Surgical treatment of breast lesions at a Day Centre: Experience of the European Institute of Oncology

Healthcare delivery to elderly and unfit patients with breast disease and comorbidities under an outpatient regime: A report of a personal surgical technique named "Cut&Sew"

Introduction

A growing need for proper geriatric assessment and short-stay surgical programs supported by the availability of less invasive approaches, even in ambulatory settings, is being recognized as a feasible option for breast cancer patients with comorbidities who are usually distressed after standard surgery with ordinary hospitalization. Few studies have been conducted in Italian breast centers with dedicated techniques and approach for frail patients with breast diseases due to a jeopardized approach to ambulatory surgery among institutions.

Methods

This study included 58 women diagnosed with breast disease and comorbidities between March 2019 and December 2022 at the Ambulatory of Senology of San Giacomo Hospital in Novi Ligure (AL, Italy) and Civil Hospital in Ovada (AL, Italy). The patients were evaluated by a multidisciplinary consensus according to the guidelines provided to limit sentinel lymph node biopsy (SLNB) in older women. This kind of ambulatory surgery technique has been designed for i) patients with advanced age and/or comorbidities, ii) frail patients who psychologically do not accept other kinds of surgery, iii) patients who do not require SLNB, and iv) patients who need a surgical biopsy for lesions classified as B3 or small lesions with dubious radiological imaging. With this technique, the quadrant and whole breast may be removed in an outpatient setting with local anesthesia to limit blood loss by immediately cutting and suturing small portions of the gland. Local anesthetic infiltration is sequential and occurs stepwise before providing short passages of approximately 2 cm during resection and immediately suturing the surgical wound. This overclock technique, named "Cut&Sew," requires no more than 20-25 min and allows for a 1-2 h patient discharge with no drainage. The follow-up period was set at 60 months during routine yearly visits.

Results

The patients were older or super-older with most primary pT1/pT2 tumors and ductal type cancers, which were distributed in molecular subtypes Luminal A (37.1 %) and Luminal B (41.5 % Luminal B, with 11.2 % being HER2 positive). The tumour grade was mostly G2-G3. Mastectomy was performed in 10 patients, whereas quadrantectomy was performed in 48 patients, with the majority of tumors localized in Q1.While accompanied by a relative or a caregiver, all 58 patients acceded the "Cut&Sew" surgical technique in an ambulatory setting reporting negligible pain during the surgery and no pain within 10 days post-surgery. No post-operative complications or readmissions were recorded, and no discomfort or recurrence was detected during scheduled visits. Finally, the extent of satisfaction with the overall surgery was recorded immediately and corroborated by most patients during the follow-up period.

Conclusions

Although the small volume of cases collected does not allow for a controlled study necessary to evaluate the safety and efficacy of this technique for approaching frail and older women with comorbidities, through the "Cut&Sew" surgical technique, frail, older, and super older patients may benefit from a minimal psychological impact of surgery, while improving the patients' disease-free life so to corroborate the advised surgical de-escalation but avoiding undertreatment for this kind of patient category. Moreover, a stricter assessment of patient pain and overall satisfaction with the collection of a larger amount of reliable data could allow this technique to be extended to frail and/or older patients as a valuable and safe alternative to the more common hospitalization with general anesthesia. Other advantages include reduced hospitalization costs for sanitary structures.

Postoperative nausea and vomiting: risk factors, prediction tools, and algorithms

PURPOSE OF REVIEW

Postoperative/postdischarge nausea and vomiting (PONV/PDNV) remain relevant issues in perioperative care. Especially in ambulatory surgery, PONV can prevent discharge or lead to unplanned readmission.

RECENT FINDINGS

The evidence for the management of PONV is now quite good but is still inadequately implemented. A universal, multimodal rather than risk-adapted approach for PONV prophylaxis is now recommended. The evidence on PDNV is insufficient.

SUMMARY

PDNV management is based primarily on consequent prophylaxis and therapy of PONV.

Postdischarge pain, nausea and patient satisfaction after diagnostic and breast-conserving ambulatory surgery for breast cancer: A cross-sectional study

BACKGROUND

The aims of this study were to assess first day postdischarge pain, nausea and patient satisfaction in ambulatory breast cancer surgical patients, after diagnostic and breast conserving procedures.

