Rika Ohkuma

Abdominally based free flap planning in breast reconstruction with computed tomographic angiography: systematic review and meta-analysis.

Background: Computed tomographic angiography is often used for preoperative mapping. The authors aimed to systematically assess breast reconstruction outcomes after abdominally based free flaps planned with preoperative computed tomographic angiography versus Doppler ultrasonography. Methods: A search of the PubMed, EMBASE, and Scopus databases and an additional hand-search of relevant articles until June of 2012 rendered 442 English-language citations. Three authors independently reviewed these citations and included all the studies comparing preoperative computed tomographic angiography versus Doppler ultrasonography with regard to short-term postoperative outcomes and operative times. A meta-analysis was performed to evaluate the incidence of flap-related complications (seven studies), donor-site morbidity (four studies), and operative times (five studies) between preoperative computed tomographic angiography and Doppler ultrasonography. A pooled relative risk was calculated using a random-effect model to compare complication rates between the computed tomographic angiography and Doppler ultrasonography groups. Results: A total of 13 studies met inclusion criteria. Preoperative computed tomographic angiography was associated with significantly fewer flap-related complications (relative risk, 0.87; 95 percent CI, 0.78 to 0.97), reduced donor-site morbidity (relative risk, 0.84; 95 percent CI, 0.76 to 0.94), and shorter reconstruction operative time by 87.7 minutes (mean difference, 87.7 minutes; 95 percent CI, 78.3 to 97.1 minutes). Conclusions: The use of preoperative computed tomographic angiography reduces the operative time, postoperative flap-related complications, and donor-site morbidity compared with Doppler ultrasonography. Preoperative computed tomographic angiography has the potential to reduce operative cost and increase efficiency in the operating room. Thus, preoperative mapping by computed tomographic angiography should be strongly considered for abdominally based free flap breast reconstruction.

Role of nutrition support in adult cardiac surgery: a consensus statement from an International Multidisciplinary Expert Group on Nutrition in Cardiac Surgery

Nutrition support is a necessary therapy for critically ill cardiac surgery patients. However, conclusive evidence for this population, consisting of well-conducted clinical trials is lacking. To clarify optimal strategies to improve outcomes, an international multidisciplinary group of 25 experts from different clinical specialties from Germany, Canada, Greece, USA and Russia discussed potential approaches to identify patients who may benefit from nutrition support, when best to initiate nutrition support, and the potential use of pharmaco-nutrition to modulate the inflammatory response to cardiopulmonary bypass. Despite conspicuous knowledge and evidence gaps, a rational nutritional support therapy is presented to benefit patients undergoing cardiac surgery.

A novel score to estimate the risk of pneumonia after cardiac surgery

OBJECTIVE The purpose of this study was to derive and validate a risk score for pneumonia (PNA) after cardiac surgery. METHODS Adults undergoing cardiac surgery between 2005 and 2012 were identified in a single-institution database. The primary outcome was postoperative PNA. Patients were randomly assigned to training and validation sets in a 3:1 ratio. A multivariable model was constructed incorporating univariate pre- and intraoperative predictors of PNA in the training set. Points were assigned to significant risk factors in the multivariable model based on their associated regression coefficients. RESULTS A total of 6222 patients were included. The overall rate of postoperative PNA was 4.5% (n = 282). A 33-point score incorporating 6 risk factors (age, chronic lung disease, peripheral vascular disease, cardiopulmonary bypass time, intraoperative red blood cell transfusion, and pre- or intraoperative intra-aortic balloon pump) was generated. The model used to generate the score in the training set was robust in predicting PNA (c = 0.72, P < .001). Predicted rates of PNA increased exponentially with increasing risk score, ranging from 1.2% (score = 0) to 59% (score = 33). There was significant correlation between predicted rates of PNA based on the training cohort and actual rates of pneumonia in the validation cohort in weighted regression analysis (r = 0.74, P < .001). The composite score outperformed the STS prolonged ventilation model in predicting PNA in the validation cohort (c-index 0.76 vs 0.71, respectively). CONCLUSIONS This 33-point risk score is strongly predictive of postoperative PNA after cardiac surgery. The composite score has utility in tailoring perioperative management and in targeting diagnostic and preventative interventions.

Hospital Bed Type, the Electronic Medical Record, and Safe Bed Elevation in the Intensive Care Setting.

