Stratification of Surgical Risk in DIEP Breast Reconstruction Based on Classification of Obesity

Abstract Background From both a medical and surgical perspective, obese breast cancer patients are considered to possess higher risk when undergoing autologous breast reconstruction relative to nonobese patients. However, few studies have evaluated the continuum of risk across the full range of obesity. This study sought to compare surgical risk between the three World Health Organization (WHO) classes of obesity in patients undergoing deep inferior epigastric perforator (DIEP) flap breast reconstruction. Methods A retrospective review of 219 obese patients receiving 306 individual DIEP flaps was performed. Subjects were stratified into WHO obesity classes I (body mass index [BMI]: 30–34), II (BMI: 35–39), and III (BMI: ≥ 40) and assessed for risk factors and postoperative donor and recipient site complications. Results When examined together, the rate of any complication between the three groups only trended toward significance (p = 0.07), and there were no significant differences among rates of specific individual complications. However, logistic regression analysis showed that class III obesity was an independent risk factor for both flap (odds ratio [OR]: 1.71, 95% confidence interval [CI]: 0.91–3.20, p = 0.03) and donor site (OR: 2.34, 95% CI: 1.09–5.05, p = 0.03) complications. Conclusion DIEP breast reconstruction in the obese patient is more complex for both the patient and the surgeon. Although not a contraindication to undergoing surgery, obese patients should be diligently counseled regarding potential complications and undergo preoperative optimization of health parameters. Morbidly obese (class III) patients should be approached with additional caution, and perhaps even delay major reconstruction until specific BMI goals are met.

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Endovascular Bariatric Surgery as Novel Minimally Invasive Technique for Weight Management in the Morbidly Obese: Review of the Literature

Nutrients ◽

10.3390/nu13082541 ◽

2021 ◽

Vol 13 (8) ◽

pp. 2541

Author(s):

Giuseppe Massimo Sangiorgi ◽

Alberto Cereda ◽

Nicola Porchetta ◽

Daniela Benedetto ◽

Andrea Matteucci ◽

...

Keyword(s):

Bariatric Surgery ◽

Minimally Invasive ◽

Weight Management ◽

World Health ◽

Invasive Technique ◽

Morbidly Obese ◽

World Population ◽

Obese Patients ◽

The World ◽

Open Bariatric Surgery

Nowadays, obesity represents one of the most unresolved global pandemics, posing a critical health issue in developed countries. According to the World Health Organization, its prevalence has tripled since 1975, reaching a prevalence of 13% of the world population in 2016. Indeed, as obesity increases worldwide, novel strategies to fight this condition are of the utmost importance to reduce obese-related morbidity and overall mortality related to its complications. Early experimental and initial clinical data have suggested that endovascular bariatric surgery (EBS) may be a promising technique to reduce weight and hormonal imbalance in the obese population. Compared to open bariatric surgery and minimally invasive surgery (MIS), EBS is much less invasive, well tolerated, with a shorter recovery time, and is probably cost-saving. However, there are still several technical aspects to investigate before EBS can be routinely offered to all obese patients. Further prospective studies and eventually a randomized trial comparing open bariatric surgery vs. EBS are needed, powered for clinically relevant outcomes, and with adequate follow-up. Yet, EBS may already appear as an appealing alternative treatment for weight management and cardiovascular prevention in morbidly obese patients at high surgical risk.

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Impact of weight on stone-free rate during percutaneous nephrolithotomy

African Journal of Urology ◽

10.1186/s12301-020-00071-4 ◽

2020 ◽

Vol 26 (1) ◽

Author(s):

Abdrabuh M. Abdrabuh

Keyword(s):

