Same-Day Discharge Following Simple and Modified Radical Mastectomies

INTRODUCTION: With the pressure to reduce both cost of care and in-patient hospitalizations, particularly in the COVID era, several groups have reported the feasibility of outpatient mastectomies utilizing enhanced recovery after surgery (ERAS) programs. Having converted most mastectomies to the outpatient setting in 2009, we examined our experience sending patients home the same day, including patient selection, unexpected admission and post-operative complications, to better inform institutions considering their own outpatient mastectomy programs. METHODS: With approval from the Institutional Review Board, we performed a retrospective cohort study of patients undergoing mastectomy at a single academic medical center from 2014-2020. Patient population included all patients undergoing mastectomy for malignant disease or risk reduction and excluded patients having immediate breast reconstruction. RESULTS: Of 1678 patients undergoing mastectomy in this time period, 810 did not have immediate reconstruction. Overall, 428 (53%) were planned as outpatient procedures. This was dependent on the type of procedure;unilateral mastectomy (UM) (70%), modified radical mastectomy (MRM) (50%), bilateral simple mastectomies (BSM) (39%) and MRM with contralateral prophylactic mastectomy (MRM/CPM) (25%). The latter two increased over the time course of the study. Admission was associated with ASA status (34% ASA 1/2 vs 51% ASA 3/4, p< 0.001). The most significant predictor was surgeon, with rates ranging from 85% to 46% for UM, 80% to 13% for MRM, 68% to 18% for BSM and 55% to 9% for MRM/CPM. Overall, 16 (3.7%) same-day surgery patients were admitted while 14 (3.8%) 23-hour admission patients were converted to inpatient admissions. Post-operative hematomas requiring a second operation were more common with planned admission compared to those planned for same day discharge (19 (4.9%) vs. 10 (2.3%), p=0.036). CONCLUSIONS: Mastectomies (including bilateral and modified radical mastectomies) without reconstruction can be safely performed on an outpatient basis. Rates of unexpected hospitalizations and post-operative complications are low and there is no difference between those patients planning on same-day discharge and those planned for admission.

MINIMAL CHANGE DISEASE SECONDARY TO SARS-COV-2 (COVID-19) INFECTION: A REPORT OF 2 CASES AND REVIEW OF RELATED LITERATURE

BACKGROUND AND AIMS: The COVID-19 pandemic has brought to the forefront a wide spectrum of renal injuries that included glomerulopathies, some of which were recently highlighted in various case reports. These consist of focal and segmental glomerulosclerosis (FSGS) and minimal change disease (MCD).1 These changes were found among seemingly vulnerable populations such as the African American and Caucasian ethnicities with paucity of reports among other races. We present two cases of biopsy-confirmed MCD secondary to COVID-19 infection among adult Filipino patients. METHODS: Case Report RESULTS: Case 1 A 40-year-old Filipino female with a history of right total mastectomy 2 years prior for a low-grade phyllodes tumor and no other medical comorbidities was admitted due to stillbirth. She was noted to have bipedal edema with a positive COVID-19 RT-PCR swab. Further workup revealed a serum creatinine 1.04 mg/dL, urine RBC 1/HPF and a 24-h urine protein of 9.22 g with hypoalbuminemia and dyslipidemia. Serologic workup was noted to be negative. She was started on Losartan, Atorvastatin, and Furosemide. A kidney biopsy was performed which demonstrated unremarkable light microscopy and immunofluorescence and widespread podocyte-foot process effacement. These biopsy findings were interpreted to be consistent with minimal change disease. She was started on Prednisone at 1 mg/kg/day with continuation of both Losartan and Atorvastatin. Six weeks after, the patient achieved complete remission with resolution of both hypoalbuminemia and dyslipidemia. She also reports no further recurrence of edema. Case 2 A 61-year-old Filipino male with a history of type 2 diabetes mellitus, hypertension, dyslipidemia and mild COVID-19 infection 4 months prior now presented with diarrhea. A routine COVID-19 RT-PCR swab revealed a re-infection. Physical examination noted bipedal edema. Further workup demonstrated a serum creatinine 3.39 mg/dL, urine RBC 2/HPF and urine ACR 2.6 g/g. Serologic tests were negative. He was diagnosed with Nephrotic Syndrome and underwent kidney biopsy. Findings showed an unremarkable light microscopy and immunofluorescence with widespread podocyte-foot process effacement. These findings were found to be consistent with minimal change disease and acute tubular injury. He was started on Prednisone (1 mg/kg/day), Losartan, Furosemide and Atorvastatin. Eight weeks later, the patient achieved complete remission with resolution of edema. CONCLUSION: It is currently suspected that APOL1 risk variants found in reported cases of COVID-19-associated glomerulopathies are underlying toxic gain-of-function mutations that drive kidney disease.2 It is interesting to note that APOL1 renal risk variants are found exclusively in African-derived chromosomes and are rarely found among European or Asian chromosomes.3 Even though an APOL1 genotyping was not performed, our case reports provide the first examples of MCD among individuals without a high-risk genotype (APOL1) by epidemiology and enlarge the literature on MCD in COVID-19. We posit that there may be other underlying predispositions or mechanisms that may be driving glomerulopathy formation among COVID-19 patients aside from their inherent APOL 1 risk. Both of our patients were started on steroid therapy with a tapering regimen and achieved complete remission on subsequent follow-up. Existing reports suggest that most cases of COVID-19-associated MCD will often achieve resolution of AKI and proteinuria with steroid therapy, even in those with high-risk APOL1 genotype, emphasizing the need for an accurate histologic classification.4 (Figure Presented).

