Elizabeth B. Odom

Difficult removal of subdermal contraceptive implants: a multidisciplinary approach involving a peripheral nerve expert

OBJECTIVES We aim to describe our experiences and identify patients who may benefit from referral to a peripheral nerve surgeon for removal of contraceptive subdermal implants in which neurovascular injury may occur, and describe a treatment pathway for optimal care. STUDY DESIGN We reviewed the charts of 22 patients who were referred to the Division of Family Planning for difficult removal of etonogestrel contraceptive implants between January 1, 2014, and April, 1 2016. Of these, five were referred to a peripheral nerve surgeon due to pain or location of the implant. We evaluated and described these cases and, from our findings, developed recommendations for care in a multidisciplinary team approach. RESULTS Two patients reported pain, including one with four previous failed removal attempts. In the two patients with pain, the implants were adherent to a sensory nerve. In another, the implant was within the biceps muscle and difficult to locate. In all cases, ultrasound imaging, general anesthesia and a wide exposure allowed for safe removal and good outcomes. Our multidisciplinary care approach has elucidated important referral and technical considerations that improve patient care and safety. CONCLUSION When necessary, multidisciplinary care with a Family Planning expert and possibly a peripheral nerve surgeon may be beneficial in safely removing etonogestrel contraceptive implants that would be difficult or risky to remove in an ambulatory setting.

Mandible Fracture Complications and Infection: The Influence of Demographics and Modifiable Factors.

Background: Mandible fractures account for 36 to 70 percent of all facial fractures. Despite their high prevalence, the literature lacks a comprehensive review of demographics, fracture patterns, timing of management, antibiotic selection, and outcomes, particularly when evaluating pediatric versus adult patients. The authors aim to determine the complication and infection rates after surgical treatment of mandibular fractures and the bacterial isolates and antibiotic sensitivities from mandible infections after open reduction and internal fixation at their institution. Methods: Data were collected retrospectively for all mandible fractures treated at the authors’ institution between 2003 and 2013. Patients were divided into pediatric (younger than 16 years) and adult (16 years or older) subgroups. Demographics, fracture location, fracture cause, comorbidities, antibiotic choice, and subsequent complications and infections were analyzed. Data were evaluated using appropriate statistical tests for each variable. Results: Three hundred ninety-five patients were evaluated. Demographics and fracture cause were similar to those reported in current literature. Of the 56 pediatric patients, complications occurred in 5.6 percent. Time from injury to operative intervention did not affect outcome. The complication rate was 17.5 percent and the infection rate was 9.4 percent in the adult subgroup. Time from injury to operative intervention, sex, and edentulism were not significant predictors of complication or infection. Tobacco use, number of fractures, number of fractures fixated, and surgical approach were predictors of complication and infection. Perioperative ampicillin-sulbactam had a significantly lower risk of infection. Conclusions: Certain demographic and operative factors lead to significantly higher risks of complications after surgical management of mandibular fractures. Ampicillin-sulbactam provides effective antibiotic prophylaxis. Risk factor modification may improve outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, IV.

Are Residents Prepared for Surgical Cases? Implications in Patient Safety and Education

OBJECTIVE In surgical education, the areas of focus and evaluation are skewed toward technical skill and operative knowledge; less emphasized is familiarity with the patients medical history. The purposes of this study were to characterize how surgical trainees prepare for cases and to determine the comprehensiveness of their preparation. DESIGN A 27-question survey was created through a web-based software program and distributed to all resident physicians and fellows in the Departments of Surgery, Neurosurgery, and Otolaryngology at our institution. Survey responses were collected anonymously and analyzed. Institutional review board exemption was obtained. SETTING This study was performed at Washington University in St. Louis, Missouri, at an institutional hospital setting. PARTICIPANTS The survey was distributed to current surgical trainees at Washington University in St. Louis in the Departments of Surgery, Neurosurgery, and Otolaryngology. Further, 130 of 169 surgical residents and fellows completed the survey. RESULTS Most respondents (96%) taught themselves case preparation. Only 57% of respondents reviewed the patients medical record before every surgery. Although most respondents (83%) felt they were prepared or very prepared from a patient-specific standpoint, only 24% felt that their handoff of a patient to on-call colleagues was comprehensive enough to include all pertinent aspects of a patients history and expected perioperative course. From a technical perspective, most residents (63%) felt they were prepared or very prepared, and this level of comfort increased with postgraduate year; 76% of respondents would not feel comfortable telling their attending they were not adequately prepared. CONCLUSIONS Although most trainees feel prepared or very prepared for cases from a patient-specific regard, only half review the patients medical record before every surgery. Furthermore, almost all trainees have taught themselves how to prepare for surgery. This represents a critical gap in residency education and an opportunity to improve patient safety and quality of care.

