Unexpected Reoperation Research Articles

Neighborhood Deprivation is Associated With Increased Postoperative Complications After Implant-Based Breast Reconstruction

PurposeThe Area Deprivation Index (ADI) ranks neighborhoods by deprivation based on US Census data. This study utilizes ADI scores to investigate the impact of neighborhood deprivation on complication rates following breast reconstruction. Patients and methodsPatients who received implant-based reconstruction from 2019 to 2023 were identified at a single institution in New York. Patients were linked to a state-specific ADI score and categorized into groups: “High ADI” (6-10) and “Low ADI” (1-5). Patient characteristics and complication rates were compared between the ADI groups with Chi-Square analysis and t-tests. The predictive value of ADI scores on complication rates was assessed using logistic regression models. ResultsIn total, 471 patients were included, of which 16% (n = 73) were in the High ADI group, and 84% (n = 398) were in the Low ADI group. There were no baseline differences between the 2 groups, except that there were more patients of Hispanic descent in the High ADI group (30% vs. 15%, P < .01). The High ADI group had a higher overall complication rate than the Low ADI group (34% vs. 21%, P < .01), as well as higher individual rates of hematoma (12% vs. 3%, P < .01) and unexpected reoperations (18% vs. 7%, P < .01). After adjusting for differences in race, High ADI scores predicted hematoma, reoperations, and any complication (P < .05). ConclusionPatients living in neighborhoods with high ADI had a higher incidence of postoperative complications, independent of comorbidities and race. This measure of disparity should be considered when counselling patients about their risk of complications following procedures like implant-based breast reconstruction.

Risk Factors for Postoperative Chylothorax Occurrence Following Pediatric Congenital Heart Surgery

Objectives: Chylothorax, a rare but potentially life-threatening complication post congenital heart surgery, warrants early identification of risk factors to implement preventive strategies and timely interventions. This study aims to determine risk factors associated with chylothorax occurrence at our cardiac intensive care unit. Methods: We conducted a nested case-control study involving 2042 children who underwent congenital heart surgery at Nhi Dong 1 hospital (Ho Chi Minh City, Vietnam) from Feb 25th, 2015, to October 12th, 2019. Among these, 38 chylothorax cases were matched by sex and year of surgery to 76 randomly selected control patients. Univariate analysis and logistic regression were performed to identify independent factors associated with chylothorax occurrence after congenital heart surgery. Results: Neonatal cardiac surgery, RACHS-1 risk category ≥ 3, aortic arch repair, the arterial switch operation, prolonged bypass time (median 160 mins vs 87 mins) and aortic clamp time (median 89.5mins vs 51 mins), delayed sternal closure and unexpected reoperation were all associated with postoperative chylothorax occurrence on univariate analysis. Additionally, body weight &lt; 4.5 kg (p=0.027), postoperative dysrhythmias (p=0.004), and high volume of chest tube output (&gt; 10% of total expected blood volume) within the first 6 postoperative hours after cardiac intensive care unit admission (p=0.014) emerged as independent risk factors for postoperative chylothorax occurrence with odds ratios and 95% confident interval of 2.78 (1.12-6.87), 3.38 (1.29-8.86) &amp; 3.82 (1.55-9.39), respectively. These factors served as predictors of postoperative chylothorax occurrence with a sensitivity of 42.1%, specificity of 90.8%, positive predictive value of 69.6% and a negative predictive value of 75.8%. Conclusions: High chest tube output within the first 6 postoperative hours, postoperative dysrhythmias, and body weight of &lt; 4.5kg at surgery significantly increase the risk of postoperative chylothorax in our institution. Keywords: Postoperative chylothorax, chylothorax post pediatric cardiac surgery, pediatric chylothorax

Opportunities for, and barriers to, uterus-preserving surgical techniques for placenta accreta spectrum.

