Patients' perspective on day case breast surgery

Perioperative protocols in ambulatory breast reconstruction: A systematic review

INTRODUCTION

Recent studies have successfully employed perioperative protocols and Enhanced Recovery After Surgery (ERAS) protocols to promote and increase the range of breast reconstruction procedures performed in ambulatory settings. This systematic review aims to identify the common perioperative protocol items associated with successful ambulatory breast reconstruction.

METHODS

A systematic review of electronic databases (Ovid Medline, EMBASE, and Cochrane) was conducted. Studies that described the perioperative care protocol for postmastectomy breast reconstruction in ambulatory settings (discharge within 24 h) were included. Two reviewers independently screened the literature and extracted the data. Risk of bias was assessed with the National Heart, Lung, and Blood Institute quality tool. The perioperative protocol details, type of reconstruction, information regarding patient selection criteria, successful discharge rates, and complication rates were extracted.

RESULTS

Twelve studies were included in the systematic review, with 1484 patients undergoing ambulatory breast reconstruction with a well-defined perioperative protocol. Sixteen perioperative items were identified. The most discussed items were preoperative counseling (11/12), preoperative and intraoperative multimodal analgesia (11/12), and postoperative analgesia (10/12). Our recommendation includes two new items and seven modified items compared to previous ERAS guidelines. Overall, the mean number of items was 9.22 in same-day discharge and 6.75 in 24-h discharge (P = 0.169). 78.4% of the patients (1123 of 1433) were successfully discharged within 24 h. No studies identified an increase in readmission or complications with ambulatory discharge.

CONCLUSION

Sixteen core items were defined for a successful perioperative ERAS protocol for 24-h discharge breast reconstruction. Implementing perioperative protocols can facilitate under-24-h discharge for alloplastic and autologous surgery.

Breast surgery: a narrative review

Breast cancer is the commonest human cancer globally and one in seven Australian women will develop it in their lifetime.

Surgery is the mainstay of management both for women who are at high risk of breast cancer and for those who have been diagnosed.

Increased understanding of how to predict who is most at risk of breast cancer is leading to the possibility of risk‐based screening, allowing better and more targeted early detection for women at high risk, and contrast imaging techniques are proving more accurate in diagnosing and staging cancer.

The evolution of surgical practice includes the widespread use of oncoplastic surgery, allowing better cosmetic and oncological outcomes; reconstructive surgical advances, using free flap techniques; and sequencing of systemic and local therapies to better tailor treatments to the patient’s cancer and improve outcomes.

Recognition of side effects of breast cancer treatment have led to improvement in the management of conditions such as chronic pain and lymphoedema, as well as addressing the psychosocial, body image and sexual complications caused by the cancer and its treatment.

Outcome reporting in therapeutic mammaplasty: a systematic review

BACKGROUND

Therapeutic mammaplasty (TM) is an oncological procedure which combines tumour resection with breast reduction and mastopexy techniques. Previous systematic reviews have demonstrated the oncological safety of TM but reporting of critically important outcomes, such as quality of life, aesthetic and functional outcomes, are limited, piecemeal or inconsistent. This systematic review aimed to identify all outcomes reported in clinical studies of TM to facilitate development of a core outcome set.

METHODS

Medline, EMBASE, CINAHL and Web of Science were searched from inception to 5 August 2020. Included studies reported clinical outcomes following TM for adult women. Two authors screened articles independently for eligibility. Data were extracted regarding the outcome definition and classification type (for example, oncological, quality of life, etc.), time of outcome reporting and measurement tools.

RESULTS

Of 5709 de-duplicated records, 148 were included in the narrative synthesis. The majority of studies (n = 102, 68.9 per cent) reported measures of survival and/or recurrence; approximately three-quarters (n = 75, 73.5 per cent) had less than 5 years follow-up. Aesthetic outcome was reported in half of studies (n = 75, 50.7 per cent) using mainly subjective, non-validated measurement tools. The time point at which aesthetic assessment was conducted was highly variable, and only defined in 48 (64.0 per cent) studies and none included a preoperative baseline for comparison. Few studies reported quality of life (n = 30, 20.3 per cent), functional outcomes (n = 5, 3.4 per cent) or resource use (n = 28, 18.9 per cent).

