Sahael M. Stapleton

A Review of the Surgical Management of Breast Cancer: Plastic Reconstructive Techniques and Timing Implications

The oncologic management of breast cancer has evolved over the past several decades from radical mastectomy to modern-day preservation of chest and breast structures. The increased rate of mastectomies over recent years made breast reconstruction an integral part of the breast cancer management. Plastic surgery now offers patients a wide variety of reconstruction options from primary closure of the skin flaps to performance of microvascular and autologous tissue transplantation. Well-coordinated partnerships between surgical oncologists, plastic surgeons, and patients address concerns of tumor control, cosmesis, and patients’ wishes. The gamut of breast reconstruction options is reviewed, particularly noting state-of-the-art techniques, as well as the advantages and disadvantages of various timing modalities.

Breast sensation after breast reconstruction: A systematic review

Studies show some return of breast sensation after breast reconstruction; however, recovery is variable and unpredictable. Efforts are being made to restore innervation by reattaching nerves (neurotization). We sought to systematically review the literature addressing breast sensation after reconstruction. The following databases were searched: EMBASE, Cochrane, and PubMed. Additionally, the PLASTIC AND RECONSTRUCTIVE SURGERY journal was hand searched from 1960 to 2009. Inclusion criteria included breast reconstruction for cancer, return of sensation with objective results, and patients aged 18 to 90 years. Studies with purely cosmetic procedures, case reports, studies with less than 10 patients, and studies involving male patients were excluded. The initial search yielded 109 studies, which was refined to 20 studies with a total pool of 638 patients. Innervated flaps have a greater magnitude of recovery, which occurs at an earlier stage compared with the noninnervated flaps. Overall, sensation to deep inferior epigastric artery perforator flaps may recover better sensation than transverse rectus abdominis myocutaneous flaps, followed by latissimus dorsi flaps, and finally implants. Womens needs and expectations for sensation have led plastic surgeons to investigate ways to facilitate its return. Studies, however, depict conflicting data. Larger series are needed to define the role of neurotization as a modality for improving sensory restoration.

Three-dimensional computed tomographic angiography to predict weight and volume of deep inferior epigastric artery perforator flap for breast reconstruction†

Background: Three‐dimensional computed tomographic angiography (3D CTA) can be used preoperatively to evaluate the course and caliber of perforating blood vessels for abdominal free‐flap breast reconstruction. For postmastectomy breast reconstruction, many women inquire whether the abdominal tissue volume will match that of the breast to be removed. Therefore, our goal was to estimate preoperative volume and weight of the proposed flap and compare them with the actual volume and weight to determine if diagnostic imaging can accurately identify the amount of tissue that could potentially to be harvested. Methods: Preoperative 3D CTA was performed in 15 patients, who underwent breast reconstruction using the deep inferior epigastric artery perforator flap. Before each angiogram, stereotactic fiducials were placed on the planned flap outline. The radiologist reviewed each preoperative angiogram to estimate the volume, and thus, weight of the flap. These estimated weights were compared with the actual intraoperative weights. Results: The average estimated weight was 99.7% of the actual weight. The interquartile range (25th to 75th percentile), which represents the “middle half” of the patients, was 91–109%, indicating that half of the patients had an estimated weight within 9% of the actual weight; however, there was a large range (70–133%). Conclusion: 3D CTA with stereotactic fiducials allows surgeons to adequately estimate abdominal flap volume before surgery, potentially giving guidance in the amount of tissue that can be harvested from a patients lower abdomen.

Race/Ethnicity and Age Distribution of Breast Cancer Diagnosis in the United States

This study assesses the age distribution of breast cancer diagnosis across race/ethnicity in US female patients using the Surveillance, Epidemiology, and End Results Program database.

Saphenous vein grafts for perforator flap salvage in autologous breast reconstruction

Although the use of saphenous vein grafts in free‐flap salvage and extremity replantation is relatively common, their use in breast reconstruction is rare. These two case reports represent extreme alternatives for breast reconstruction flap salvage. In our normal daily practice, the overwhelming majority of elective breast reconstructions proceed smoothly. However, the occasional patient may require saphenous vein graft flap rescue for completion of the reconstruction.