Placenta accreta spectrum (PAS) can lead to major peripartum morbidity. Appropriate management approaches depend on the clinical severity, each individual's preference, and the treating team's expertise. Peripartum hysterectomy is the most frequently used treatment option. However, it can impact psychological well-being and fertility. We investigated whether conservative treatment with focal resection or leaving the placenta insitu is associated with comparable or lower maternal morbidity than hysterectomy in centers of excellence within the International Society for placenta accreta spectrum (IS-PAS). Furthermore, a survey was conducted to explore potential barriers to conservative management in antenatal counseling and intraoperative decision-making. Confirmed PAS cases in the prospective IS-PAS database from 22 registered centers between January 2020 and June 2022 were included in the analysis. A separate online survey with 21 questions was answered by the IS-PAS center experts about indications, diagnostic criteria, patient counseling, surgical practice, changes from the preoperative treatment plan, and why conservative management may not be offered. A total of 234 cases were included in the analysis: 186 women received hysterectomy and 38 women were treated by focal resection, and 10 by leaving the placenta insitu. Blood loss was lower in the focal resection group and in the placenta insitu group compared to the hysterectomy group (p = 0.04). 46.4% of the women initially planned for focal resection, and 35.7% of those initially planned for leaving the placenta insitu were ultimately treated by hysterectomy. Our survey showed that the IS-PAS centers preferred hysterectomy according to a woman's wishes (64%) and when they expected less blood loss and morbidity (41%). Eighteen percent of centers did not offer focal resection at all due to a lack of experience with this technique. Reasons for not offering to leave the placenta insitu were avoidance of unexpected reoperation (36%), puerperal infection (32%), or skepticism about the method (23%). Uterus-preserving treatment strategies such as focal resection appear to be safe alternatives to peripartum hysterectomy. However, less than half of the IS-PAS centers perform them. Acceptance of conservative treatments could be increased by standardized criteria for their implementation and by systematic training for PAS experts.

Mitral valve orifice area predicts outcome after biventricular repair in patients with hypoplastic left ventricles

BackgroundIdentification of risk factors for biventricular (BiV) repair in children with hypoplastic left ventricles (HLV) has been challenging. We sought to identify preoperative cardiovascular magnetic resonance (CMR) predictors of outcome in patients with HLVs who underwent BiV repair, with a focus on the mitral valve (MV). MethodsSingle center retrospective analysis of preoperative CMRs on patients with HLV (≤50ml/m2) and no endocardial fibroelastosis who underwent BiV repair from 2005-2022. CMR measurements included MV orifice area in diastole. The primary composite outcome included time to death, transplant, BiV takedown, heart failure admission, left atrial decompression, or unexpected reoperation; and the secondary outcome included ≥ moderate mitral stenosis and/or regurgitation. ResultsMedian follow-up was 0.7 (IQR 0.1, 2.2) years. Of 122 patients [48% atrioventricular canal (AVC) and 52% non-AVC] age 3 ± 2.8 years at the time of BiV repair, freedom from the primary outcome at 2 years was 53% for AVC and 69% for non-AVC (log rank p=0.12), and freedom from the secondary outcome at 2 years was 49% for AVC and 79% for non-AVC (log rank p<0.01). Independent predictors of primary outcome for AVC patients included MV orifice area z-score < -2 and transitional AVC; for non-AVC patients, predictors included MV orifice area z-score < -2, abnormal MV anatomy, and conal-septal ventricular septal defect. Independent predictors of secondary outcome for AVC patients included older age at surgery, transitional AVC, and transposition of the great arteries. ConclusionsIn children with HLV, low MV orifice area and pre-existing MV pathology are risk factors for adverse outcome after BiV repair.

Postoperative Bloodstream Infection Is Associated with Early Vascular Complications in Pediatric Liver Transplant Recipients with Biliary Atresia.

Bloodstream infection (BSI) after pediatric liver transplantation (PLT) is a common and severe complication that affects patient survival. Children with biliary atresia (BA) are at an increased risk for clinically significant infections. This study evaluated the impact of post-PLT BSI on clinical outcomes in children with BA. A total of 67 patients with BA aged <18 years who underwent PLT between April 2006 and September 2020 were analyzed and divided into two groups according to the occurrence of post-PLT BSI within 1 month (BSI vs. no BSI = 13 [19.4%] vs. 54 [80.6%]). The BSI group was significantly younger at the time of PLT and had a higher frequency of BSI at the time of PLT than the no BSI group. Early vascular complications within 3 months and reoperations were significantly more frequent in the BSI group. Univariate and multivariate analyses revealed that bacteremia within 1 month of PLT and graft-to-recipient weight ratio >4% were significantly associated with vascular complications. In conclusion, BSI after PLT is associated with increased vascular complications and reoperations. Proper control of bacterial infections and early liver transplantation before uncontrolled BSI may reduce vascular complications and unexpected reoperations in children with BA.

