The Impact of the Cosurgeon Model on Bilateral Autologous Breast Reconstruction

Background Microsurgical breast reconstructions (MBRs) are time and labor intensive procedures. To circumvent these barriers, plastic surgeons have started working together as cosurgeons (CSs). This study aims to evaluate the impact of the CS model (CSM) specifically on bilateral MBR. The hypothesis is that CS procedures reduce operative time and surgical complications. Study Design This was a single institutional retrospective cohort study, which included all consecutive patients who underwent bilateral MBR from 2014 to 2016. Patients were grouped into single surgeon (SS) or CSs based on the number of the attending plastic surgeons present. Demographic and clinical characteristics including age, body mass index, smoking, American Society of Anesthesiologist class, radiation, and the timing of the reconstruction were assessed. Univariate and multivariate analyses were performed for outcomes including operative time and postoperative complications. Results Of the 136 patients included in the study, 41% had breast reconstruction performed by CSs, whereas 59% had a SS. Sociodemographic features were evenly distributed with the exception of a greater number of delayed reconstructions in the SS group (33 vs. 13%; p <0.01). Pedicle TRAMS (transverse rectus abdominis musculocutaneous flaps) were performed in 5 versus 0% of SS versus CS cases, respectively. Rates of major (4 vs. 16%) and minor (11 vs. 24%) complications were significantly lower in CS procedures. Multivariate analyses demonstrated CS operations required significantly shorter operative time by 73 minutes (p <0.001), and trended toward a reduced postoperative complication rate (p = 0.07). Conclusion The CSM is associated with improved operative efficiency for bilateral MBR. Further evaluation of the CSM may prove useful in other surgical disciplines with time and labor intense procedures.

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Attending Surgeon Variation in Operative Case Length: An Opportunity for Quality Improvement

The American Surgeon ◽

10.1177/000313481808401011 ◽

2018 ◽

Vol 84 (10) ◽

pp. 1595-1599

Author(s):

Kirollos S. Malek ◽

Jukes P. Namm ◽

Carlos A. Garberoglio ◽

Maheswari Senthil ◽

Naveen Solomon ◽

...

Keyword(s):

Operative Time ◽

Resident Training ◽

Careful Consideration ◽

Analysis Of Covariance ◽

Surgical Resident ◽

Or Efficiency ◽

American Society ◽

Case Logs ◽

American Society Of Anesthesiologists ◽

The Impact

Balancing resident education with operating room (OR) efficiency, while accommodating different styles of surgical educators and learners, is a challenging task. We sought to evaluate variability in operative time for breast surgery cases. Accreditation Council for Graduate Medical Education case logs of breast operations from 2011 to 2017 for current surgical residents at Loma Linda University were correlated with patient records. The main outcome measure was operative time. Breast cases were assessed as these operations are performed during all postgraduate years (PGY). Breast procedures were grouped according to similarity. Variables analyzed included attending surgeon, PGY level, procedure type, month of operation, and American Society of Anesthesiologists class. Of 606 breast cases reviewed, median overall operative time was 150 minutes (interquartile range 187–927). One-way analysis of covariance demonstrated statistically significant variation in operative time by attending surgeon controlling for covariates (PGY level, procedure, American Society of Anesthesiologists class, and month) ( P = 0.04). With institutional OR costs of $30 per minute, the average difference between slowest and fastest surgeon was $2400 per case [(218–138) minutes 3 $30/min]. Minimizing variability for common procedures performed by surgical educators may enhance OR efficiency. However, the impact of case length on surgical resident training requires careful consideration.

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How Does Autologous Breast Reconstruction Impact Downtime?

Journal of Reconstructive Microsurgery ◽

10.1055/s-0038-1641711 ◽

2018 ◽

Vol 34 (07) ◽

pp. 530-536 ◽

Cited By ~ 3

Author(s):

Daniel Rais ◽

Jian Farhadi ◽

Giovanni Zoccali

Keyword(s):

Breast Reconstruction ◽

Donor Site ◽

Diep Flap ◽

Autologous Reconstruction ◽

Autologous Breast Reconstruction ◽

Superior Gluteal Artery ◽

Free Flap Surgery ◽

Recovery Times ◽

Time Required ◽

The Impact

Background Although autologous breast reconstruction is technically quite demanding, it offers the best outcomes in terms of durable results, patient perceptions, and postoperative pain. Many studies have focused on clinical outcomes and technical aspects of such procedures, but few have addressed the impact of various flaps on patient recovery times. This particular investigation entailed an assessment of commonly used flaps, examining the periods of time required to resume daily activities. Methods Multiple choice questionnaires were administered to 121 patients after recovery from autologous reconstruction to determine the times required in returning to specific physical activities. To analyze results, the analysis of variance F-test was applied, and odds ratios (ORs) were determined. Results Among the activities surveyed, recovery time was not always a function of free-flap surgery. Additional treatments and psychological effects also contributed. Adjuvant chemotherapy increased average downtime by 2 weeks, and postoperative irradiation prolonged recovery as much as 4 weeks. Patient downtime was unrelated to flap type, ranging from 2.9 to 21.3 weeks for various activities in question. Deep inferior epigastric perforator (DIEP) flaps yielded the highest OR and transverse upper gracilis (TUG) flaps the lowest. Conclusion Compared with superior gluteal artery perforator and TUG flaps, the DIEP flap was confirmed as the gold standard in autologous breast reconstruction, conferring the shortest recovery times. All adjuvant therapies served to prolong patient recovery as well. Surgical issues, patient lifestyles, and donor-site availability are other important aspects of flap selection.