Fifteen years of adrenalectomies: impact of specialty training and operative volume

Background. Previous associations between surgeon volume with adrenalectomy outcomes examined only a sample of procedures. We performed an analysis of all adrenalectomies performed in New York state to assess the effect of surgeon volume and specialty on clinical outcomes. Methods. Adrenalectomies performed in adults were identified from the New York Statewide Planning and Research Cooperative System from 2000–2014. Surgeon specialty, volume, and patient demographics were assessed. High volume was defined using a significance threshold at ≥4 adrenalectomies per year. Outcome variables included in‐hospital mortality, duration of stay, and in‐hospital complications. Results. A total of 6,054 adrenalectomies were included. Median patient age was 56 years; 41.9% were men and 68.3% were white. Urologists (n = 462) performed 46.8% of adrenalectomies, general surgeons (n = 599) performed 35.0%, and endocrine surgeons (n = 23) performed 18.1%. Significantly more endocrine surgeons were high‐volume compared with urologists and general surgeons (65.2% vs 10.2% and 6.7%, respectively, P < .001). High‐volume surgeons had significantly lower mortality compared with low‐volume surgeons (0.56% vs 1.25%, P = .004) and a lower rate of complications (10.2% vs 16.4%, P = < .001). Endocrine surgeons were more likely to perform laparoscopic procedures (34.8% vs 22.4% general surgeons and 27.7% US, P < .001) and had the lowest median hospital duration of stay (2 days vs 4 days general surgeons and 3 days urologists, P < .001). After risk adjustment, low surgeon volume was an independent predictor of inpatient complications (odds ratio = 0.96, P = .002). Conclusion. Patients with adrenal disease should be referred to surgeons based on adrenalectomy volume regardless of specialty, but most endocrine surgeons that perform adrenalectomy are high‐volume for the procedure.

Is Annual Volume Enough? The Role of Experience and Specialization on Inpatient Mortality After Hepatectomy

Objective: To investigate the effect of subspecialty practice and experience on the relationship between annual volume and inpatient mortality after hepatic resection. Background: The impact of annual surgical volume on postoperative outcomes has been extensively examined. However, the impact of cumulative surgeon experience and specialty training on this relationship warrants investigation. Methods: The New York Statewide Planning and Research Cooperative System inpatient database was queried for patients’ ≥18 years who underwent wedge hepatectomy or lobectomy from 2000 to 2014. Primary exposures included annual surgeon volume, surgeon experience (early vs late career), and surgical specialization—categorized as general surgery (GS), surgical oncology (SO), and transplant (TS). Primary endpoint was inpatient mortality. Hierarchical logistic regression was performed accounting for correlation at the level of the surgeon and the hospital, and adjusting for patient demographics, comorbidities, presence of cirrhosis, and annual surgical hospital volume. Results: A total of 13,467 cases were analyzed. Overall inpatient mortality was 2.35%. On unadjusted analysis, late career surgeons had a mortality rate of 2.62% versus 1.97% for early career surgeons. GS had a mortality rate of 2.98% compared with 1.68% for SO and 2.67% for TS. Once risk-adjusted, annual volume was associated with reduced mortality only among early-career surgeons (odds ratio 0.82, P = 0.001) and general surgeons (odds ratio 0.65, P = 0.002). No volume effect was seen among late-career or specialty-trained surgeons. Conclusions: Annual volume alone likely contributes only a partial assessment of the volume-outcome relationship. In patients undergoing hepatic resection, increased annual volume did not confer a mortality benefit on subspecialty surgeons or late career surgeons.

How Much Data are Good Enough? Using Simulation to Determine the Reliability of Estimating POMR for Resource-Constrained Settings

AbstractIntroductionPerioperative mortality rate (POMR) is a suggested indicator for surgical quality worldwide. Currently, POMR is often sampled by convenience; a data-driven approach for calculating sample size has not previously been attempted. We proposed a novel application of a bootstrapping sampling technique to estimate how much data are needed to be collected to reasonably estimate POMR in low-resource countries where 100% data capture is not possible.nMaterial and methodsSix common procedures in low- and middle-income countries were analysed by using population database in New York and California. Relative margin of error by dividing the absolute margin of error by the true population rate was calculated. Target margin of error was ±50%, because this level of precision would allow us to detect a moderate-to-large effect size.Results and discussionTarget margin of error was achieved at 0.3% sampling size for abdominal surgery, 7% for fracture, 10% for craniotomy, 16% for pneumonectomy, 26% for hysterectomy and 60% for C-section. POMR may be estimated with fairly good reliability with small data sampling. This method demonstrates that it is possible to use a data-driven approach to determine the necessary sampling size to accurately collect POMR worldwide.