0445 Real-world Evaluation of Upper Airway Stimulation system survival using post-market surveillance data

Abstract Introduction Upper airway stimulation (UAS) has become a viable treatment alternative for well selected patients with moderate to severe obstructive sleep apnea (OSA) who struggle to tolerate positive pressure (PAP) therapy. Post-market surveillance is required of medical device manufacturers to assess treatment outcomes, complications, and device failure. We aim to utilize this surveillance data to assess rates of revision and removal of the Inspire (Minneapolis, MN) UAS system in a real-world setting. Methods Post market surveillance data was compiled from manufacturer’s complaint handling system for explants and revisions of the hypoglossal nerve stimulator. Data collection began in January 2018 and was available through September 30 2022 at the time of analysis. Implant procedures from January 2018 through September 2021 were analyzed for events within one year of implant. Events were classified into categories. A subset of these devices implanted before September 30 2019 were analyzed for events between one and three years after implant. Results Between Jan 01 2018 and Sep 30 2021, 15282 devices were implanted. Within one year of the implant, 121 devices (0.8%) were explanted for: infection (66), elective (32), MRI (10), other (10), and twiddler syndrome (3). Surgical revisions were required for 245 patients (1.6%) for: surgical correction (139), device defect (81), other (21), cardioversion (2), twiddler syndrome (1), and MRI (1). A subset of 5080 of these devices were implanted prior to September 30 2019. Between one year and three years following implant 119 devices (2.3%) were explanted for: elective (58), MRI (35), infection (15), Other (9), and twiddler syndrome (2). Surgical revisions were performed for 160 patients (3.1%) for: surgical correction (64), device defect (57), other (32), twiddler syndrome (5), and cardioversion (2). Conclusion As with any implantable medical device, a certain rate of revision and explant is expected for device, patient, and medical indications. The rate of UAS revision and explantation is low at both the 1 year and 3 year time points. UAS implantation is a safe alternative to CPAP for well selected patients with a low rate of unexpected reoperation for either revision or hardware explantation. Support (if any) Inspire Medical

PC3. A Nationally Validated Risk Assessment Score for Predicting Unplanned Reoperations in Hand Surgery

PURPOSE: To present a validated model that reliably predicts unplanned reoperation after upper extremity/hand surgery. METHODS: A total of 83,409 hand surgery patients were identified using the 2012-2019 ACS-NSQIP databases. Thirty-day unplanned reoperation was defined as unexpected reoperation for a postoperative occurrence related to the principal hand surgery. Independent predictors of 30-day unplanned reoperation were identified using multivariable logistic regression with backward variable selection on the testing sample. Subsequently, the predictors were weighted according to β-coefficients to generate an integer-based Novel Risk Score (NRS) predictive of reoperation. The NRS was then validated 1000 bootstrapped replications of the original sample, and validated on NSQIP patients who had undergone hand surgery in 2020 (n = 15,247). The NRS was compared to two other widely used risk scores with receiver operating characteristics (ROC) analysis. RESULTS: The rate of 30-day unplanned reoperation in the 2020 cohort was 1.1%. Independent risk factors included male gender, inpatient status, smoking, dialysis dependence, transfusion within 72 hours of surgery, wound classification, ASA Class, diabetes mellitus, CHF, sepsis or septic shock, emergent case, and long initial operative time (all P < 0.05). ROC analysis of the testing (2020) cohort rendered an area under the curve of 0.730, which demonstrates the accuracy of this prediction model. The mFI-5 and mCCI rendered AUCs of 0.580 and 0.585, respectively. CONCLUSION: We present a validated risk stratification tool for unplanned reoperations following hand surgery. Future studies should determine if implementation of this NRS optimizes safety and reduces reoperation rates in hand surgery patients.