Complications and thromboembolic events associated with tamoxifen therapy in patients with breast cancer undergoing microvascular breast reconstruction: a systematic review and meta-analysis

PurposeTamoxifen therapy is integral in the treatment of patients with hormone receptor-positive breast cancer. However, there is an association between tamoxifen and thromboembolic events. Flap and systemic thromboembolic events have devastating consequences in microvascular breast reconstruction. Currently, there are conflicting data on the association between tamoxifen therapy and thromboembolic complications for patients undergoing microvascular breast reconstruction. The objective of this study is to determine if perioperative tamoxifen therapy modifies the risk of complications and thromboembolic events for patients with breast cancer undergoing microvascular breast reconstruction.MethodsA comprehensive literature search was performed across six databases from January 2003 to February 2016. Pooled estimates and relative risk (RR) were calculated using a random-effects model, confounding was examined with meta-regression, and risk of bias was evaluated. Primary outcomes were thrombotic flap complications and total flap loss. Study quality was assessed using Downs and Black criteria.ResultsOf 95 studies reviewed, 4 studies comprising 1700 patients and 2245 procedures were included for analysis. Compared to non-recipients, patients on tamoxifen were at increased risk of developing thrombotic flap complications (pooled RR 1.5; 95% CI 1.14–1.98) and total flap loss (pooled RR 3.35; 95% CI 0.95–11.91). There was no significant heterogeneity present in either outcome and no evidence of publication bias.ConclusionsPerioperative tamoxifen therapy may increase the risk of thrombotic flap complications and flap loss for patients with breast cancer undergoing microvascular reconstruction. These findings further the ability of providers to make evidence-based recommendations in the perioperative management of patients with breast cancer.

The Impact of Radiation and Its Timing on Donor Internal Mammary Vessel Histopathology at the Time of Autologous Microvascular Breast Reconstruction

Background We evaluate the impact of radiation and its early versus late effects on internal mammary vessel histomorphometry and implications for autologous breast reconstruction. Methods Patients received no radiation or radiation within the previous 6 weeks (early) or at least 6 months prior to biopsy (late) of the internal mammary vessels during free flap surgery. Clinical outcomes, and vessel measurements and markers for macrophages, smooth muscle actin (SM‐ACTIN), elastin, and collagen were analyzed. Results We analyzed 36 internal mammary arteries (IMAs) and veins (IMV) in 22 patients. Six had no radiation, 12 had radiation less than 6 weeks, and 18 had radiation more than 6 months ago. Demographics, surgical variables, and cardiovascular comorbidity did not differ between groups. Macrophage counts were higher in patients who had radiation (p < 0.001) and in the early group when compared with the late group (p = 0.03). There were similar findings in the IMV. Intimal thickness of the IMA increased significantly after radiation (p < 0.001), particularly in the late group when compared with the early group (p = 0.007). Intima‐media thickness of the IMV was significantly elevated (p = 0.02) after radiotherapy. Radiation decreased percentage of SM‐ACTIN in the IMA (p = 0.05). Other histomorphometric parameters did not differ significantly. Conclusion Higher macrophage counts but less intimal thickening of the IMA differentiates donor vessels utilized within 6 weeks of radiotherapy and those performed after 6 months or more. Although the timing of reconstruction is based on several other factors, histologic parameters support reconstruction within 6 weeks of radiation therapy.