CONCLUSION

Given the oncological equivalence of TM and mastectomy, treatment decisions are often driven by aesthetic and functional outcomes, which are infrequently and inconsistently reported with non-validated measurement tools.

Day-case approach to immediate breast reconstruction: pushing the boundaries of ambulatory breast surgery in the post-COVID-19 era

INTRODUCTION

Day-case surgery is safe and efficacious for most breast surgical procedures. Limited data exist on its use in immediate breast reconstruction. We present our experience of day-case management of mastectomy with immediate pre-pectoral implant-based reconstruction (IBR).

METHODS

Data were collected on 47 patients who underwent day-case skin-sparing (SSM) or nipple-sparing (NSM) mastectomy with pre-pectoral IBR between October 2017 and September 2019. Clinicopathological data were collected, including postoperative complications, re-admission and re-operation. The data were compared to published national standards.

RESULTS

Median age was 52 years (range 37-74). Thirty-two patients (68%) had an SSM and 15 (32%) had an NSM. Two patients (4%) had risk-reducing mastectomies and 45 had treatment for invasive cancer or ductal carcinoma in situ (DCIS). Mean tumour size was 33.3mm (range 7-85mm). Forty-two (89%) patients went home on the day of surgery. No patients required re-operation in the first 48 hours. The median postoperative follow-up time was 11.4 months (range 1.8-22.7 months). During the first 90-day postoperative period, eight patients (17%) developed superficial skin necrosis, five patients (10.6%) developed postoperative infections and five patients (10.6%) suffered an implant loss. Eight patients (17%) were readmitted for re-operation. Compared to UK national standards set in the iBRA study, our cohort has demonstrated comparable postoperative infection, implant loss and re-operation and re-admission rates.

CONCLUSION

We have demonstrated close to 90% day-case success rate for mastectomy with IBR. These early data suggest that immediate IBR can be carried out in a manner that is cost-efficient without impacting surgical outcomes.

Is same-day discharge associated with increased 30-day postoperative complications and readmissions in patients undergoing laparoscopic adrenalectomy?

BACKGROUND

Advances in minimally invasive surgery and perioperative care have decreased substantially the duration of time that patients spend recovering in hospital, with many laparoscopic procedures now being performed on an ambulatory basis. There are limited studies, however, on same-day discharge after laparoscopic adrenalectomy. The objectives of this study were to investigate the outcomes and trends of ambulatory laparoscopic adrenalectomy in a multicenter cohort of patients.

METHODS

Adult patients who underwent elective laparoscopic adrenalectomy between 2005 and 2016 were identified in the database of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). Baseline demographics and 30-day outcomes were compared between patients who underwent ambulatory laparoscopic adrenalectomy and those who were discharged after an inpatient stay. Multivariable logistic regression and Cox proportional hazards modelling were used to investigate the association between same-day discharge and 30-day complications and unplanned readmissions.

RESULTS

Of the 4,807 patients included in the study, 88 (1.8%) underwent ambulatory laparoscopic adrenalectomy and 4,719 (98.2%) were admitted after the adrenalectomy. The same-day discharge group contained fewer obese patients (37.2% vs 50%; P = .04), a lesser proportion of American Society of Anesthesiologists class III patients (45.5% vs 61%; P = .003), and more patients with primary aldosteronism (14.8% vs 6%; P = .002) compared with the inpatient group. After adjustment for confounders, same-day discharge was not associated with 30-day overall complications (OR 1.17, 95% CI 0.35-3.85; P = .80) or unplanned readmissions (HR 2.77, 95% CI 0.86-8.96; P = .09). The percentage of laparoscopic adrenalectomies performed on an ambulatory basis at hospitals participating in the ACS NSQIP remained low throughout the study period (0-3.1% per year) with no evidence of an increasing trend over time (P = .21).

CONCLUSION

Ambulatory laparoscopic adrenalectomy is a safe and feasible alternative to inpatient hospitalization in selected patients. Further study is needed to determine the cost savings, barriers to uptake, and optimal selection criteria for this approach.