Comparison of patient satisfaction and outcomes of day case mastectomy versus inpatient model, using a validated questionnaire

Introduction: Many women undergoing simple mastectomy have an overnight hospital stay. Offering a day case procedure for simple mastectomy has the potential to improve outcomes in terms of patient safety, feasibility, and reduction in associated costs. We aimed to study the proportion of day case mastectomies over a 2-year period and assessed relative readmission and complication rates alongside patient reported outcome measures (PROMs). Following this, we wanted to analyse whether a day case procedure should be routinely offered. Method: A retrospective audit was conducted on all patients undergoing a simple mastectomy. Data were collected from patient and pathology records. PROMs were obtained via telephone conversation using the validated BREAST-Q survey. Patient demographics, reason for mastectomy and readmission for complications were all assessed. Results: Out of the 202 patients analysed, over 75%had an overnight stay. The most common complications for both groups of patients were readmission due to infection and haematoma evacuation, with similar rates across the two (p=0.26, p=0.69). Data from PROMs also suggested that patients had similar outcome and satisfaction levels (p=0.27). Conclusions: The result from this study shows that it is safe as well as acceptable to patients to offer simple mastectomies as a day case procedure. This has become more important since COVID-19 reduced inpatient theatre capacity, and it is anticipated that these outcomes will allow a routine day case mastectomy pathway to be established even when normal operations recommence as encouraged by the association of day case surgery.

