'23 h Model' for breast surgery: an early experience

[Surgical management of breast cancer in outpatient versus overnight hospitalization: Satisfaction study]

OBJECTIVES

Breast cancer is the primary female cancer. In cancerology, it is essential to give to the patient some support. The advent of outpatient surgery optimizes the care path. This need for support of patients raises the question of its compatibility with the day surgery. The purpose is to compare the satisfaction of outpatients with those who stay overnight after surgery of breast cancer. MéTHODS: Patients who underwent breast conservative surgery were included. It is a mixed study, a quantitative, observational and prospective one using a satisfaction survey and a qualitative one which consisted on semi - directive individual interviews. We compared the satisfaction rate (highest marks).

RESULTS

There were 91 patientes, 38 in the ambulatory group and 53 in the overnight group. There was no significant difference in satisfaction between the two groups (P=0.18). The difficulties frequently highlighted by the patients during their stay were the organizational management, the lack of hospital comfort and the sometimes long wait. The need for human support was unanimous.

CONCLUSION

The satisfaction was excellent in the study. The mode of hospitalization does not seem to play a role here on satisfaction. This hospitalization mode can only be envisaged by providing sufficient human and technical resources. Enhanced recovery after surgery appears to be an alternative to outpatient surgery.

Major ambulatory surgery in breast diseases

INTRODUCTION

The use of ambulatory surgery (AS) for breast pathology (BP) has increased. The objective of this study is to analyse a group of patients treated surgically for breast pathology in order to evaluate its quality and security in a MAS setting in 2017.

METHODS

A retrospective review of all patients undergoing breast surgery was conducted within an AS programme from January to December 2017 in Consorcio Hospital General Universitario of Valencia (CHGUV). The study analysed the number of patients, exclusion reasons, type of surgical procedures, evolution of substitution rate (SR), rate and causes of conversion to admission, postoperative complications, motives for not being included in the ambulatory programme and the satisfaction rate of the patients treated with ambulatory surgery. This has been compared with a 2013 group.

RESULTS

In 2017, 396 procedures for BP were performed: 170 for benign and 226 for malignant disease. The SR for the global mammary pathology was 72.8%. The SR for benign pathology was 93.4% and the SR for malignant pathology was 57.2%, which has increased in recent years from 45.4% in 2013. The unexpected hospitalization rate (HR) of malignant pathologies was 14.1%, while the HR in benign pathologies was 0.6%. Patients hospitalized for malignant pathologies presented higher complications (17%) than ambulatory patients (8.5%) and benign pathologies (6.5%).

CONCLUSIONS

At the CHGUV, the SR has steadily increased in malignant pathologies. The unexpected hospitalization rate is determined by perioperative sentinel lymph node biopsy results. AS for the treatment of mammary pathology is efficient and safe.

Fast-Track Approach for Breast Reconstructive Surgery in Patients With Breast Cancer

Aim:

The aim of this study was to develop and implement the concept of fast-track surgery (FTS) for reconstructive breast surgery in patients with breast cancer (BC) to improve early and long-term results of treatment.

Materials and methods:

The study includes 749 patients with stage 1 to 3 BC. A total of 253 patients with BC got treatment according to FTS program and were included to the core group. Other 496 patients with BC (control group) were not included to the FTS program. Patients were treated from December 2010 to December 2014. All age groups were covered (18-70 years old).

Results:

There was a significant difference in the average length of hospital stay (LOS) which was 14.27 ± 7.00 days in the core group and 20.11 ± 7.70 days in the control group (P < .001). In advanced BC cases in the core group, LOS was >8 days lower comparing with the control group on average. The LOS in patients who underwent adjuvant chemotherapy was 2.7 times lower in the FTS group comparing with the control group.

Conclusions:

The study results allow us to recommend the concept of FTS for implementation in broad medical practice for breast reconstructive surgery in patients with BC. The FTS program was shown to be effective in all types of breast surgery, including immediate oncoplastic and reconstructive surgeries. The gradual reduction of LOS increased the number of surgeries in our department by 75% from 2008 till 2018.

[Breast cancer and outpatient surgery: State of play of the activity and assessment of patient satisfaction]

OBJECTIVE

The objective of this study was to evaluate an outpatient breast cancer surgery activity in our center and to collect the satisfaction of patient having benefited.

METHOD

Descriptive and retrospective study about patients who underwent surgery for breast cancer scheduled on ambulatory between March 2015 and March 2017. Patients' satisfaction was collected retrospectively by a questionnaire.