Percutaneous Nephrolithotomy ◽

Operative Procedure ◽

World Health ◽

Fluoroscopy Time ◽

Morbidly Obese ◽

Obese Patients ◽

Co Morbidity ◽

Stone Free Rate ◽

Morbid Obese ◽

Free Rate

Abstract Background To assess Impact of weight on stone-free rate during percutaneous nephrolithotomy. Methods Hundred and twenty-three PNL procedures were done between January 2016 and July 2017. The patients were divided into four groups according to the World Health Organization (WHO) classification of body mass index (BMI): < 25 ((group 1, average)), 25–29.9 (group 2, overweight), 30–39.9 (group 3, obese), and ≥ 40 kg/m2 (group 4, morbidly obese). All groups were compared as regarding preoperative variables, intra-operative procedure and postoperative results. Results The non-obese groups were younger in age than obese and morbid obese groups (P = 0.005). The difference in BMI was statistically significant between non-obese and obese groups (P = 0.0001). Most of females gender were obese and morbid obese (P = 0.0001) and most of the obese patients had left-sided renal stone (P = 0.001). Most of overweight and obese groups had radiopaque stones (P = 0.02). There were no statistically significant differences between all groups as regarding co-morbidity, stone size, stone locations, and hydronephrosis grade. Operative time (P = 0.034), length of hospital stay (P value = 0.014) and fluoroscopy time (P = 0.0001) were statistically significant differences between all groups. Number of accesses, access site, postoperative hemoglobin drop, post- operative complications, fate of residual stones and stone-free rate were not statistically significant differences between all groups. BMI was correlated with mean fluoroscopy time and mean hospitalization duration in our study as the time of hospitalization and time of x-ray exposure increase with obesity. Conclusion PNL is a safe and effective procedure for obese patients. BMI do not predict clearance post PNL.

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Increase of major complications with a longer ischemia time in breast reconstruction with a free deep inferior epigastric perforator (DIEP) flap

European Journal of Plastic Surgery ◽

10.1007/s00238-019-01584-0 ◽

2019 ◽

Vol 43 (2) ◽

pp. 133-138

Author(s):

Nadine S. Hillberg ◽

Jop Beugels ◽

Sander M. J. van Kuijk ◽

René R. J. W. van der Hulst ◽

Stefania M. H. Tuinder

Keyword(s):

Breast Reconstruction ◽

Medical Center ◽

Major Complication ◽

P Value ◽

Diep Flap ◽

Level Of Evidence ◽

Recipient Site ◽

Ischemia Time ◽

Flap Loss ◽

Major Complications

Abstract Background The deep inferior epigastric artery perforator (DIEP) flap is one of the most used free flaps for postmastectomy breast reconstruction. Prolonged ischemia can result in (partial) flap loss. The aim of this study was to evaluate the association between ischemia time and postoperative complications of DIEP flap breast reconstruction. Methods A retrospective study of all patients who received a breast reconstructionwith aDIEP flap atMaastricht University Medical Center in theNetherlands, between January 2010 and June 2017 (n = 677). The flaps were divided into two groups: flaps with an ischemia time less than 60 min and those with 60 min or more. Recipient site complications, in particular major complications equal to re-exploration, and partial or total flap loss were the primary outcome measures. Results In 23.9% of the 677 included DIEP flaps, the ischemia time was 60 min or longer. Within this group, a complication of the recipient site occurred in 30.9% of the flaps. A major complication occurred in 17.3% of the flaps with 60 min or more ischemia time.With regard to the flaps with less than 60-min ischemia time, a complication occurred in 22.1% of the cases of which 8.9%would be considered amajor complication. A significant association was found between ischemia time and major complications on univariate (p value = 0.003) and multivariate analyses (p value = 0.016). Conclusions This study demonstrates that an ischemia time less than 60 min is associated with a significantly lower risk of major recipient site complications compared to an ischemia time of 60 min or more. Level of evidence: Level III, therapeutic, risk/prognostic study.

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Refractory Donor-Site Seroma Following DIEP Breast Reconstruction

Plastic Surgery Case Studies ◽

10.1177/2513826x19898831 ◽

2020 ◽

Vol 6 ◽

pp. 2513826X1989883

Author(s):

Trina V. Stephens ◽

Nancy Van Laeken ◽

Sheina A. Macadam

Keyword(s):

Literature Review ◽

Breast Reconstruction ◽

Donor Site ◽

Diep Flap ◽

First Line ◽

Percutaneous Aspiration ◽

Autologous Breast Reconstruction ◽

History Of ◽

Deep Inferior Epigastric Perforator ◽

Latissimus Dorsi Flaps

Donor-site seroma formation is a complication of autologous breast reconstruction reported most commonly with the use of latissimus dorsi flaps. First-line treatment is percutaneous aspiration which leads to resolution in the majority of cases. Those that persist may progress to a chronic, refractory seroma, which can prove challenging in terms of treatment. The aim of this article is to provide an updated literature review of interventions for chronic donor-site seroma and present the case of a 65-year-old female with a recalcitrant abdominal seroma following deep inferior epigastric perforator (DIEP) flap breast reconstruction. Literature review revealed a single article that reported 2 cases of persistent donor-site seroma after DIEP flap breast reconstruction. The patient presented here underwent repeat aspiration, drain placement, and multiple surgical procedures to achieve resolution. In total, the post-reconstruction seroma history of the patient extended over approximately 14 months. We conclude with evidence-based suggestions for chronic, donor-site seroma prevention and treatment.