Effective drain care and management in community settings

The literature indicates that drain monitoring is a frequently undervalued aspect of patient care, and that the drain care provided is often inconsistent and inadequate. There are numerous potential implications of suboptimal drain care for patients, nurses, teams and healthcare organisations. Since acute care is increasingly being delivered in the community, there is a greater need for nurses to have an understanding of effective drain care. This article describes the rationale for drain insertion and its associated complications. It uses a case study to illustrate how suboptimal drain monitoring and documentation can negatively affect patient care and safety. This article also discusses several important issues raised in the case study, such as suboptimal documentation, and how these may have consequences for nurses, teams and healthcare organisations. Recognition of these elements supports initiatives that nurses could apply to practice to reduce the occurrence of similar incidents.

Is group and save still a necessary test in the preoperative workup for breast cancer surgery?

INTRODUCTION

Trust guidelines state that patients undergoing mastectomy have one group and save (G&S) sample preoperatively, or two for bilateral or complex mastectomy. Breast surgical patients rarely require blood transfusion, and G&S testing is costly and labour intensive. Our study assessed whether preoperative G&S testing is warranted for breast surgery patients.

METHODS

Retrospective review of consecutive patients undergoing mastectomies from one centre, from June 2018 to June 2019 identified 190 women. Review of electronic records for G&S tests was performed and transfusions prescribed. Discussion with laboratory personnel regarding costs of processing G&S tests.

RESULTS

Forty-six (32%) patients who underwent simple mastectomies had one G&S, eight (6%) patients had two. Twenty (45%) patients who underwent bilateral/complex mastectomy/reconstruction had one G&S and four (9%) had two. No patients required peri or postoperative blood transfusions. Seventy-eight G&S tests performed cost the trust £1,082.

CONCLUSION

Simple mastectomies rarely require blood transfusions. G&S tests cost £13.83 and are time consuming for the patient and laboratory. We propose that G&S tests are unnecessary for patients undergoing simple mastectomies and preoperative protocols require adjustment. Trust policy is to have 'routine G&S'; however, 124 patients did not have any G&S testing. Had the guideline been followed, this would have cost the Trust a further £1,715.

Effective drain care and management in community settings

The literature indicates that drain monitoring is a frequently undervalued aspect of patient care, and that the drain care provided is often inconsistent and inadequate. There are numerous potential implications of suboptimal drain care for patients, nurses, teams and healthcare organisations. Since acute care is increasingly being delivered in the community, there is a greater need for nurses to have an understanding of effective drain care. This article describes the rationale for drain insertion and its associated complications. It uses a case study to illustrate how suboptimal drain monitoring and documentation can negatively affect patient care and safety. This article also discusses several important issues raised in the case study, such as suboptimal documentation, and how these may have consequences for nurses, teams and healthcare organisations. Recognition of these elements supports initiatives that nurses could apply to practice to reduce the occurrence of similar incidents.

Role of dexmedetomidine as an anaesthetic adjuvant in breast cancer surgery as a day-care procedure: A randomised controlled study

Background and Aims:

Breast cancer surgery can be carried out as day-care procedure to increase patient turnover, decrease disease progression and financial burden. The present study was carried out to assess the role of dexmedetomidine in breast cancer surgery as a day-care procedure.

Methods:

This prospective randomised, double-blind study was carried out on 100 patients screened for day-care breast cancer surgery. They were divided into two groups of 50 each; who received either normal saline (Group NS) or 0.6 μg/kg/h dexmedetomidine (Group D) infusion from 10 min before induction until skin closure. All patients were given general anaesthesia. The incidence of discharge, post-operative pain (POP), average rescue analgesia (fentanyl) required and side effects were noted. Statistical analysis was performed using Student's t-test and Chi-square test.

Results:

Incidence of discharge in group NS was 60% compared to 88% in Group D (P = 0.001). Average rescue analgesia requirement by group NS was 136.07 ± 43.06 μg, whereas it was 77.5 ± 29.86 μg in Group D (P = 0.01). The incidence of POP in 6 h and within 2 h of expected discharge time in Group NS was 56% and 28%, respectively, and in Group D, it was 8% in both the periods (P < 0.001 and 0.01). Side effects such as post-operative nausea, vomiting and bleeding were encountered in eight and two patients, respectively, in Group NS and two and one patients, respectively, in Group D.