RESULTS

Six hundred and thirty-nine breast cancer surgeries were performed during the study period, of which 56.2% were scheduled for outpatient surgery: 33 axillary procedures (9.2%), 289 conservative surgeries (80.5%) and 37 radical surgeries (10.3%). Forty-nine patients initially managed on ambulatory had to be hospitalized on conventional service, representing a conversion rate of 13.6%. The main reason was the establishment of drainage (30.6%). The complication rate was 0.6% with 2 patients rehospitalized for hematoma requiring surgical revision. Of the 359 patients treated on ambulatory, 61% responded to the satisfaction questionnaire. Overall satisfaction was 96.3%. In addition, 68.3% of patients said they had seen a real benefit in this mode of care. After returning home, 59,8% of patients reported feeling no or low pain.

CONCLUSION

Outpatient management seems to be both safe and satisfying for breast cancer surgery. A better organization of patient going home is in progress in order to reduce rate of conversion.

Associations between hospital structures, processes and patient experiences of preparation for discharge in breast cancer centers: A multilevel analysis

BACKGROUND

Discharge management is a central task in hospital management. Mitchell's quality health outcomes model offers a contextual framework to derive expectations about the relationship between indicators of hospital structures and processes with patient experiences of preparation for discharge.

PURPOSE

The aim is to analyze the association between hospital structures and processes with patient experiences of preparation for discharge in breast cancer centers.

METHODOLOGY

The data were collected between February 1 and July 31, 2014-2016, with annual cross-sectional postal surveys on patient experiences of preparation for discharge in breast cancer center hospitals in Germany. These data were combined with secondary data on hospital structures, obtained from structured quality reports 2014 and the accreditation institution certifying breast cancer centers, constituting a hierarchical data structure. A total of 10,750 newly diagnosed breast cancer patients from 67 hospitals were analyzed. Following listwise deletion, 9,762 patients could be included in linear hierarchical regression analyses.

RESULTS

Patients felt better prepared for discharge in hospitals that communicate the discharge date timely to patients, with good coordinative processes, and which cooperate with two other breast cancer center hospitals. Hospital structures, size, teaching status, and ownership were not associated with the patient experiences of preparation for discharge.

CONCLUSION

The results suggest that timely and informative communication, well-organized care processes, and the network structure of centers allow for an improvement of preparation for discharge. Current and future approaches for the improvement of hospital discharge should consider the identified hospital resources.

PRACTICE IMPLICATIONS

Hospital management should increase the focus on structured communication and coordination processes to improve the discharge process. Cooperating networks should be expanded to increase expertise and resources. Results can be generalized to other care domains with caution. Patients' characteristics should further be assessed in order to use resources efficiently.

Multimodal Pain Management for Enhanced Recovery: Reinforcing the Shift From Traditional Pathways Through Nurse-Led Interventions

Despite recent advances in perioperative patient care, postsurgical pain continues to be undermanaged. There is increasing acceptance of the concept that effective postsurgical pain management is best achieved through combined use of more than one analgesic agent or technique, and overreliance on opioids produces unwanted side effects limiting their utility. Accordingly, a balanced, multimodal approach to pain management within the larger framework of an Enhanced Recovery After Surgery (ERAS) pathway has become standard at many institutions for perioperative care, to control postsurgical pain, reduce opioid-related adverse events, hasten postsurgical recovery, and shorten length of hospital stay. The success of ERAS is dependent on nurses and the multidisciplinary team to execute its standardized processes across the care continuum, including patient education, perioperative care, and postsurgical evaluation. Here, we review current concepts related to multimodal analgesia and ERAS regarding care of adult surgical patients and discuss the perioperative nurse's role within this paradigm.

Multimodal Analgesia in Breast Surgical Procedures: Technical and Pharmacological Considerations for Liposomal Bupivacaine Use

Enhanced recovery after surgery is a multidisciplinary perioperative clinical pathway that uses evidence-based interventions to improve the patient experience as well as increase satisfaction, reduce costs, mitigate the surgical stress response, accelerate functional recovery, and decrease perioperative complications. One of the most important elements of enhanced recovery pathways is multimodal pain management. Herein, aspects relating to multimodal analgesia following breast surgical procedures are discussed with the understanding that treatment decisions should be individualized and guided by sound clinical judgment. A review of liposomal bupivacaine, a prolonged-release formulation of bupivacaine, in the management of postoperative pain following breast surgical procedures is presented, and technical guidance regarding optimal administration of liposomal bupivacaine is provided.

Is Enhanced Recovery the New Standard of Care in Microsurgical Breast Reconstruction?

BACKGROUND

At present, there are limited data available regarding the use and feasibility of enhanced recovery pathways for patients undergoing microsurgical breast reconstruction. The authors sought to assess patient outcomes before and after the introduction of an enhanced recovery pathway that was adopted at a single cancer center.

