Medicine Matters: Special Considerations For Sglt2 Inhibitors And Prolonged Nothing Per Os Status Following Free Flap Surgery (Preprint)

UNSTRUCTURED A 59-year-old female patient undergoing deep inferior epigastric perforator flap surgery for autologous breast reconstruction became acutely ill with tachypnea, nausea, and vomiting on post-operative day three. A work-up elucidated a diagnosis of diabetic ketoacidosis (DKA) with lower-than-expected glucose levels as a result of recent semaglutide use. She required intensive care unit resuscitation with an insulin drip and glucose administration. Sodium-glucose cotransporter-2 inhibitors (SGLT2i) are a class of oral anti-hyperglycemic agents used for the treatment of type II diabetes (DMII). As the use of these medications become more prevalent, surgeons must be educated of this serious complication and plan for patient management in advance of minor and major surgeries.

Observations from Implementation of the ERAS Protocol after DIEP Flap Breast Reconstruction

Background The Enhanced Recovery After Surgery (ERAS) protocol is a multivariate intervention requiring the help of several departments, including anesthesia, nursing, and surgery. This study seeks to observe ERAS compliance rates and obstacles for its implementation at a single academic institution. Methods This is a retrospective study looking at patients who underwent deep inferior epigastric perforator (DIEP) flap breast reconstruction from January 2016 to September 2019. The ERAS protocol was implemented on select patients early 2017, with patients from 2016 acting as a control. Thirteen points from the protocol were identified and gathered from the patient's electronic medical record (EMR) to evaluate compliance. Results Two hundred and six patients were eligible for the study, with 67 on the control group. An average of 6.97 components were met in the pre-ERAS group. This number rose to 8.33 by the end of 2017. Compliance peaked with 10.53 components met at the beginning of 2019. The interventions most responsible for this increase were administration of preoperative medications, goal-oriented intraoperative fluid management, and administration of scheduled gabapentin postoperatively. The least met criterion was intraoperative ketamine goal of >0.2 mg/kg/h, with a maximum compliance rate of 8.69% of the time. Conclusion The introduction of new protocols can take over a year for full implementation. This is especially true for protocols as complex as an ERAS pathway. Even after years of consistent use, compliance gaps remain. Staff-, patient-, or resource-related issues are responsible for these discrepancies. It is important to identify these issues to address them and optimize patient outcomes.

Management of Postsurgical Pyoderma Gangrenosum Following Deep Inferior Epigastric Perforator Flap Breast Reconstruction: A Role for a Dermal Regeneration Template

Introduction. Pyoderma gangrenosum (PG) is a relatively uncommon necrotizing and ulcerative cutaneous disorder. It is often associated with a systemic inflammatory disease but may also present following trauma to the skin due to pathergy. Given its rare occurrence and nonspecific histology, PG is primarily a diagnosis of exclusion, which often results in delayed treatment. Very few cases of PG following autologous breast reconstruction have been reported in the literature, particularly in the absence of systemic disease. Case Report. Presented is the case of a 62-year-old female with a history of ductal carcinoma in situ who underwent a left breast mastectomy with immediate deep inferior epigastric perforator flap breast reconstruction complicated by fever and leukocytosis as well as erythema, edema, and bullae involving the mastectomy flaps. Initially, necrotizing soft-tissue infection was suspected, and 2 debridements were performed. A diagnosis of PG was made on postoperative day 7, and the patient responded favorably to high-dose prednisone. Reconstruction was performed with a bilayer wound matrix and delayed skin grafting. Despite significant loss of mastectomy skin flap, the free flap was preserved. Conclusions. Although PG is a rare complication, it should be considered in the differential diagnosis for patients with atypical presentation of infection following breast reconstruction, even in the absence of systemic inflammatory disease. Early diagnosis and multidisciplinary management may prevent unnecessary surgical intervention and enable flap preservation. Furthermore, bilayer wound matrix placement may be useful as an intermediate reconstruction to determine if it is safe to proceed with skin grafting to avoid further pathergy. The findings in this case suggest that final reconstruction may be safely performed sooner than noted in the literature.

ĐẶC ĐIỂM GIẢI PHẪU LÂM SÀNG VẠT D.I.E.P TRONG TẠO HÌNH VÚ SAU CẮT BỎ TUYẾN VÚ DO UNG THƯ

Mục tiêu: Mô tả các đặc điểm giải phẫu lâm sàng vạt mạch xuyên động mạch thượng vị sâu dưới (D.I.E.P: Deep Inferior Epigastric Perforator Flap) trong tạo hình vú sau cắt bỏ toàn bộ tuyến vú do ung thư. Phương pháp nghiên cứu: Nghiên cứu mô tả trên 29 bệnh nhân được phẫu thuật tạo hình vú sử dụng vạt D.I.E.P tại Bệnh viện Đại học Y Hà Nội từ 08/2019 tới 05/2021. Kết quả: Kích thước vạt phẫu tích trung bình dài 35,0 ± 4,33 cm, rộng 12,41 ± 1,9 cm. Thể tích vạt phẫu tích trung bình 573,62 ± 130,39 ml, thể tích vạt sử dụng trung bình 408,97 ± 111,27 ml (thấp nhất là 240 ml, lớn nhất là 750 ml). Thể tích vạt sử dụng tạo hình lớn hơn thể tích vú cắt bỏ trung bình 10,02 ± 7,4%. Số lượng mạch xuyên sử dụng trung bình 1,97 ± 0,5 mạch xuyên/ vạt. 100% trường hợp vạt có ít nhất 1 mạch xuyên lớn ở trong đường tròn bán kính 5 cm với tâm là rốn. Chiều dài cuống mạch trung bình là 8,95 ± 1,69cm. Kết luận: Vạt D.I.E.P là chất liệu phù hợp và đáng tin cậy với những ưu điểm về giải phẫu hằng định, cuống mạch dài và cấp máu an toàn, kích thước và thể tích vạt phù hợp với tạo hình vú.