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Identification of factors associated with morbidity and postoperative length of stay in surgically managed chronic subdural haematoma using electronic health records: a retrospective cohort study

BMJ Open ◽

10.1136/bmjopen-2020-037385 ◽

2020 ◽

Vol 10 (6) ◽

pp. e037385 ◽

Cited By ~ 1

Author(s):

Daniel J Stubbs ◽

Benjamin M Davies ◽

Tom Bashford ◽

Alexis J Joannides ◽

Peter J Hutchinson ◽

...

Keyword(s):

Retrospective Cohort ◽

Subdural Haematoma ◽

Postoperative Morbidity ◽

Operative Time ◽

Chronic Subdural Haematoma ◽

Electronic Health Record Data ◽

Postoperative Stay ◽

Intraoperative Management ◽

Electronic Health ◽

The Impact

IntroductionChronic subdural haematoma (cSDH) tends to occur in older patients, often with significant comorbidity. The incidence and effect of medical complications as well as the impact of intraoperative management strategies are now attracting increasing interest.ObjectivesWe used electronic health record data to study the profile of in-hospital morbidity and examine associations between various intraoperative events and postoperative stay.Design, setting and participantsSingle-centre, retrospective cohort of 530 cases of cSDH (2014–2019) surgically evacuated under general anaesthesia at a neurosciences centre in Cambridge, UK.Methods and outcome definitionComplications were defined using a modified Electronic Postoperative Morbidity Score. Association between complications and intraoperative care (time with mean arterial pressure <80 mm Hg, time outside of end-tidal carbon dioxide (ETCO2) range of 3–5 kPa, maintenance anaesthetic, operative time and opioid dose) on postoperative stay was assessed using Cox regression.Results53 (10%) patients suffered myocardial injury, while 24 (4.5%) suffered acute renal injury. On postoperative day 3 (D3), 280 (58% of remaining) inpatients suffered at least 1 complication. D7 rate was comparable (57%). Operative time was the only intraoperative event associated with postoperative stay (HR for discharge: 0.97 (95% CI: 0.95 to 0.99)). On multivariable analysis, postoperative complications (0.61 (0.55 to 0.68)), anticoagulation (0.45 (0.37 to 0.54)) and cognitive impairment (0.71 (0.58 to 0.87)) were associated with time to discharge.ConclusionsThere is a high postoperative morbidity burden in this cohort, which was associated with postoperative stay. We found no evidence of an association between intraoperative events and postoperative stay.

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The Impact of Autologous Breast Reconstruction on Body Mass Index Patterns in Breast Cancer Patients

Plastic & Reconstructive Surgery ◽

10.1097/prs.0000000000003841 ◽

2017 ◽

Vol 140 (6) ◽

pp. 1121-1131 ◽

Cited By ~ 3

Author(s):

Eugenia H. Cho ◽

Ronnie L. Shammas ◽

Adam D. Glener ◽

Rachel A. Greenup ◽

E. Shelley Hwang ◽

...

Keyword(s):

Breast Cancer ◽

Body Mass Index ◽

Breast Reconstruction ◽

Cancer Patients ◽

Body Mass ◽

Breast Cancer Patients ◽

Autologous Breast Reconstruction ◽

The Impact

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The impact of obesity on abdominal wall function after free autologous breast reconstruction

Microsurgery ◽

10.1002/micr.22218 ◽

2013 ◽

Vol 34 (5) ◽

pp. 352-360 ◽

Cited By ~ 7

Author(s):

Jonas A. Nelson ◽

John P. Fischer ◽

Chen Yan ◽

Joshua Fosnot ◽

Jesse C. Selber ◽

...

Keyword(s):

Breast Reconstruction ◽

Abdominal Wall ◽

Wall Function ◽

Autologous Breast Reconstruction ◽

The Impact ◽

Abdominal Wall Function

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The impact of complications on function, health, and satisfaction following abdominally based autologous breast reconstruction: A prospective evaluation

Journal of Plastic Reconstructive & Aesthetic Surgery ◽

10.1016/j.bjps.2014.01.017 ◽

2014 ◽

Vol 67 (5) ◽

pp. 682-692 ◽

Cited By ~ 19

Author(s):

Stephen M. Lu ◽

Jonas A. Nelson ◽

John P. Fischer ◽

Joshua Fosnot ◽

Jesse Goldstein ◽

...