Institutional Outcomes for Patients Receiving Adjuvant Radiotherapy with a Remote History of Augmentation Mammoplasty with Implants

<h3>Purpose/Objective(s)</h3> Postmastectomy radiotherapy (RT) in patients with immediate breast reconstruction has well known risks of late complications including delayed wound healing, capsular contracture and poor cosmesis. For patients with a remote history of augmentation mammoplasty with implants (AMI) receiving adjuvant RT for breast cancer, the risk of complications is not well documented. At our institution, due to concerns about cosmesis, patients receiving adjuvant RT with remote AMI receive standard fractionation rather than hypofractionation. The purpose of this quality assurance project is to review outcomes for patients who received RT with remote AMI. <h3>Materials/Methods</h3> Using our radiation treatment planning interface, patients were identified who underwent adjuvant RT to the breast and/or regional nodes in 25 to 28 fractions between January 1, 2013, and December 31, 2019. Chart review was performed to determine demographics, type of reconstruction, complications, subsequent unexpected re-operations due to cosmesis, and dosimetry. EQD2 calculations were generated assuming an α/β=3.4 for normal breast tissue. Patients with and without cosmetic complication were compared for significance using the Mann Whitney U-test (two tailed, p<0.05). <h3>Results</h3> Thirty-two patients underwent RT with remote AMI. Four patients (12.5%) had documented cosmetic complications after adjuvant RT requiring reoperation. Complications included rupture (n=1), contracture (n=2), asymmetry (n=1). The mean time from radiation to reoperation was 697 days (353-1045 days). For patients with cosmetic complications, 75% received chemotherapy prior to RT while 32.1% of patients without complications received chemotherapy prior to RT. Doses ranged from 45-50 Gy in 25 fractions vs 50.4 Gy in 28 fractions. Boost doses ranged 10-16 Gy in 5-8 fractions. In addition to whole breast irradiation (WBI), one patient (25%) with cosmetic complications also received regional nodal RT while 6 patients without complications (21.5%) received adjuvant nodal RT. Of the patients with cosmetic complications, all received boost with electrons and none of the patients had bolus. The total EQD2 for WBI and boost was statistically higher in the group of patients requiring reoperation for cosmesis (57.8 Gy vs 52.3 Gy, p=0.02). <h3>Conclusion</h3> For our cohort of patients receiving RT after remote AMI, the rate of cosmetic complications requiring reoperation was low (12.5%). This rate is significantly lower than institutional and documented rates of cosmetic complications for patients with immediate reconstruction followed by adjuvant RT. While the sample size was small, it is worthwhile to note that patients receiving chemotherapy, boost, and a higher EQD2 were more likely to experience cosmetic complications. Future investigation should include prospective review of a larger cohort of patients with remote AMI and the risk profile of boost.

Intraperitoneal Instillation of Local Anesthetic (IPILA) in Bariatric Surgery and the Effect on Post-operative Pain Scores: a Randomized Control Trial

BackgroundEffective analgesia after bariatric procedures is vital as it can reduce post-operative opioid use. This leads to less nausea which may be associated with shorter post-operative length of stay (LOS). Understanding analgesic requirements in patients with obesity is important due to the varied physiology and increased number of comorbidities.ObjectivesThe aim of this study was to evaluate the efficacy of intraperitoneal instillation of local anesthetic (IPILA) to reduce opioid requirements in patients undergoing laparoscopic bariatric surgery.MethodsA double-blinded randomized control trial was conducted to compare intraperitoneal instillation of ropivacaine to normal saline in 104 patients undergoing bariatric surgery. The primary endpoint was pain in recovery with secondary endpoints at 1, 2, 4, 6, 24, and 48 h post-operatively. Further endpoints were post-operative analgesic use and LOS. Safety endpoints included unexpected reoperation or readmission, complications, and mortality.ResultsThere were 54 patients in the placebo arm and 50 in the IPILA. Pain scores were significantly lower in the IPILA group both at rest (p = 0.04) and on movement (p = 0.02) in recovery with no difference seen at subsequent time points. Equally, IPILA was independently associated with reducing severe post-operative pain at rest and movement (adjusted odds ratio [aOR] 0.28, 95% CI 0.11–0.69, p = 0.007 and aOR 0.25, 95% CI 0.09–0.62, p = 0.004, respectively). There was no significant difference in LOS, opioid use, antiemetic use, morbidity, or mortality between the intervention and placebo groups.ConclusionThe administration of ropivacaine intraperitoneally during laparoscopic bariatric surgery reduces post-operative pain in the recovery room but does not reduce opioid use nor LOS.