Conclusion:

Dexmedetomidine as an anaesthetic adjuvant makes breast cancer surgery feasible on day-care basis.

Distress and Psychosocial Needs in Patients Accessing a Cancer Day Surgery Division: Implications for Clinical Decision Making

Introduction: The Distress Thermometer (DT) was built and validated for screening cancer patients for distress, as suggested by the National Comprehensive Cancer Network. The current work was designed to measure the rates of distress in a sample of patients being hospitalized in a multidisciplinary outpatient surgery clinic.

OBJECTIVE

To measure the rates of distress in a sample of patients referring to a multidisciplinary day surgery division in a comprehensive cancer center based in Northern Italy. Methods: A total of 177 patients were asked to fill in the (DT) before surgery. Results: Out of 177 patients, 154 (87%) patients completed the DT. While 13% of the patients indicated a total absence of distress, more than half of the sample declared a moderate or high distress. A total of 55% of patients presented at least three difficulties in the Problem List Checklist. Distress was not correlated with age or other medical and clinical variables. Number of emotional problems was the best predictor of distress at admission (β = 0.655, p = 0.000). Conclusion: Screening for distress in a day surgery multidisciplinary oncology division is feasible and a relevant percentage of patients can be identified as clinically distressed. Outcomes also highlight the impact of age and precise physical and psycho-social signs as prognostic indicators of clinically significant distress. Measurement of distress and associated problems list represent the preliminary endpoint toward adequate recommendations that contribute to taking care of distress in cancer patients in cost-effective clinical setting.

The safety of same-day breast reconstructive surgery: An analysis of short-term outcomes

BACKGROUND

We sought to examine the safety of same-day breast reconstructive (BR) surgery.

METHODS

An analysis of the American College of Surgeons, National Surgical Quality Improvement Program (ACS-NSQIP) files was performed. Patients undergoing BR for breast cancer were examined, excluding those with high-risk co-morbidities or concurrent surgery. A propensity score was calculated and a multivariable logistic regression analysis was used to calculate the difference in 30-day complications between those undergoing SDS versus longer hospital stay.

RESULTS

The study consisted of 21,539 patients; 17,449 had implant and 4090 had autologous breast reconstruction. 1195 (5.5%) underwent SDS, whereas 20,344 (94.5%) were admitted at least overnight. On unadjusted analysis, the rate of post-operative complications was nearly three times higher in those admitted compared to those undergoing SDS (6.7% vs. 2.5%; p < 0.001). On propensity score adjusted multivariable regression there was no significant difference in complications amongst those undergoing SDS versus staying in hospital (OR 1.4 (95%CI: 0.9, 2.2)).

CONCLUSIONS

These results suggest that admitting BR patients does not prevent short-term complications and same day BR surgery is safe when co-morbidities are accounted for.

Patient anxiety on the use of one step nucleic acid amplification (OSNA) during breast cancer surgery

INTRODUCTION

Assessment of the sentinel lymph node biopsy (SLNB) is used to stage the axilla in patients with breast cancer. There are a variety of methods to assess metastatic disease within the SLN. One-step nucleic acid amplification (OSNA) has a high sensitivity for detecting metastatic disease within the SLN and avoids the use of staged axillary surgery. However there remains a paucity of data within the literature on the psychological effects upon patients with the use of OSNA.

METHODS

All patients undergoing breast surgery (breast-conserving surgery or mastectomy) and assessment of the SLNB with OSNA from December 2011 to June 2012 were included in the study. A questionnaire was sent to patient within four weeks of surgery to assess their understanding and satisfaction with the OSNA procedure.

RESULTS

60 patients responded to the questionnaire (83% response rate). All patients were female with a mean age of 63 years (range 38-71 years). 19 patients had positive SLNB as assessed by OSNA and all had ALND. 15 patients expressed pre-operative anxiety about having OSNA although 97% stated that they would be happy to undergo the same procedure again.

CONCLUSION

Our study has identified the anxiety points that patients experience with OSNA based management and this will allow improved direct emotional support and provision of information.