering delayed breast reconstruction

BACKGROUND The decision to have post-mastectomy breast reconstruction (PMBR) is highly complex and many women feel ill equipped to make this decision. Decision aids have been advocated to promote patient involvement in decision-making by streamlining and standardizing communication between the patient and the health care professional. In this study, we report on the development and testing of a decision aid (DA) for breast cancer survivors considering delayed PMBR. METHODS The DA was developed and evaluated in three phases. The first phase included the development of the DA with input and review by practitioners and key stakeholders. The second phase involved pilot testing of the feasibility and acceptability of the DA with a convenience sample of women with delayed PMBR. The third phase involved a pretest/post-test evaluation of the DA for women who were making decisions about their PMBR options. RESULTS The DA was developed using the Ottawa Decision Support Framework. In the second phase of the study, 21 women completed the acceptability survey, of whom 100% reported that they would recommend the DA to other women. In the third phase, decisional conflict decreased significantly (p < 0.001) and knowledge increased significantly (p < 0.001) from prior to using the DA to 1-2 weeks after using the DA. CONCLUSIONS The DA is feasible and acceptable to women considering delayed PMBR. Furthermore, the DA is effective at reducing decisional conflict and increasing knowledge about delayed PMBR. The DA is an appropriate tool to be used in addition with standard care in women considering PMBR.

Flap choice does not affect complication rates or functional outcomes following extremity soft tissue sarcoma reconstruction

BACKGROUND Flap reconstruction plays an essential role in facilitating limb preservation in patients with extremity soft tissue sarcoma (ESTS). However, the effect of flap choice on the rates of postoperative complications and functional outcomes has not been clearly established. This study directly compares the outcomes of free and pedicled flap reconstructions in patients with ESTS. METHODS Two hundred sixty-six patients who underwent flap reconstruction following ESTS resection were included. Associations between flap type and complications were determined using logistic regression analyses. Functional outcome was evaluated using the Toronto Extremity Salvage Score (TESS) and the Musculoskeletal Tumor Society Scales (MSTS). RESULTS There was no significant difference between complication rates in the pedicled and free flap groups (32% vs. 38%, p = 0.38). In the lower limb, pedicled flaps had complication rates similar to those of free flaps on univariate analysis (odds ratio [OR] = 1.12, 95% confidence interval [CI] = 0.56-2.26, p = 0.75). Conversely, in the upper limb, pedicled flaps were associated with fewer complications on univariate analysis (OR = 0.31, 95% CI = 0.11-0.86, p = 0.03), but this was not significant on multivariate analysis (OR = 0.45, 95% CI = 0.13-1.59, p = 0.22). Obesity was a strong predictor of complications in the upper limb group on multivariate analysis (body mass index [BMI] ≥ 30 kg/m2, OR = 7.01, 95% CI = 1.28-38.51, p = 0.03). There was no significant difference in functional outcomes between both flap groups in either upper or lower limbs. CONCLUSIONS Postoperative complications and functional outcomes for patients undergoing free and pedicled flaps are similar in ESTS reconstruction. Selecting the most suitable reconstructive option in each individual case is paramount to preserving function while minimizing postoperative morbidity.