Reoperation after primary operation for pre-axial polydactyly of the hand: A 12-year experience at a single institute

This study aimed to evaluate and describe the rate, reasons, and detailed procedures of reoperations for pre-axial polydactyly of the hand at our institute conducted within 12 years. We retrospectively reviewed the medical records and radiographs of 268 patients (292 digits) with pre-axial polydactyly of the hand, who were treated surgically at our institute from November 2006 to May 2018 and followed up for >12 months. Fifty-two thumbs of 47 patients underwent reoperations, yielding a 17.8% reoperation rate. According to the initial deformity type, the highest reoperation rate was observed in the cases classified under modified Wassel type VIIA (60.9%, 14/23 thumbs), followed by those under type VIIB (44.4%, 8/18 thumbs). Scheduled reoperations were performed in seven type VIIA and four type VIIB cases with a triphalangeal thumb and eight with triangular epiphysis of the distal phalanx. Unexpected reoperations were conducted in 33 cases, 31 (93.9%) of which had deviated thumbs. Various surgical treatments, including corrective osteotomy, collateral ligament plication, and flexor pollicis longus tendon relocation, were performed to correct deviations. A total of 23 cases (74.2% of 31 thumbs) received a corrective osteotomy at the second or third operation. The reoperation rate after primary operation for pre-axial polydactyly of the hand was 17.8%. It was higher in the cases initially classified under modified Wassel type VII; however, a considerable number of cases received scheduled reoperations. A deviated thumb was the most common cause of unexpected reoperation, and corrective osteotomy was the most commonly performed procedure. The rate and details of reoperation should be routinely mentioned for preoperative planning and patient education in pre-axial polydactyly. Therapeutic level IV.

Postmastectomy Radiotherapy Using 5040 cGy in 28 Fractions for Patients with Immediate Breast Reconstruction: Institutional Outcomes

For patients planned to undergo adjuvant postmastectomy radiotherapy (PMRT) for breast cancer, immediate breast reconstruction (IBR) has been considered a relative contraindication. Delayed wound healing, increased risk of capsular contracture, fat necrosis, poor cosmesis, and rates of reoperation are of concern. Patients who have undergone IBR at our institution with an indication for PMRT are prescribed extended fractionation as per institutional policy. The aim of this quality assurance project is to review rates of reoperation for patients who received PMRT after IBR with autologous tissue (AT), tissue expanders (TE), or permanent implants (PI). Using a patient information system, patients were identified who underwent adjuvant PMRT to the chest wall and regional nodes to a total dose of 5040 cGy in 28 fractions between January 1, 2013 and January 31, 2019. Radiotherapy plans were reviewed. Medical records were reviewed for patient and treatment characteristics, and unexpected reoperation rate. Seventy-three patients underwent IBR and PMRT. Eleven (15.1%) patients had AT, 24 (32.9%) had TE, and 38 (52.1%) had PI. Twenty-four patients (32.9%) had documented cosmetic complications (including capsular contracture and asymmetry) after PMRT requiring reoperation. Cosmetic complications (CC) leading to reoperation were documented in 45.5% of patients with AT, 37.5% of patients with TE, and 26.3% of patients with PI. The mean elapsed time from PMRT completion to reoperation for cosmetic complications was 12.3 months (range = 2.3-33.1 months). Most patients received either adjuvant or neoadjuvant chemotherapy (97.3%). Of the patients having CC leading to reoperation compared to those without complication, a higher proportion received neoadjuvant chemotherapy, but this difference was not statistically significant (39.1% vs 19.4%, p = 0.135). For patients with CC leading to reoperation, there was a significantly higher volume of chest wall receiving ≥5040 cGy (851cc vs 680 cc, p = 0.023). Bolus was slightly more common in patients with CC but this difference was not statistically significant (91.7% vs 81.5, p = 0.461). For our cohort of patients receiving PMRT after IBR, the rate of CC is comparable to those quoted elsewhere. Interestingly, for our cohort, patients having PI had the lowest rate of CC leading to reoperation compared those with AT and TE. Patients with CC had a higher volume of chest wall receiving ≥ 5040 cGy. Further dosimetric analysis is needed to determine if there is a correlation with capsule dose and cosmetic outcomes.

Severe Hypocalcemia After Thyroidectomy: An Analysis of 7366 Patients.

