Non-reconstructive Breast Surgery Research Articles

The Use of Medicinal Leeching in Breast Surgery: A Systematic Review.

Background: The medicinal leech has been used in plastic surgery to resolve venous congestion that can threaten the viability of tissue transfer. Within the context of breast surgery, venous congestion is a pertinent consideration for reconstructive and non-reconstructive breast surgery such as mammoplasty and mastopexy. However, leeching is closely associated with complications such as infection, pain, and anaemia. This is the first systematic review that examines the methodology, efficacy, and post therapeutic outcome data across all existing studies on medicinal leeching in breast surgery. Methods: A systematic search of PubMed and Embase databases from their inception to November 2023 was conducted. Inclusion criteria included studies reporting on the use of leeches to resolve venous congestion in any breast surgery. The JBI Critical Appraisal Checklist for Case Series tool was used for bias analysis. Descriptive statistics were undertaken in Microsoft Excel. Results: A total of 18 studies with a combined sample size of 28 were examined, including 4 case series and 14 case reports. Patients mostly underwent reconstructive breast surgery (75%). The median number of leeches used was two, with a median number of three leeching sessions per day and 3 days of leeching. Medicinal leeching successfully prevented the loss of 75% of all tissue transfers. The complication rate was high at 81.14% and mainly included infection and anaemia. Conclusions: Medicinal leeching is an effective method to relieve venous congestion in breast surgery but must be judiciously used within the clinical context of the patient to maximise efficacy and mitigate harm from complications.

Do we need antibiotic prophylaxis in non-reconstructive breast surgery?

IntroductionBreast surgery is a clean surgery with variation in the reported incidence of surgical site infection (SSI) (2% to 38%) which in higher than expected in a clean surgery. Due to a higher reported incidence of SSI, there are variable protocols regarding the usage of antibiotics. Therefore, the objective of this study was to compare the incidence of infection after breast surgery with or without use of perioperative antibiotics.MethodsThis prospective study included 68 patients who underwent non reconstructive elective breast surgery and were randomized equally into two groups who received or who did not receive perioperative antibiotics. Demographic profile and factors which increase the incidence of SSI were recorded. All patients were followed until the wound healing was complete. SSI was diagnosed based on CDC criteria and wounds were graded according to Southampton wound score.ResultsMean age, etiology of breast lesions, presence of risk factors and duration of drain kept was comparable among groups. No patient developed SSI in either group according to CDC criteria and developed only minor complications according to Southampton wound score (p > 0.05). In addition there was no significant interaction on two way mixed models ANOVA between use of antibiotics and on wound healing (p 0.101).ConclusionsThis study highlights that wound healing is not dependant on the use of perioperative antibiotics. Therefore, rational and effective use of antimicrobial agents for the prevention of SSI in clean breast surgeries will decrease the development of antibiotics related complications, antibiotic resistance and the cost of treatment.

Prospective, randomized comparative study of ultrasound-guided blocking of the lateral cutaneous branches of the intercostal nerves versus conventional analgesia in non-reconstructive breast surgery

Abstract Objective The objective of this study is to determine whether the accomplishment of an interfascial blockade, the blocking of the cutaneous branches of the intercostals nerves in the axillary line (BRILMA) associated with a multimodal analgesic regimen improves post-operative analgesia and allows saving opioids after non-reconstructive surgery of breast. Material and methods A prospective, randomized and simple blind study was conducted on patients that underwent non-reconstructive breast surgery. The patients were randomly assigned to the blocking group, or to the standard post-operative analgesia group (paracetamol and dexketoprofen). The main variables analysed were the pain intensity assessed by the verbal numerical scale and the analgesic rescue needs with tramadol. Results Statistically significant differences were observed in the consumption of tramadol during the study period (10.5 mg in the BRILMA group, compared to 34.3 in the control group, p = .0001). There were also differences in the pain assessment, with lower values found in the BRILMA group. Conclusions In non-reconstructive breast surgery, performing a BRILMA block allows obtaining lower pain scores, which implies less need for rescue analgesics and a significant saving of tramadol in the study period.