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Alternative flaps for microsurgical breast reconstruction

10.1093/med/9780199682874.003.0093 ◽

2021 ◽

pp. 1107-1114

Author(s):

Hinne A. Rakhorst

Keyword(s):

Breast Reconstruction ◽

Standard Care ◽

Donor Site ◽

Perforator Flap ◽

Donor Site Morbidity ◽

The Body ◽

Diep Flap ◽

Deep Inferior Epigastric Perforator ◽

Muscle Sparing ◽

Breast Reconstructive Surgery

Microsurgery in general has made dramatic improvements over the past decades. This applies to microsurgery in general and to breast reconstructive surgery especially. The demand for autologous breast reconstruction has risen. Since the introduction of the free transverse rectus abdominis myocutaneous (TRAM) flaps, through the muscle-sparing TRAM, flaps designs have evolved into the current gold standard, the deep inferior epigastric perforator (DIEP) flap. From experiences and increasing numbers of flap procedures performed by surgeons, techniques became more familiar and part of standard care. These factors gave rise to the development of a growing number of areas of the body where tissues of interest can be harvested using perforator flap-based techniques. This chapter discusses the most common as well as the ‘rising stars’ in terms of flaps to be used as alternative flaps to the DIEP flap for breast reconstruction. It discusses practical issues on dissection as well as donor site morbidity.

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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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1260 High Tidal Volume Non-invasive Ventilation Required to Treat Obesity Hypoventilation

SLEEP ◽

10.1093/sleep/zsaa056.1254 ◽

2020 ◽

Vol 43 (Supplement_1) ◽

pp. A479-A480

Author(s):

Talayeh Rezayat ◽

Abigail Beggs ◽

Alon Y Avidan ◽

Shahrokh Javaheri

Keyword(s):

Tidal Volume ◽

Upper Airway ◽

Morbidly Obese ◽

Obese Patients ◽

Invasive Ventilation ◽

Class Iii ◽

Non Invasive ◽

Non Invasive Ventilation ◽

Patient Reported ◽

Obesity Hypoventilation

Abstract Introduction Current guidelines recommend CPAP or non-invasive ventilation with tidal volume (VT) <10ml/kg of ideal body weight (IBW) for the treatment of obesity hypoventilation. However, in select patients with significant obesity hypoventilation, this recommendation may not be sufficient to resolve nocturnal hypoventilation. Report of Case A 35 y/o male with hypertension and class III obesity (BMI 58 kg/m2) was referred for evaluation of acute respiratory failure with hypoxia and hypercapnia. ABG demonstrated daytime PCO2 of 71 mmHg. Patient reported sleep fragmentation, snoring, choke awakenings, poor concentration, depression and sleep attacks. PSG demonstrated severe OSA, with an AHI of 154 events/hour, persistent hypoxia and hypercapnia with a SpO2 nadir of 50% and ET-CO2 of 83 mmHg during REM sleep. Respiratory events persisted with CPAP and bilevel, up to a setting of 25/16. Average volume assured pressure support (AVAPS) S/T titration study was performed and resolved sleep apnea at settings of IPAP 24-30, EPAP 4-15, VT 790 (10 mL/kg IBW), 0.5 LPM O2, rate 16. The patient reported having had the best sleep of his life at the end of this study and has since been started on treatment. Conclusion Treatment of OHS should be individualized and may require use of tidal volumes above 10ml/kg for effective treatment. We suggest that in super morbidly obese patients, with extremely noncompliant respiratory system, larger than recommended tidal volume is necessary to ventilate the patient and improve gas exchange. The sustained higher pressures achieved by AVAPS to impose the augmented tidal volume more effectively ameliorate OSA, by keeping the upper airway open. Higher pressures achieved also could elevate FRC, not only increasing oxygen stores, but also contributing to maintenance of open upper airway through its tethering effect. Further physiological studies are needed in super morbidly obese patients comparing low and high tidal volumes.

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