Keyword(s):

Breast Reconstruction ◽

Prospective Evaluation ◽

Autologous Breast Reconstruction ◽

The Impact

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Cyclooxygenase-2 inhibitors and free flap complications after autologous breast reconstruction: A retrospective cohort study

Journal of Plastic Reconstructive & Aesthetic Surgery ◽

10.1016/j.bjps.2017.06.007 ◽

2017 ◽

Vol 70 (11) ◽

pp. 1543-1546 ◽

Cited By ~ 7

Author(s):

Christian Bonde ◽

Hoda Khorasani ◽

Jens Hoejvig ◽

Henrik Kehlet

Keyword(s):

Cohort Study ◽

Breast Reconstruction ◽

Free Flap ◽

Retrospective Cohort Study ◽

Retrospective Cohort ◽

Cyclooxygenase 2 ◽

Autologous Breast Reconstruction ◽

Cyclooxygenase 2 Inhibitors

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COLONOSCOPY COMPLICATIONS IN THE ELDERLY: the impact of age and multimorbidity

Arquivos de Gastroenterologia ◽

10.1590/s0004-28032013000400003 ◽

2013 ◽

Vol 50 (4) ◽

pp. 251-256

Author(s):

Francine de Cristo STEIN ◽

Naira Hossepian Salles de Lima HOJAIJ ◽

Jose Guilherme Nogueira da SILVA ◽

Luana Vilarinho BORGES ◽

Wilson JACOB-FILHO ◽

...

Keyword(s):

Bowel Preparation ◽

Retrospective Cohort ◽

Gastrointestinal Endoscopy ◽

Rating Scale ◽

Significant Risk ◽

The Elderly ◽

Primary Objective ◽

Charlson Index ◽

American Society ◽

The Impact

ContextAge has been considered an independent risk factor for colonoscopy complications, especially when associated with multimorbidity.ObjectivesThe primary objective was to verify the relationships between age, multimorbidity and colonoscopy complications in the elderly.MethodsA retrospective cohort including patients of 60 years or older who had undergone a colonoscopy. Data relating to age, multimorbidities according to the cumulative illness scale for geriatrics and the Charlson index and complications related to bowel preparation and procedure (sedation and exam) were collected.ResultsOf the 207 patients (mean age 70.47 ± 7.04) with appropriate indication for colonoscopy according to the American Society for Gastrointestinal Endoscopy, 43 (20.77%) patients had some colonoscopy complications: 1 (0.48%) with the sedation (apnea), 4 (1.93%) with the procedure (abdominal pain and bacteremia) and 38 (18.35%) with the bowel preparation (acute renal failure, hypotension). Individuals ≥80 years had an RR = 3.4 (1.2-10.1),P = 0.025, and those with a Charlson index 3 had an RR = 5.2 (1.6-16.8), P = 0.006, for complications. The cumulative illness rating scale for geriatrics was not associated with complications (P = 0.45).ConclusionThere was a significant risk of complications in ≥80 years and in the group with a Charlson index 3. The cumulative illness rating scale for geriatrics was not a good predictor of risk in this sample.

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Intraoperative Microvascular Complications in Autologous Breast Reconstruction: The Effects of Resident Training on Microsurgical Outcomes

Journal of Reconstructive Microsurgery ◽

10.1055/s-0040-1716404 ◽

2020 ◽

Author(s):

Sumeet S. Teotia ◽

Ryan M. Dickey ◽

Yulun Liu ◽

Avinash P. Jayaraman ◽

Nicholas T. Haddock

Keyword(s):

Breast Reconstruction ◽

Operative Time ◽

Microvascular Complications ◽

Autologous Reconstruction ◽

Autologous Breast Reconstruction ◽

Intraoperative Complication ◽

Total Operative Time ◽

Ischemia Time ◽

Flap Loss ◽

Artery Perforator

Abstract Background Academic medical centers with large volumes of autologous breast reconstruction afford residents hand-on educational experience in microsurgical techniques. We present our experience with autologous reconstruction (deep inferior epigastric perforators, profunda artery perforator, lumbar artery perforator, bipedicled, and stacked) where a supervised trainee completed the microvascular anastomosis. Methods Retrospective chart review was performed on 413 flaps (190 patients) with microvascular anastomoses performed by postgraduate year (PGY)-4, PGY-5, PGY-6, PGY-7 (microsurgery fellow), or attending physician (AP). Comorbidities, intra-operative complications, revisions, operative time, ischemia time, return to operating room (OR), and flap losses were compared between training levels. Results Age and all comorbidities were equivalent between groups. Total operative time was highest for the AP group. Flap ischemia time, return to OR, and intraoperative complication were equivalent between groups. Percentage of flaps requiring at least one revision of the original anastomosis was significantly higher in PGY-4 and AP than in microsurgical fellows: PGY-4 (16%), PGY-5 (12%), PGY-6 (7%), PGY-7 (2.1%), and AP (16%), p = 0.041. Rates of flap loss were equivalent between groups, with overall flap loss between all groups 2/413 (<1%). Conclusion With regard to flap loss and microsurgical vessel compromise, lower PGYs did not significantly worsen surgical outcomes for patients. AP had the longest total operative time, likely due to flap selection bias. PGY-4 and AP groups had higher rates of revision of original anastomosis compared with PGY-7, though ultimately these differences did not impact overall operative time, complication rate, or flap losses. Hands-on supervised microsurgical education appears to be both safe for patients, and also an effective way of building technical proficiency in plastic surgery residents.

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