Estudio prospectivo, aleatorizado comparativo entre el bloqueo guiado por ultrasonidos de las ramas cutáneas laterales de los nervios intercostales frente a analgesia convencional en cirugía no reconstructiva de mama

ObjectiveThe objective of this study is to determine whether the accomplishment of an interfascial blockade, the blocking of the cutaneous branches of the intercostal nerves in the axillary line (BRILMA) associated with a multimodal analgesic regimen improves post-operative analgesia and allows saving opioids after non-reconstructive surgery of breast. Material and methodsA prospective, randomised and simple blind study was conducted on patients that underwent non-reconstructive breast surgery. The patients were randomly assigned to the blocking group, or to the standard post-operative analgesia group (paracetamol and dexketoprofen). The main variables analysed were the pain intensity assessed by the verbal numerical scale and the analgesic rescue needs with tramadol. ResultsStatistically significant differences were observed in the consumption of tramadol during the study period (10.5mg in the BRILMA group, compared to 34.3 in the control group, P=.0001). There were also differences in the pain assessment, with lower values found in the BRILMA group. ConclusionsIn non-reconstructive breast surgery, performing a BRILMA block allows obtaining lower pain scores, which implies less need for rescue analgesics and a significant saving of tramadol in the study period.

Serratus-intercostal interfascial block as an opioid-saving strategy in supra-umbilical open surgery

Abstract Introduction The administration of local anaesthetic in the serratus-intercostal space provides adequate analgesia in non-reconstructive breast surgery. The aim of this study was to evaluate whether the blockage of the last intercostal nerves (T7–T11) can lead to opioid savings in supra-umbilical open surgery procedures. Material and methods A prospective observational study was conducted on patients undergoing open supra-umbilical surgery under general anaesthesia and with a serratus-intercostal plane block [modified Blocking the bRanches of IntercostaL nerves in the Middle Axillary line (BRILMA)] as an associated analgesic strategy. Post-operative pain was assessed with the numerical verbal scale (NVS 0–10) on admission to the post-anaesthesia recovery unit, at 6, 12, 24, and 48 h post-intervention and by need for analgesic rescues with opioids (2 mg iv of morphine, if values higher than 3 in NVS). Adverse events related to the technique were also recorded. The statistical package used in the analysis of the data was SPSS® for Windows. Results The study recruited 52 patients. Differences, with a p Conclusion The intercostal nerves block (T7–T11) in the serratus-intercostal space may constitute an opioid-sparing analgesic strategy in open supra-umbilical surgery.

Ultrasound-guided pectoral nerve blocks versus serratus intercostal plane block in breast surgeries

Introduction Analgesia in breast surgeries can be delivered orally, intravenously, intramuscularly, neuroaxially, or using regional nerve blocks. Pectoral nerve block (Pecs) and serratus intercostal plane block (SIPB) are a recently introduced ultrasound-guided technique for providing intraoperative and postoperative analgesia. Aim The aim of the present study was to compare intraoperative and postoperative analgesic effect of Pecs versus SIPB in breast surgeries. Patients and methods The current study was carried out on 60 female patients of American Society of Anaesthesiologists class I or II. The patients were undergoing nonreconstructive breast surgery. The patients were randomly divided into two equal groups. The Pecs group included 30 patients who received ultrasound-guided Pecs with 40 ml of levobupivacaine with adrenaline 1 : 200 000. The SIPB group included 30 patients who received ultrasound-guided SIPB with 40 ml of levobupivacaine with adrenaline 1 : 200 000. After assessing the efficacy of the block using sensory block scale, standard general anesthesia was induced in both groups using intravenous fentanyl (1 µg/kg), propofol (2.5 mg/kg) and cisatracurium (0.15 mg/kg). Results The completion of block was significant shorter in SIPB group than Pecs group. The duration of paresthesia in the SIPB group extended to 8 h postoperatively, whereas in the Pecs group the duration extended to 3 h postoperatively. Visual analog scale at rest and in movement was significantly higher in the Pecs group compared with the SIPB group. The number of patients who received postoperative fentanyl was significantly increased in the Pecs group than in the SIPB group. The first request for postoperative fentanyl was significantly delayed in the SIPB group than in the Pecs group. There was no significant difference in the total dose of fentanyl consumption during 24 h postoperatively between the two groups. Conclusion The present study found that SIPB provided superior postoperative analgesia compared with Pecs in patients undergoing nonreconstructive breast surgeries.