The aim of the study was to determine severe hypocalcemia rate following thyroidectomy and factors associated with its occurrence. Hypocalcemia is the most common complication after thyroidectomy. Severe post-thyroidectomy hypocalcemia can be life-threatening; data on this specific complication are scarce. Patients who underwent thyroidectomy in the American College of Surgeons-National Surgical Quality Improvement Program thyroidectomy-targeted database (2016-2017) were abstracted. A severe hypocalcemic event was defined as hypocalcemia requiring intravenous calcium, emergent clinic/hospital visit, or a readmission for hypocalcemia. Multivariable regression was used to identify factors independently associated with occurrence of severe hypocalcemia. Severe hypocalcemia occurred in 5.8% (n = 428) of 7366 thyroidectomy patients, with 83.2% necessitating intravenous calcium treatment. Rate of severe hypocalcemia varied by diagnosis and procedure (0.5% for subtotal thyroidectomy to 12.5% for thyroidectomy involving neck dissections). Overall, 38.3% of severe hypocalcemic events occurred after discharge; in this subset, 59.1% experienced severe hypocalcemia despite being discharged with calcium and vitamin D. Severe hypocalcemia patients had higher rates of recurrent laryngeal nerve injury (13.4% vs 6.6%), unplanned reoperations (4.4% vs 1.3%), and longer hospital stay (30.4% vs 6.2% ≥3 days (all P < 0.01). After multivariate adjustment, severe hypocalcemia was associated with multiple factors including Graves disease [odds ratio (OR) = 2.06], lateral neck dissections (OR: 3.10), and unexpected reoperations (OR = 3.55); all P values less than 0.01. Severe hypocalcemia and suboptimal hypocalcemia management after thyroidectomy are common. Patients who experienced severe hypocalcemia had higher rates of nerve injury and unexpected reoperations, indicating surgical complexity and provider inexperience. More biochemical surveillance particularly a parathyroid hormone-based protocol, fine-tuned supplementation, and selective referral could reduce occurrence of this morbid complication.

Implant-based Breast Reconstruction Outcomes Comparing Freeze-dried Aseptic Alloderm and Sterile Ready-to-use Alloderm.

Background:The use of acellular dermal matrix has revolutionized implant-based breast reconstruction in the 21st century. There have been a number of different dermal matrices introduced to clinical use and their equivalence has been debated. The purpose of this study is to examine a sequential series of acellular dermal matrix assisted implant-based breast reconstructions by a single surgeon and to compare the outcomes between a freeze-dried (FD) Alloderm cohort and a sterile ready to use Alloderm cohort.Methods:After institutional review board approval, all consecutive implant-based breast reconstructions of a single surgeon (D.S.W.) from January 2009 to June 2016 were examined. Two hundred thirty-six patients received either FD Alloderm in the first 151 breasts reconstructed or sterile ready-to-use Alloderm in the last 227 breasts.Results:The FD Alloderm patients had more tissue expander reconstructions performed and were all subpectoral placement. The ready-to-use Alloderm patients had more direct-to-implant procedures and some prepectoral placements. The complication rates were similar for seroma, hematoma, skin necrosis, and dehiscence. There were more infections, implant losses, and unexpected reoperations in the FD Alloderm group.Conclusion:The rate of infection, explantation, and unexpected reoperation was lower in the sterile ready-to-use Alloderm group versus the FD Alloderm group.

Prepectoral Versus Subpectoral Direct to Implant Immediate Breast Reconstruction.

Implant-based reconstruction is currently the most common postmastectomy breast reconstruction modality with over 86,000 procedures performed in 2017. Although various methods for reconstruction techniques have been described, partial subpectoral implant placement with or without acellular dermal matrix coverage remains the most popular approach. Recently, prepectoral implant placement has gained increased recognition as a method that avoids some of the potential morbidities of submuscular implant placement. Currently, few studies have examined the outcomes of performing this approach. The purpose of this study was to evaluate and compare the outcomes of prepectoral and subpectoral direct to implant (DTI) immediate breast reconstruction. Data from a prospective cohort of consecutive patients undergoing prepectoral DTI immediate breast reconstructions at our institution from February 2016 to November 2017 were collected. The incidence of complications such as mastectomy skin flap necrosis, seroma, hematoma, infection, implant loss, and unexpected reoperation were recorded and compared with a cohort of consecutive patients who underwent subpectoral DTI immediate breast reconstruction from May 2014 to July 2015. One hundred twelve prepectoral DTI immediate breast reconstructions were performed on 62 patients. Four breasts (4.4%) were diagnosed with infection. There were 8 breasts (7.1%) that suffered from mastectomy skin flap necrosis (5 partial thickness necrosis, 3 full thickness necrosis). There was 1 implant loss related to full thickness necrosis that required salvage with autologous tissue reconstruction. Prepectoral breast reconstruction had less esthetic revisions and comparable complications when compared with the historical subpectoral cohort. When compared with the subpectoral DTI approach, prepectoral DTI breast reconstruction grants favorable complication rates and improved esthetic outcomes. Prepectoral DTI breast reconstruction is a safe modality that should be considered in any patient who is a candidate for immediate breast reconstruction.

