Jacqueline S. Israel

Does Postoperative Drain Amylase Predict Pancreatic Fistula after Pancreatectomy

BACKGROUND Previous studies suggest that after pancreatectomy, drain fluid amylase obtained on postoperative day 1 (DFA1) >5,000 U/L correlates with the development of postoperative pancreatic fistula (PF).(1,2) We sought to validate whether DFA1 is a clinically useful predictor of PF and to evaluate whether DFA1 correlates with PF severity. STUDY DESIGN Using a prospective database, we reviewed records from patients having pancreatectomy between 2010 and 2012. Presence and grade of PF were determined using the consensus guidelines from the International Study Group on Pancreatic Fistula (ISGPF).(1) RESULTS: Sixty-three patients who underwent pancreatectomy had a documented DFA1. There were 27 (43%) who developed PF: 2 (7%) were grade A, 18 grade B (67%), and 7 were grade C (26%). Median DFA1 in patients with PF (4,600 U/L, range 32 to 16,900 U/L) was significantly higher than in those without PF (45 U/L, range 2 to 5,840 U/L; p < 0.001). When DFA1 was analyzed at varying cutoff values, correlation of DFA1 with PF was high. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were assessed at varying levels of DFA1. Highest sensitivity (96%) and NPV (96%) were obtained with a cutoff DFA1 of <100 U/L. On multivariate analysis, DFA1 >100 U/L was the only significant predictor of PF when controlling for gland texture, duct size, pathology, and neoadjuvant radiation. There was no statistically significant relationship between DFA1 and PF grade. CONCLUSIONS In patients undergoing pancreatic resection, a cutoff DFA1 of 100 U/L resulted in high sensitivity and NPV. Early drain removal may be safe in these patients. Further studies are recommended to validate the role of DFA1 in excluding PF and assisting in management of surgical drains.

Patient preferences for coronary artery bypass graft surgery or percutaneous intervention in multivessel coronary artery disease.

Objectives: Determine if patients prefer multivessel percutaneous coronary intervention (mv‐PCI) over coronary artery bypass graft surgery (CABG) for treatment of symptomatic multivessel coronary artery disease (mv‐CAD) despite high 1‐year risk. Background: Patient risk perception and preference for CABG or mv‐PCI to treat medically refractory mv‐CAD are poorly understood. We hypothesize that patients prefer mv‐PCI instead of CABG even when quoted high mv‐PCI risk. Methods: 585 patients and 31 physicians were presented standardized questionnaires with a hypothetical scenario describing chest pain and medically refractory mv‐CAD. CABG or mv‐PCI was presented as treatment options. Risk scenarios included variable 1‐year risks of death, stroke, and repeat procedures for mv‐PCI and fixed risks for CABG. Participants indicated their preference of revascularization method based on the presented risks. We calculated the odds that patients or physicians would favor mv‐PCI over CABG across a range of quoted risks of death, stroke, and repeat procedures. Results: For nearly all quoted risks, patients preferred mv‐PCI over CABG, even when the risk of death was double the risk with CABG or the risk of repeat procedures was more than three times that for CABG (P < 0.0001). Compared to patients, physicians chose mv‐PCI less often than CABG as the risk of death and repeat procedures increased (P < 0.001 and P = 0.004, respectively). Conclusion: Patients favor mv‐PCI over CABG to treat mv‐CAD, even if 1‐year risks of death and repeat procedures far exceed risk with CABG. Physicians are more influenced by actual risk and prefer mv‐PCI less than patients despite similarly quoted 1‐year risks.

The Affordable Care Act: a primer for plastic surgeons.

Summary: The Patient Protection and Affordable Care Act, sometimes referred to as Obamacare, was signed into law on March 23, 2010. It represents the most extensive overhaul of the country’s health care system since the passage of Medicare and Medicaid in 1965. The Affordable Care Act has two goals. The first goal is to reduce the uninsured population in the United States. Key elements to covering the uninsured include the following: (1) expanding Medicaid coverage for low-income individuals and (2) establishing health insurance marketplaces for moderate-income individuals with subsidies and tax cuts in an effort to make health insurance more affordable. The second goal of the Affordable Care Act is to address concerns about quality and the overall cost of U.S. health care. It is imperative that plastic surgeons thoroughly understand the impact that the Affordable Care Act will undoubtedly have on the country, on our patients, and on our clinical practices. Plastic surgery will see many changes in the future. This will include an overall increase in the number of insured patients, a push toward joining accountable care organizations, and a shift in payment systems to bundled reimbursement for episodes of care. In this article, the authors describe how these changes are likely to occur and what plastic surgeons must do to be part of the change.

Plastic Surgeons’ Perceptions of the Affordable Care Act: Results of a National Survey

Background: The Affordable Care Act (ACA) aims to expand coverage to the uninsured, improve quality, and contain costs. The goal of this study was to ascertain how plastic surgeons perceive the ACA. Methods: An electronic questionnaire was e-mailed to members of the American Society of Plastic Surgeons between May and June 2014. The survey was anonymous and voluntary and included questions to assess understanding and opinions of the ACA. Results: The survey was sent to 3070 members of the American Society of Plastic Surgeons, and the response rate was 17%. Sixty-eight percent agree or strongly agree that they understand the basic concepts of the ACA. The majority of respondents disagree (38% strongly disagree, 31% disagree) with the notion that the ACA will positively affect their practice, and 51% agree with the statement, “I do not support the ACA, and I believe it did too much.” Two thirds (66%) believe that the ACA deserves a grade of D or F. When answers were analyzed across demographics, 42% of respondents with “Academic” practice background identify with the statement, “I support the ACA but I think it needs more work,” compared to 15% of those who selected “Solo Practice” (p <0.001). Conclusions: The ACA will affect all specialties, including plastic surgery. The results of this survey suggest that many plastic surgeons believe that they have a baseline understanding of current health-care reform. The majority of surveyed surgeons do not support the Act. It is imperative that plastic surgeons possess the knowledge of the ACA; its changes, both current and impending, will likely affect patient mix, coverage of procedures, and reimbursement.