Abstract P1-11-09: The impact of a change in margin width on rates of re-excision following breast conserving surgery

Abstract Background: Surgical margin status is a predictor of ipsilateral breast tumor recurrence but the definition of an adequate surgical margin following breast conserving surgery (BCS) remains controversial despite published recommendations for acceptance of 'no tumor at ink'. BCS can be compromised by the need for a re-excision procedure which incurs inconvenience to patients and additional healthcare costs. We have previously shown that reducing the margin mandate from 5mm to 2mm does not influence rates of re-excision and the impact of adopting a more stringent margin policy of 'no tumor at ink' is now reported. Methods:A retrospective analysis examined rates of re-excision amongst patients undergoing BCS for both invasive carcinoma with or without admixed ductal carcinoma in situ (DCIS) or pure DCIS over two sequential 12 month time periods either prior to (GROUP 1; n=225) or immediately following (GROUP 2; n=238) a change in minimum margin policy from 2mm to 'no tumor at ink' when the latter was deemed an adequate definition of a negative margin. A total of 611 patients underwent non-reconstructive breast surgery for symptomatic and screen-detected cancers during these time periods among whom 463 received BCS. Wire-localization was undertaken in 51% (114/225) and 42% (101/238) of patients in groups 1 and 2 respectively. Data was extracted from electronic patient records of histopathology reports and clinic letters with further information available from documentation of MDT discussions. Statistical analysis used Fisher-Exact test. Results: Rates of re-excision were significantly lower for group 2 (32/238=13%) compared with group 1 48/225=21%). Re-excision encompassed cavity re-excision alone, cavity re-excision followed by mastectomy and completion mastectomy. Residual disease in re-excision specimens was significantly higher for group 2 (40.6%) compared with group 1 (16.6%) [p=0.02] with more than one-third of cases of residual disease in group 2 being exclusively DCIS. Three patients in each group required 2 additional operations to achieve negative margins. For groups 1 and 2, three-quarters or more cases (87% and 77% respectively) had only 1 or two margins positive and 2 cases in group 2 were re-excised for reasons other than a positive margin (e.g. tumor type). For group 1, re-excision cases were prompted by margin categories of 0mm (n=22), <1mm (n=18) and ≥1mm; <2mm (n=8) whilst for group 2 all re-excisions were prompted by tumor at ink (0mm). A hypothetical minimum margin of 1mm would have reduced the re-excision rate for group 1 to 40/225 or 17.7%. Conclusion: Re-excision was usually prompted by margins of <2mm when a 5mm margin policy prevailed. A more relaxed margin mandate of 'no tumor at ink' has led to halving of re-excision rates from 21% to 13% as opposed to 17.7% for a minimum margin of 1mm. This reduction in rates of re-excision is accompanied by an increase in the proportion of cases with residual disease in re-operation specimens. Longer-term follow up is essential to monitor in-breast local recurrence. Citation Format: Jiwa NE, Ayyar S, Provenzano E, Benson JR. The impact of a change in margin width on rates of re-excision following breast conserving surgery [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P1-11-09.

Quality of postoperative recovery after breast surgery. General anaesthesia combined with paravertebral versus serratus-intercostal block

IntroductionThe quality of postoperative recovery is one of the most important among all the quality indicators used in clinical situations. This is even more important after cancer surgery. Our aim was to evaluate this after non-reconstructive breast surgery under general anaesthesia and paravertebral blockade or serratus–intercostal plane blockade, in the early and late post-operative period. Material and methodsA prospective observational study was conducted on 60 patients (25 paravertebral blockade group and 35 serratus–intercostal plane blockade group) scheduled for non-reconstructive breast surgery during a 6 month period. Every patient received general anaesthesia and were randomised to receive either paravertebral blockade or serratus–intercostal plane blockade. The quality of post-anaesthetic recovery was quantified by Postoperative Quality Recovery Scale, which is used to assess physiological, nociceptive, emotional, autonomy, cognitive and general state domains at different times: baseline (before surgery), 15min after the end of surgery, at discharge to home, and one month after surgery. ResultsA total recovery of 95.93% was achieved in the early postoperative period (15min PACU), 99.07% at discharge to home, and 99.25% at one month after the intervention. No significant differences were found between groups in total score or in each evaluated area. ConclusionsA progressive improvement was observed in the scores assessed with the Postoperative Quality Recovery Scale, reaching values that would allow the discharge to home and early return to usual active life from the immediate postoperative period, with no significant differences between the 2 analgesic techniques. Savings in opioid use and the excellent recovery were observed in all measured domains observed.

Calidad de la recuperación posquirúrgica tras cirugía de mama. Anestesia general combinada con bloqueo paravertebral versus bloqueo del espacio serrato-intercostal