Single Fusion Vs Growth Friendly Device in Older EOS Patients. How do Outcomes Compare

Purpose: To compare outcomes of growth-friendly (GF) constructs versus primary posterior spinal fusion (PSF) in 8-11 y/o patients with EOS. Methods: Prospectively collected data from a multicenter registry was retrospectively analyzed. 141 ambulatory scoliosis patients, 68% female, aged 8-11 at initial surgery with 2 year follow-up were included. Cobb angles, # of surgeries, unexpected reoperations, and complications were collected at an average 4.9 years. Quality of Life (QoL) using …

Does the form of venous thromboembolism prophylaxis following primary total knee arthroplasty alter the rate of early reoperation or revision surgery?

Currently there is significant variation in the management of venous thromboembolism prophylaxis following total knee arthroplasty (TKA). Excessive wound ooze and bleeding is thought to increase a patient's risk of haematoma formation and possible infection. We evaluated the rate of unexpected reoperation in the perioperative period in patients who received aspirin, rivaroxaban or enoxaparin following primary TKA. A systematic literature search was conducted in MEDLINE, CENTRAL and Embase to identify patients who underwent primary TKA. Two researchers independently reviewed the references identified in the literature search. The final 11 studies included for review were published between 1996 and 2016. There was a higher rate of reoperation in patients treated with aspirin following TKA when compared to enoxaparin and rivaroxaban in the perioperative period. Of the 5141 patients treated with enoxaparin, 11 (0.21%) required reoperation; of the 2764 patients treated with rivaroxaban, 12 (0.43%) required reoperation; and of the 228 patients treated with aspirin, seven (3.07%) required reoperation. The average time to follow-up in the 11 studies was 55 days, ranging from 30 to 180 days post-operatively. There was a higher rate of reoperation in patients treated with aspirin following TKA when compared to enoxaparin and rivaroxaban in the perioperative period. While there is extensive data on the safety and efficacy of these medications following joint arthroplasty, improved reporting of surgically relevant outcomes are needed to assist both the surgeon and patient in clinical decision-making.

Intraoperative SPY Reduces Post-mastectomy Skin Flap Complications: A Systematic Review and Meta-Analysis.

Indocyanine-green and laser-assisted fluorescence angiography, known as the SPY system, is a recently developed tool that has shown promise in assessing tissue perfusion. Its intraoperative use is becoming more common particularly in breast surgery. This systematic review aims to determine whether SPY technology can reduce postoperative complications related to tissue ischemia, specifically skin necrosis of the mastectomy native breast skin flaps. A systematic review of the literature was performed based on the PRISMA guideline. All studies that involved use of the SPY system to assess perfusion of postmastectomy skin flaps from January 1, 1960, to March 1, 2018 were included. Postoperative complications, including mastectomy skin flap necrosis were extracted from the selected studies. The perfusion-related complication rates and unexpected reoperation rates across multiple studies were then reviewed. Five relevant articles were identified including 902 patients undergoing mastectomy and native breast flap reconstructive procedures. Groups that used indocyanine-green angiography had statistically less incidence of native breast skin flap necrosis and unexpected reoperations due to perfusion-related complications compared with groups that monitored flaps with only clinical observation (odds ratio 0.54 for skin necrosis, and 0.36 for reoperation). In this systematic review, the incidence of native breast skin flap necrosis and unexpected reoperations were found to be statistically lower in cases where SPY was used. However, more prospective studies are required to establish SPY angiography as an accurate and cost-effective tool for assessment of tissue perfusion.

Routine Laser-assisted Indocyanine Green Angiography in Immediate Breast Reconstruction: Is It Worth the Cost?