The clinical conundrum of perioperative pain management in patients with opioid dependence: lessons from two cases.

Sir:Patients receiving medication to treat opioid dependence present unique perioperative pain management challenges. As illustrated by the following two case examples, these challenges are significant for providers of all specialties, including plastic surgeons.The patient in the first case was a 2

Variations in Burn Excision and Grafting: A Survey of the American Burn Association

It is unknown whether variations in burn care affect outcomes or affect the success of emerging therapeutics. The purpose of this study was to assess burn surgeons’ preferences in excision and grafting to determine if surgical technique affects outcomes. A 71-item survey evaluating skin grafting techniques and preferences was emailed to members of the American Burn Association in July and August 2015. The survey was anonymous and voluntary. Relationships between variables were evaluated using Fisher’s exact test. A P-value of ⩽.05 was deemed statistically significant. The survey was sent to 607 burn surgeons, and the response rate was 24%. Clinical judgment is the most widely used method to determine depth of injury. Surgeons who practice in the United States and surgeons who are board certified in general surgery are more likely to determine depth of the burn based on clinical judgment alone (P < .001). Fifty-six percent of surgeons will perform excision as early as postburn day 1 and 73% will excise greater than 20% TBSA in one setting. Surgeons at centers with bed number of ⩽10 (P = .024) or surgeons with board certification in plastic surgery (P = .008) are more likely to excise deep partial-thickness burns with an attempt to retain viable dermis. Geographic location, board certification, and burn unit size all contribute to variations in practice. Strong individual preferences make standardization of therapies challenging and may affect the success of new technologies. Burn surgery continues to be an art as much as a science, and accurate documentation of techniques and outcomes is essential for optimizing successes and documenting failures of new treatment methods.

Abstract 55: Osseointegrated Neural Interface (ONI)

area burn (C57BL6 mice; n=4 per time point). Imaging of the injured limb and skin incision only contra-lateral limb (control) was performed weekly (1–9 weeks post-injury) in a longitudinal fashion. Acoustic concentration (10*log(mm-3)) was calculated for each ultrasound frame. Houndsfield units were used to calculate HO volume on microCT imaging. Histology was used to confirm the presence of HO and to correlate with imaging findings at each time point.

Abstract: Paravertebral Regional Blockade is Associated with Reduced Opioid Requirements and Less Post-Operative Nausea and Vomiting in Reduction Mammaplasty

PURPOSE: We evaluate the safety and effectiveness of paravertebral block (PVB) as an adjunct to general anesthesia (GA) for reduction mammaplasty.

Evaluation of Migraine Surgery Outcomes through Social Media.

Background: Social media have been used to study many aspects of health and human behavior. Although social media present a unique opportunity to obtain unsolicited patient-reported outcomes, its use has been limited in plastic and reconstructive surgical procedures, including migraine nerve surgery. The goal of this study was to utilize the most popular social media site, Facebook, to evaluate patients’ experience with migraine surgery. Methods: Six months of data regarding nerve surgery, nerve stimulators, and radiofrequency nerve ablation were collected from posts and comments written by members of 2 Facebook groups. Outcomes were classified by degree of resolution of symptoms. Results: A total of 639 posts related to migraine surgery. Of 304 posts commenting on postoperative success of nerve surgery, 16% reported elimination of headaches and 65% significant improvement (81% with complete or significant improvement), 5% partial improvement, 11% no change, and 3% worsening symptoms. Nerve surgery had a higher success rate than nerve stimulators and radiofrequency ablation. Nerve surgery was recommended by 90% of users. Conclusions: The 81% rate of complete or significant improvement of symptoms in this study is close to the 79% to 84% shown in current literature. Similar to the findings of a recent systematic review, surgery is more efficacious compared with nerve stimulators and ablation. This study adds to evidence favoring migraine surgery by removing evaluator bias and demonstrates that surgical outcomes and satisfaction data may be obtained from social media.

Reconstructive surgery and patients with spinal cord injury: Perioperative considerations for the plastic surgeon

Abstract Background: Patients with spinal cord injury (SCI) requiring reconstructive surgery, particularly for pressure ulcers, are ubiquitous in Plastic and Reconstructive Surgery practices. Much of the current literature focuses on operative techniques, antibiotic indications, sitting protocols, and dressing and bedding choices. Methods: This paper reviews normal neuroanatomy, outlines changes in neurophysiology observed in spinal cord injury, and addresses concepts related to perioperative care that are highly relevant but often under-emphasised. Results: Vascular disturbances such as autonomic dysreflexia and orthostatic hypotension are dangerous phenomena occurring in this patient population that, if not properly recognised and treated, may result in complications such as haematoma, flap loss, inadequate tissue perfusion, and death. The management of spasticity, deep venous thrombosis, and perioperative pain are also relevant and discussed in this paper. Conclusion: A basic understanding of these concepts is essential for the Plastic Surgeon involved in the care of patients with SCI and pressure ulcers, particularly before and after debridement or reconstruction.