Long-Term Incisal Relationships After Palatoplasty in Patients With Isolated Cleft Palate.

Purpose:Various palatoplasty techniques have limited incisions in the hard palate due to concerns that these incisions may limit maxillary growth. There is little convincing long-term evidence to support this. Our purpose is to determine incisal relationships, an indicator for future orthognathic procedure, in patients after repair of an isolated cleft of the secondary palate. Methods:Our craniofacial database was used to identify patients aged 10 years or greater with an isolated cleft of the secondary palate who underwent palatoplasty between 1985 and 2002. Data collected included age at palatoplasty and follow-up, cleft type, associated syndrome, Robin sequence, surgeon, repair technique, number of operations, and occlusion. Incisal relationship was determined through clinical observation by a pediatric dentist and orthodontist. Results:Seventy eligible patients operated on by 9 surgeons were identified. Class III incisal relationship was seen in 5 patients (7.1%). Palatoplasty techniques over the hard palate (63 of 70 patients) included 2-flap palatoplasty, VY-pushback, and Von Langenbeck repair. There was an association between class III incisal relationship and syndromic diagnosis (P <0.001). Other study variables were not associated with class III incisal relationships. Conclusion:In patients with an isolated cleft of the secondary palate, there was no association between class III incisal relationship and surgeon, age at repair, cleft type, palatoplasty technique, or number of operations. Increased likelihood of class III incisal relationship was associated primarily with syndromic diagnosis.

Systemic Preoperative Antibiotics with Mandible Fractures: Are They Indicated at the Time of Injury?

Mandible fractures are the most common result of facial trauma. The proximity of oral flora to the site of both the injury and resulting surgical instrumentation makes managing infection a unique challenge. The benefit of antibiotic prophylaxis at the time of surgical treatment of mandible fractures is well established. However, the routine use of antibiotics between the time of injury and surgery is of unclear benefit. We aim to define the role of antibiotics in the preoperative period: from the time of injury to surgical intervention. Demographic and clinical data were collected retrospectively on all patients who were treated for mandible fracture by the Division of Plastic and Reconstructive Surgery at our institution between 2003 and 2013. The use of both preoperative (between injury and surgery) and perioperative (at the time of surgery) systemic antibiotics was recorded along with the incidence of postoperative infections and other complications. Complete data were available for 269 patients. Of the 216 patients who received preoperative antibiotics, 22 (10%) developed an infection postoperatively. Of the 53 patients who did not receive preoperative antibiotics, 2 (4%) developed infection (p = 0.184). Likewise, preoperative antibiotics were not significantly associated with hardware complication rates. In our retrospective review, the use of antibiotics between injury and surgical repair had no impact on postoperative infection rates. These data suggest that preoperative antibiotic use may actually be associated with an increased incidence of postoperative infection. Our results do not support the routine use of antibiotics between injury and surgical repair in patients with mandible fractures.

Attending Surgeons as Teachers: What the Residents Want.

Results: 148 survey responses were obtained. 66% of respondents were male, and 33% female. 86% were from integrated programs. 60% were PGY level 1-4, while 40% were senior residents or fellows. 74% of respondents prefer teaching faculty to be flexible based on resident input and intraoperative events when planning for a surgical case. While 82% prefer informal didactic teaching, with a clear separation of teacher from student, 72% prefer interaction outside of teaching sessions or cases to be casual with some career focus. Overall, females prefer a more casual teaching environment, but desire a greater patient-focused approach in the operating room versus resident-benefit. Male residents and those planning to enter private practice, on the other hand, favor an operative approach focused more on resident benefit. The most important skills residents want to learn from teachers are: clinical judgment, operative technique, and clinical diagnostic skills. Abilities in grant and manuscript writing, basic laboratory skills, and bedside manner were of less value. Reputation, research background, and national connections are the most highly valued professional characteristics, while practice type, years in practice, and gender are of less importance. Approachability and teaching style ranked highly among residents as important personal qualities in a teacher, and females found approachability a more valuable characteristic than did males.