In mechanically ventilated patients, head of bed (HOB) elevation above 30° decreases the risk of ventilator-associated pneumonia. The research team studied (a) compliance with proper HOB elevation in their cardiac surgical intensive care unit, (b) the accuracy of HOB angles recorded in the electronic medical record (EMR), and (c) the effect of bed type on (a) and (b). Nurses were polled to discover how HOB angles were measured in practice. HOB angles were compliant in 80% of observations. Compliance was more frequent in beds with side-of-bed angle indicators (SBI) than beds with under-bed angle indicators (UBI; 88% vs 77%, P = .04). Charting in the EMR was accurate in 50% of SBI bed observations but only 20% of UBI bed observations (P < .0001). Sixty-seven percent of nurses used the SBI; 27% used the UBI; 6% used estimation alone. Though compliance was suboptimal, compliance and EMR accuracy were significantly associated with bed type. Bedside indicators are underutilized.

Patient-Reported Assessment of Functional Gait Outcomes following Superior Gluteal Artery Perforator Reconstruction.

Background: Harvesting the superior gluteal artery perforator (SGAP) flap involves dissection of vessels through the gluteal muscle, potentially compromising gait and ambulation. We compared patient-reported gait and ambulation problems between SGAP flap and deep inferior epigastric perforator (DIEP) flap reconstructions. Methods: Forty-three patients who underwent bilateral free flap breast reconstruction (17 SGAP, 26 DIEP) participated in the study. The Lower Extremity Functional Score (LEFS) was administered with a supplementary section evaluating gait, balance, fatigue, and pain. Patients evaluated how they felt 2 months postoperatively and at time of survey administration. Multivariate regressions were fit to assess association between type of reconstruction and self-reported lower extremity function controlling for potential confounding factors. Results: Although there was no significant difference in overall LEFS between the cohorts on the date of survey, the SGAP patients reported greater difficulty performing the following activities after surgery (P < 0.05): work, usual hobbies, squatting, walking a mile, walking up stairs, sitting for an hour, running, turning, and hopping. The SGAP patients also reported easier fatigue (P < 0.01) both during the early postoperative period and on the date of survey. Conclusions: SGAP flap surgery causes no statistically significant differences in overall LEFS. However, SGAP patients did report donor-site morbidity with decreased ability to perform certain activities and increased fatigue and pain in the longer follow-up period. We feel that patients should be educated regarding gait issues and undergo physical therapy during the early postoperative period.

The Effect of Radiation on Quality of Life throughout the Breast Reconstruction Process: A Prospective, Longitudinal Pilot Study of 200 Patients with Long-Term Follow-Up

Background: Despite well-established correlation of postmastectomy radiotherapy and surgical complications in breast reconstruction, its impact on patient reported outcomes is less clear. We sought to determine the effect of postmastectomy radiotherapy on patient reported outcomes throughout the breast reconstruction process. Methods: Patients undergoing prosthetic and autologous breast reconstruction from November 2010 to June 2013 were prospectively followed with BREAST-Q surveys (preoperatively, after expander placement, and 6 and 12 months after final reconstruction). Paired t test, Wilcoxon rank sum test, and multiple linear regression were used to determine the effect of radiation on patient reported outcomes. Results: Two hundred patients were included in the study, of which 51 (25.5 percent) received postmastectomy radiotherapy. Prosthetic reconstruction was performed in 75 patients (37.5 percent), autologous reconstruction was performed in 118 (59 percent), and pure fat grafting was performed in seven (3.5 percent). At one-year follow-up, the nonirradiated group reported higher BREAST-Q scores when compared with the irradiated group, in Satisfaction with Breasts (p = 0.003), Psychosocial Well-being (p = 0.003), Sexual Well-being (p < 0.001), Physical Well-being of Chest (p = 0.024), and Satisfaction with Outcome (p = 0.03). When accounting for baseline values, Satisfaction with Breasts and Physical Well-being of Chest significantly worsened in irradiated patients undergoing prosthetic reconstruction, an effect not seen with autologous reconstructions. All irradiated patients significantly worsened in Psychosocial Well-being and Sexual Well-being scores. Conclusions: Postmastectomy radiotherapy is associated with worse patient reported outcomes following breast reconstruction. Autologous reconstruction can mitigate patient dissatisfaction in some domains. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.