IntroductionThe quality of postoperative recovery is one of the most important among all the quality indicators used in clinical situations. This is even more important after cancer surgery. Our aim was to evaluate this after non-reconstructive breast surgery under general anesthesia and paravertebral blockade or serratus-intercostal plane blockade, in the early and late post-operative period. Material and methodsA prospective observational study was conducted on 60 patients (25 paravertebral blockade group and 35 serratus-intercostal plane blockade group) scheduled for non-reconstructive breast surgery during a 6 month period. Every patient received general anaesthesia and were randomised to receive either paravertebral blockade or serratus-intercostal plane blockade. The quality of post-anaesthetic recovery was quantified by Postoperative Quality Recovery Scale, which is used to assess physiological, nociceptive, emotional, autonomy, cognitive and general state domains at different times: baseline (before surgery), 15min after the end of surgery, at discharge to home, and one month after surgery. ResultsA total recovery of 95.93% was achieved in the early postoperative period (15min PACU), 99.07% at discharge to home, and 99.25% at one month after the intervention. No significant differences were found between groups in total score or in each evaluated area. ConclusionsA progressive improvement was observed in the scores assessed with the Postoperative Quality Recovery Scale, reaching values that would allow the discharge to home and early return to usual active life from the immediate postoperative period, with no significant differences between the 2 analgesic techniques. Savings in opioid use and the excellent recovery were observed in all measured domains observed.

Day surgery for non-reconstructive breast surgery – Audit and patient satisfaction survey

Day surgery for non-reconstructive breast surgery – Audit and patient satisfaction survey

P112. Optimising the enhanced recovery programme at Royal Bolton Hospital for non-reconstructive breast surgery

Introduction: Primary endocrine therapy (PET) is used in breast cancer, for patients deemed unsuitable for surgery due to co-morbidities or frailty. A review of the first 12 months of a nurse-led primary endocrine clinic was performed to determine whether the clinic was effective and whether referrals and patient selection was appropriate. To determine frailty, the Vulnerable Elders score (VES-13), a short frailty-screening tool, was used for new referrals. Methods: Patients currently on PET were identified from a prospectively collected database, including those who began treatment prior to the initiation of the clinic and VES-13 scoring. Demographics and treatment information including duration, therapeutic agent, changes in treatment, VES-13 score and discharge to GP, was determined from patient records. Missing information was sought from the patient’s GP. Results: 128 patients were identified; 49 patients previously on PETand 79 new patients. Average age was 83 and 82 years respectively. 62.0% had a VES-13 score recorded. 91.8%were deemed frail (VES-13>3). 94.0%were on aromatase inhibitors with an average treatment duration of 2.4 years. 15.7% had treatment agent changed and 10.1%were referred for other treatment. Mortality was 11.8%. 11.0% were discharged to the GP. Conclusion: These results demonstrate that a nurse-led clinic for PET is effective and patients were appropriately selected. It highlighted the difficulty of implementing a screening tool as well as areas for improvement. Development of the service includes involvement of geriatric services with cognitive assessment as well as the safe discharge of patients on PET to the community.

Abordaje guiado por ultrasonidos de los nervios intercostales en la línea media axilar para cirugía de mama no reconstructiva y de la axila

IntroductionSeveral nerve blocks have recently been used for pain treatment in breast surgery. The main objective of our study was to determine the efficacy and safety of ultrasound-assisted blocking of the anterior and lateral cutaneous branches of the intercostal nerves in the mid-axillary line for non-reconstructive breast and axilla surgery. Material and methodsA prospective observational study was conducted on 30 patients scheduled for non-reconstructive breast and axilla surgery. An intercostal branches block was performed in the mid-axillary line with 0,5% levobupivacaine (3ml in each intercostal space). Clinical efficacy was assessed by standard intraoperative hemodynamic response to surgical stimulus and the need for opioids, and in the postoperative period, by assessing pain intensity as a verbal numerical scale and the need for rescue treatment. We also evaluated the quality of sleep the first night after surgery, any adverse events that occurred, and the satisfaction of patients and surgeons with the anesthetic technique. ResultsThe intercostal branches block in the mid-axillary line was effective in most cases, with only 2 patients requiring intraoperative opioids, and in one case analgesic rescue was necessary in the postoperative period. The duration of postoperative analgesia was 19±4h. There were no notable adverse events or complications. The satisfaction with the chosen technique was assessed as «very good» in all patients, and by 97% of the surgeons. ConclusionsIntercostal branches block in the mid-axillary line provides adequate intraoperative and postoperative analgesia for non-reconstructive breast and axilla surgery. It is a simple, reproducible technique in most patients of this study, with an easy to understand ultrasound anatomy, in which adequate analgesia could be provided through a single puncture, and may be an alternative to neuroaxial blocks.