METHODS

A total of 781 women, aged 18-85 years were included in this prospective, cross-sectional study. All patients received standardized multimodal pain prophylaxis with paracetamol, COX-II inhibitor, dexamethasone and wound infiltration with local anaesthetics. Nausea prophylaxis was provided with ondansetron. Most patients received general anaesthesia with propofol and remifentanil. Data were collected using a validated questionnaire during telephone follow-up on the first postoperative day.

RESULTS

The response rate was 94.5%. NRS ≥ 4 was reported by 5.3% at rest, by 17% during activity and by 30.7% as the worst pain score. Young age was strongly associated with more pain both at rest, during activity and regarding worst pain since discharge. Postdischarge nausea was present in 17.8%, and vomiting in 1.2%. High pain score during activity and higher level of worst pain, were associated with nausea. There was no association between nausea and age, type of anaesthesia, surgical procedure or pain at rest. Patient satisfaction was high (97.8%-99.7%) regarding information, time for discharge and overall satisfaction.

CONCLUSION

Pain scores and incidence of nausea were generally low on the day after surgery. Young age was a strong predictor for postdischarge pain. A high worst pain score and high pain score during the activity were associated with postdischarge nausea. Patient satisfaction was high.

Same‐day mastectomy and axillary lymph node dissection is safe for most patients with breast cancer

Background and Objective

The aim of this study was to evaluate the safety of same‐day mastectomy, with or without a sentinel node biopsy (SNB) and/or axillary lymph node dissection (ALND).

Methods

In this retrospective study, we reviewed 913 consecutive women who underwent a simple mastectomy for breast cancer between the years 2014 and 2019 and were treated either with same‐day surgery (SDS) or an overnight stay (OS) regime. We reviewed all surgical complications, any unplanned return to care (RTC) and the rehospitalization rate for 30 postoperative days.

Results

A total of 259 patients (28%) were treated with SDS and 654 patients (72%) with an OS regime. There was no difference in RTC (odds ratio: 0.79 [95% confidence interval: 0.53–1.18], p = 0.26) or any major complications between the groups. None of the investigated subgroups, such as patients with previous neoadjuvant therapy, diabetes, obesity (up to a body mass index of 40 kg/m²), the American Society of Anaesthesiologist Class of 3, or elderly patients aged 75–84 years, showed an increased complication rate when treated with the SDS regime.

Conclusion

A same‐day simple mastectomy is safe with SNB and/or ALND. It can be performed safely for most patients with stable co‐morbidities.

[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.

Same-Day Surgery for Mastectomy Patients in Alberta: A Perioperative Care Pathway and Quality Improvement Initiative

BACKGROUND

Same-day surgery (SDS) following mastectomy is safe and well accepted. Overnight admission in patients fit for discharge is an inefficient use of health resources. In response to a national review highlighting SDS following mastectomy at 1.4% in Alberta, a perioperative pathway was conceived.

METHODS

The pathway was implemented across Alberta at 13 hospitals beginning in 2016. A steering committee was assembled, and clinical and administrative leads at each site were identified. Opportunities along the patient care experience whereby action could be taken to promote uptake of SDS were identified. Provincially branded support materials including presentations, order sets, and standard operating procedures were developed. Nurse educators provided in-service teaching such as standardized drain care and discharge teaching. Educational booklets, group classes, and online resources were developed for patients and families. An audit of SDS rates, unscheduled return to the emergency department (ED), and readmission rates was reported to teams quarterly, allowing for iterative modifications. Patient-reported experience measures (PREMs) were collected.

RESULTS

SDS following mastectomy increased from 1.7 to 47.8%, releasing an estimated 831 bed days per year. No differences in unexpected return to the ED or readmission to hospital existed between SDS patients and those admitted overnight. A total of 102 patients completed the PREM survey, of whom 90% felt "excellent or good" with the plan to go home, how to care for themselves once home, and who to contact should issues arise.

CONCLUSIONS

Implementation of a provincial perioperative pathway improved uptake of SDS following mastectomy and demonstrated favorable PREMs.