METHODS

A multidisciplinary enhanced recovery pathway was developed for patients undergoing deep inferior epigastric perforator or free transverse rectus abdominis myocutaneous flap breast reconstruction. Core elements of the enhanced recovery pathway included substituting intravenous patient-controlled analgesia with ketorolac and transversus abdominis plane blocks using liposomal bupivacaine, as well as intraoperative goal-directed fluid management. Patients who underwent surgery between April and August of 2015 using the enhanced recovery pathway were compared with a historical control cohort. The primary endpoints were hospital length of stay and total postoperative opioid consumption.

RESULTS

In total, 91 consecutive patients were analyzed (enhanced recovery pathway, n = 42; pre-enhanced recovery pathway, n = 49). Mean hospital length of stay was significantly shorter in the enhanced recovery pathway group than in the pre-enhanced recovery pathway group (4.0 days versus 5.0 days; p < 0.0001). Total postoperative morphine equivalent consumption was also lower in the enhanced recovery pathway group (46.0 mg versus 70.5 mg; p = 0.003). There was no difference in the incidence of 30-day complications between the groups (p = 0.6).

CONCLUSION

The adoption of an enhanced recovery pathway for deep inferior epigastric perforator and transverse rectus abdominis myocutaneous flap reconstruction by multiple surgeons significantly decreased opioid consumption and reduced length of stay by 1 day.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

[Mastectomy in ambulatory hospitalization or 24hours: Feasibility, satisfaction and preferences of the patients]

The aim of this study is to analyze the feasibility of ambulatory hospitalization or 24hours hospitalization for breast cancer treatment by mastectomy, as well as the satisfaction and the preferences of patients with regard to these ways of hospitalization.

METHODS

This observational retrospective study listed the patients operated for breast cancer who had required a mastectomy at the institute Paoli-Calmettes between the 1st of January 2013 and June 30th, 2015. A questionnaire of satisfaction was proposed to the patients regarding their mode of hospitalization.

RESULTS

One hundred and thirteen patients were included among which 29 were in the ambulatory group and 84 in the 24hours hospitalization group. The complications were represented by the rate of hematomas (3.5 %), which required a surgical resumption for two of the patients in the 24hours hospitalization group and for one patient in the ambulatory group (P=0.75). Patient's satisfaction rate was globally high: 72.7 % regardless of the mode of hospitalization (P=0.064).

CONCLUSION

The realization of mastectomy in ambulatory hospitalization seems feasible when the organization in pre- and postoperative is anticipated with a high degree of satisfaction of the patients. The psychological impact of this radical surgery seems to be a factor to be taken into account and requires a meticulous selection of the patients.

Perceived factors affecting distress among women taking part in surgical continuity of care for breast cancer: a systematic review protocol

REVIEW QUESTION/OBJECTIVE

The objective of this systematic review is to identify, appraise and synthesize the evidence on perceived factors affecting distress among women taking part in surgical continuity of care for breast cancer to provide evidence for improving support and care.The specific review question is: What are the perceived factors that contribute to an increase or a reduction in distress among women taking part in surgical continuity of care for breast cancer?

[Can we enhance the one-day part in breast conservative surgery?]

INTRODUCTION

French national guidelines lead us to increase the part of one-day breast cancer conservative surgery. Our objective was to check if we can enhance our outpatient part and to identify solutions to improve our practices.

METHODS

From 01/01/2013 to 31/12/2014, we conducted a monocentric and retrospective register about all cases of breast conservative surgery (infiltrating or in situ carcinoma, atypical hyperplasia). The collected data were: patients' sociodemographic characteristics, modality of hospitalization, surgical characteristics, preoperative exams organization, complications and reasons for an absence of surgery planned in one-day modality. We compared the two groups (one-day and standard hospitalization).

RESULTS

We reported 324 surgeries of which 50.3% planned in one-day mode. The outpatient part increased from 39.8% in 2013 to 60.8% in 2014. There was no difference for postoperative complications between the two groups. We found a higher rate of outpatient for sentinel node axillary dissection in 2014 (65% versus 37% in 2013). We reported a rate of axillary dissection in one-day mode of 20%, of which 15% were drained. The proportion of patients unplanned in one-day mode without contraindications was reduced from 81% in 2013 to 57% for 2014.

DISCUSSION

Increasing our outpatient part in breast conservative surgery was possible. There are still efforts to do to reach the national goals of one-day conservative breast cancer surgery, especially for the organizational aspects that remains the main obstruction. The implementation of pathways specifically for outpatient in and out of the hospital could be an interesting solution.