Variation in Amputation Risk for Black Patients: Uncovering Potential Sources of Bias and Opportunities for Intervention

BACKGROUNDnDifferences in amputation rates for limb ischemia between white and black patients have been extensively studied. Our goal was to determine whether biases in provider decision-making contribute to the disparity. We hypothesized that the magnitude of the disparity is affected by surgeon and hospital factors.nnnSTUDY DESIGNnAnalysis of the New York Statewide Planning and Research Cooperative System database was performed for 1999 to 2014. Black and white patients with ICD9 codes for peripheral vascular disease, who received either an amputation or salvage procedure, were included. The primary endpoint was treatment choice.nnnRESULTSnWe analyzed 215,480 inpatient admissions. The overall amputation rate was 38.0%, and blacks were significantly more likely to receive amputations than whites on unadjusted (42.6% vs 28.6%, p < 0.001), and multivariable analyses (odds ratio [OR] 1.45, 95% CI 1.31 to 1.60, p < 0.001). This difference was more pronounced among high total vascular volume surgeons (OR 1.74, 95% CI 1.50 to 2.00, p < 0.001), but not among those with low total vascular volume (OR 1.06, 95% CI 0.90 to 1.24, pxa0= 0.49); high volume hospitals (OR 1.57, 95% CI 1.39 to 1.78, p < 0.001), but not among those with low amputation volume (OR 0.96, 95% CI 0.73 to 1.27, p < 0.80); and surgeons who treat fewer black patients (OR 1.58, 95% CI 1.44 to 1.73, p < 0.001) vs surgeons who see more black patients (OR 1.43, 95% CI 1.30 to 1.57, p < 0.0.001).nnnCONCLUSIONSnBlack patients are significantly more likely to receive an amputation than a salvage procedure when presenting with significant peripheral vascular diseases. High procedural volume does not seem to reduce unequal treatment; diversity of surgeon practice does.

Reducing road traffic deaths: where should we focus global health initiatives?

BACKGROUNDnCurrent global surgery initiatives focus on increasing surgical workforce; however, it is unclear whether this approach would be helpful globally, as patients in low-resource countries may not be able to reach hospitals in a timely fashion without formal Emergency Medical Services (EMS). We hypothesize that increased surgical workforce correlates with decreased road traffic deaths (RTDs) only in countries with EMS.nnnMETHODSnEstimated RTDs were obtained from the Global Status Report on Road Safety 2013, which estimated the RTD rate in 2010 (RTD 2010). The classification of EMS was defined by the Global Status Report on Road Safety 2009. The density of surgeons, anesthesiologists, and obstetricians (SAO density) and 2010 income classification were accessed from the World Bank. Multivariable regression analysis was performed adjusting for different countries, income levels, and trauma system characteristics. Sensitivity analysis was performed.nnnRESULTSnOne-fourth of the countries reported not having formal EMS (nxa0=xa041, 23.4%). On adjusted analysis, SAO density was not associated with changes in RTD 2010 in countries without EMS (nxa0=xa025, Pxa0=xa00.50). However, in countries with EMS, each increase in SAO density per 100,000 population decreased RTDs by 0.079 per 100,000 population (nxa0=xa097, Pxa0<0.001). Income was the only other factor resulting in reduced mortality rates (Pxa0=xa00.004). Sensitivity analysis confirmed these findings.nnnCONCLUSIONSnIncreases in surgical workforce reduce RTDs only when EMS exist. Surgical workforce and EMS must be seen as part of the same system and developed together to maximize their effect in reducing RTDs. Global health initiatives should be tailored to individual country need.nnnLEVEL OF EVIDENCEnLevel II (Ecological study).