‘23 h Model’ for breast surgery: An early experience

The principles of fast track surgery are well established in colorectal surgery. It is an evidence based model aimed at reducing length of stay, convalescence and morbidity by optimising both clinical and organisational factors. Despite this, the implementation of fast track surgery in breast cancer patients has been slow.The 23 h discharge model for breast cancer surgery patients has been outlined by the NHS Improvement Programme and is a breakthrough from traditional inpatient care. This paper outlines the early experience of implementation of this model in a single institution during a 3-month audit period. Over 80% of patients undergoing non-reconstructive breast surgery were discharged safely within ‘23 h’. This suggests that good communication links, reorganisation of existing resources, active user involvement (both patients and clinical team) and strong project management ensures fast-tracking to be safe for the patient with significant economic benefits for the hospital.

Commentary on: A Multi-Institutional Perspective of Complication Rates for Elective Nonreconstructive Breast Surgery: An Analysis of NSQIP Data From 2006 to 2010

I commend the authors for performing a unique epidemiological study of surgical outcomes in the elective breast surgery population. This study represents an innovative approach using the National Surgical Quality Improvement Program (NSQIP) database to evaluate surgical outcomes across different providers and a variety of health systems. Large database analyses are important benchmarking techniques to provide general information on surgical outcomes that are not specific to one particular surgeon or technique. This type of epidemiological study gives greater insight into what is most effective, not just efficacious, under real-world conditions that are usually less than ideal. Difficulties arise when attempting to use large administrative or claims-based databases to evaluate surgical outcomes in plastic surgery as often the data of interest are not collected or collected in the wrong patient population. For example, many databases are claims based and therefore …

A Multi-Institutional Perspective of Complication Rates for Elective Nonreconstructive Breast Surgery: An Analysis of NSQIP Data From 2006 to 2010

As elective nonreconstructive breast surgery increases in popularity, there is greater demand for accurate multi-institutional data on minor and major postoperative complications. The authors utilized a multi-institutional database to compare 30-day morbidities and reoperation rates among the different types of elective nonreconstructive breast surgery. Patients in the National Surgical Quality Improvement Program (NSQIP) participant use file who underwent elective nonreconstructive breast surgery between 2006 and 2010 were identified. Twenty defined morbidities were compared among mastopexy, reduction mammaplasty, and augmentation mammaplasty patients using analysis of variance and χ(2) tests for continuous variables and categorical variables, respectively. Logistic regression modeling was employed to identify preoperative risk factors for complications. Of the 3612 patients identified, 380 underwent mastopexy, 2507 underwent reduction mammaplasty, and 725 underwent augmentation mammaplasty. Complication rates were low in all cohorts, and patients undergoing augmentation mammaplasty had the lowest overall complication rate compared with mastopexy and reduction mammaplasty (1.24%, 2.37%, and 4.47%). Patients undergoing reduction mammaplasty had a modestly elevated incidence of overall morbidity, superficial surgical site infections, and wound disruptions (P < .05). Moreover, 30-day reoperation rates for mastopexy, reduction mammaplasty, and augmentation mammaplasty were low (1.58%, 2.07%, and 0.97%), as were the rates of life-threatening complications (0%, 0.16%, and 0%). One death was observed for all 3612 procedures (0.03%). Elective breast surgery is a safe procedure with an extremely low incidence of life-threatening complications and mortality. Comprehensive data collated from the NSQIP initiative add to the literature, and the findings of this multi-institutional study may help further guide patient education and expectations on potentially deleterious outcomes.

Variations in Complication Rates for Elective Non-Reconstructive Breast Surgery

Variations in Complication Rates for Elective Non-Reconstructive Breast Surgery

Randomized clinical trial of single-dose antibiotic prophylaxis for non-reconstructive breast surgery

The aim of this randomized clinical trial was to determine whether a single intravenous dose of 2 g flucloxacillin could prevent wound infection after primary non-reconstructive breast surgery. The study included 618 patients undergoing local excision (n = 490), mastectomy (n = 107) or microdochectomy (n = 21). Patients were randomized to receive either a single dose of flucloxacillin immediately after the induction of anaesthesia or no intervention. Wound morbidity was monitored by an independent research nurse for 42 days after surgery. The incidence of wound infection was similar in the two groups: 10 of 311 (3.2 percent) in the flucloxacillin group and 14 of 307 (4.6 percent) in the control group (chi(2) = 0.75, P = 0.387; relative risk 0.71, 95 percent confidence interval 0.32 to 1.53). The groups also had similar wound scores and rates of moderate or severe cellulitis. Wound infection presented a median of 16 days after surgery. The administration of a single dose of flucloxacillin failed to reduce the rate of wound infection after non-reconstructive breast surgery.

A randomised clinical trial evaluating the role of prophylactic antibiotics in patients undergoing non-reconstructive breast surgery

A randomised clinical trial evaluating the role of prophylactic antibiotics in patients undergoing non-reconstructive breast surgery