Background:Laser-assisted indocyanine green angiography (LAIGA) has been proven to accurately detect mastectomy skin flap necrosis (MSFN) intraoperatively and prevent postoperative complications in breast reconstruction. The purpose of this study was to examine the cost-effectiveness of the routine use of LAIGA in immediate breast reconstruction and to perform a break-even point analysis.Methods:This is a retrospective review of prospectively gathered data from all patients who underwent immediate breast reconstruction from January 2014 to January 2015. LAIGA was routinely used in all cases. Patients were followed for at least 90 days to capture postoperative complications. Costs were calculated by reviewing itemized bills and Medicare Reimbursement Current Procedural Terminology codes to assess surgeon fees. Outcomes and costs were compared with a historical cohort of patients who underwent breast reconstruction before the implementation of LAIGA.Results:Two-hundred-and-six immediate breast reconstructions (126 patients) were performed using LAIGA for a total cost of $210,700. The average cost of MSFN in our LAIGA cohort was $30,496. The routine use of LAIGA decreased the MSFN rate from 12.4% to 6.3% and prevented MSFN on 13 breasts resulting in a gross cost savings of $396,453, and net savings of $185,753. Break-even point analysis demonstrated that number of cases needed to break even decreases as the average MSFN cost and MSFN reduction rate increase.Conclusion:The routine use of LAIGA in immediate breast reconstruction is cost-effective in reducing the incidence of MSFN, implant loss, and overall unexpected reoperation rate.

A Prospective Study of Immediate Breast Reconstruction with Laser-Assisted Indocyanine Green Angiography.

Background:Complication rates following immediate breast reconstruction range from 4% to 60%. Mastectomy skin flap necrosis (MSFN) is often the sentinel event leading to secondary complications.Methods:All patients undergoing immediate reconstruction were enrolled. Upon mastectomy completion, the surgeon visually interpreted the skin flaps, performed laser-assisted indocyanine green angiography (LAIGA), and intervened if needed. Patients were followed for 90 days, documenting skin necrosis, infection, seroma, hematoma, implant loss, and reoperation.Results:There were 126 patients who had 206 immediate breast reconstructions. The complication rate was 22.3%. The incidence of MSFN was 14.1%. The reoperation rate was 8.7%. There was 1 necrosis-related implant loss. Postoperative surveys were completed on 193 breasts: 137 had visual and LAIGA interpretation of well or adequately perfused, resulting in 5.8% rate of necrosis, 2 reoperations, and no implant losses. Twenty breasts had visual and LAIGA interpretation of marginal or poor perfusion. Sixteen of these underwent intervention. The necrosis rate in this group was 35% with no implant losses. A third group with 26 breasts had adequate visual interpretation with marginal or poor perfusion on LAIGA. Ten breasts had no intervention, and 16 received intervention. The overall necrosis rate in this group was 42.3%, with 4 reoperations for necrosis and 1 implant loss.Conclusions:LAIGA can more accurately predict complications from MSFN than surgeon assessment alone. When surgeon decision making is supplemented with LAIGA, it reduces the incidence of MSFN, infection, implant loss, and overall unexpected reoperation rate. LAIGA is a valuable adjunct for intraoperative decision making.

The Impact of Different Postgraduate Year Training in Neurosurgery Residency on 30-Day Return to Operating Room: A National Surgical Quality Improvement Program Study.

Because of the health care initiative on quality improvement projects in academic medicine, this study explores the impact of different postgraduate years (PGYs) on unexpected re-operation rates. Using the National Surgical Quality Improvement Program 2005-2014, adult neurosurgical cases were divided into subspecialties: spine, open vascular, cranial, and functional. Comparison groups were cases involving junior residents (PGY 1-PGY 3), mid-level residents (PGY 4+ PGY 5), and senior residents (PGY 6+ PGY 7). Comorbidity disease burden was measured by frailty index. The primary outcome measure was 30-day unintended return to the operating room. Of the 9782 cases, re-operations were higher for those cases featuring a senior resident (5.6%) compared with mid-level resident (4.1%) and junior resident (3.8%) (P= 0.001). Although senior residents operated on patients with a statistically significantly higher neurologic disease burden, greater relative value units, longer operative times, and more 30-day postoperative adverse events, the level of resident training did not have an impact on revision surgery after multivariable logistical regression. The strongest predictors of return to the operating room included the frailty index (adjusted odds ratio [ORadj]= 5.18, P < 0.001), functional subspecialty (ORadj= 2.65, P<0.001), and Wound Class 4 - dirty/infected wound (ORadj= 2.33, P= 0.016). Resident participation in neurosurgical cases does not affect 30-day unplanned re-operation rates, which were affected by frailty index, functional subspecialty, and wound class.