Teleconsultation after outpatient total mastectomy

Background: In response to regulations related to the COVID 19 pandemic and to patient demand, an outpatient total mastectomy pathway has been implemented at the Léon Bérard Center (CLB). This study evaluates the implementation of this pathway in terms of postoperative complications and patient satisfaction. Materials and Methods: Observational, retrospective, uni-centric study comparing two care pathways: traditional hospitalization versus outpatient care, for a total mastectomy associated or not with an axillary lymph node procedure. In the outpatient care, a teleconsultation by the coordinating nurses (IDEC) was performed the day after the surgery (D1 postoperative). Patient satisfaction in the outpatient care protocol was assessed by means of a satisfaction questionnaire sent by e-mail, in person or by telephone. Results: Between January 2020 and March 2021, 314 total mastectomies, without immediate breast reconstruction, associated or not with an axillary lymph node procedure, were performed at CLB. Thirty-six patients (11.46%) benefited from the outpatient program. We matched them in age and ASA score with 36 patients who underwent total mastectomy in traditional hospitalization during the same period. The complication rate in our cohort was 54.2%, 30.6% of which were lymphoceles. The postoperative complication rate and the revision surgery rate were not significantly different between the 2 groups (p=0.509, p=0.614). Five patients (13.9%) in the outpatient protocol were converted to traditional hospitalization. No patient in the outpatient program was rehospitalized for a surgical complication. In 66.7% of cases, the teleconsultation on D1 post-operation was carried out between the patient, the IDEC and the nurse in the patient's home who was responsible for the rest of the management. The patients in the outpatient protocol responded to the satisfaction questionnaire in 83.3% of cases. The overall satisfaction rate was rated at 4 or 5 out of 5 in 72.2% of cases. Patients would recommend the outpatient program to a relative in 90% of cases. Conclusions: Our study highlights the feasibility of outpatient total mastectomy, with good patient satisfaction. Teleconsultation at D1 post-op facilitates the link between the surgical management center and the city, favoring continuity of care.

Why do people remain in hospital after mastectomy?

Aims: Mastectomy is established as a safe day-case procedure. Amidst the ongoing COVID-19 pandemic it is essential to find ways to continue elective surgery with greater efficiency. The aim of this study is to establish factors associated with overnight admission after simple mastectomy, enabling more effective pre-operative planning. Methods: All patients undergoing simple mastectomy in our unit between January and October 2020 were included. Those undergoing immediate reconstruction were excluded. The electronic case notes were reviewed to include procedure performed and patient characteristics. Basic statistical analysis was performed. Results: 95 patients underwent simple mastectomy (28 with axillary clearance and 58 with sentinel node biopsy). 56% of procedures were day-case. Axillary clearance was more common in the inpatient compared to the day-case surgery group (24% vs 45%). Both average age and ASA were significantly lower in the day-case compared to the inpatient group (p<0.05). There was no significant difference in BMI or specimen weight between groups. 16 patients underwent simple mastectomy without drain insertion, none required admission. Of the patients admitted overnight following surgery, 50% were pre-planned admissions. 57% of these were for patients identified as high surgical or anaesthetic risk at pre-operative assessment. Overall 5 patients stayed in hospital due to patient preference. Conclusions: In addition to axillary surgery performed, age, ASA and perceived pre-operative risk are associated with overnight admission following simple mastectomy. Knowledge of these factors can better inform pre-operative planning. Providing enhanced post-operative support at home may enable more patients to be discharged on day of surgery.

The reliability of breast cancer surgery in a regional pandemic hospital during the COVID-19 pandemic: Delay or Do?

Purpose: The purpose of this study was to examine the effect of COVID-19 infection on the morbidity and mortality rates of breast cancer patients performed in the East Mediterranean region of Turkey during the COVID-19 pandemic and to share the results of those investigations. Methods: This retrospective study included all breast cancer patients that underwent surgery during the COVID-19 pandemic in the General Surgery Clinic of Adana City Training and Research Hospital, a regional pandemic hospital, between March 11, 2020 and December 25, 2020. The patients were evaluated preoperatively and postoperatively (the first 30 days) in terms of COVID-19 infection. Moreover, these patients were also evaluated in terms of admission to the hospital, length of hospital stay, and mortality due to COVID-19 infection during the follow-up period of the study. Results: Included in the study were 139 patients that underwent surgery for breast cancer during the pandemic period, with no observed mortality or morbidity associated with COVID-19 in any patient postoperatively within the first 30 days. In addition, within 121.22±70.05 days, the mean and standard deviation of the study's follow-up period, 19 patients (15.7%) were admitted to the hospital with a suspected COVID-19 infection (after the first 30 days postoperatively) and 6 of them (4.3%) returned a positive PCR test. All of the COVID-19 positive patients (6 patients, 4.3%) were hospitalised and 3 of them (2.2%) died due to the COVID-19 infection. Conclusions: Breast cancer surgery can be performed safely during the COVID-19 pandemic period after taking the necessary precautions.