Flap Anchoring Following Primary Breast Cancer Surgery Facilitates Early Hospital Discharge and Reduces Costs.

BACKGROUND: Routine drain placement after breast cancer surgery is standard practice. Anchoring the axillary and mastectomy flaps to the underlying chest wall with sutures has been advocated as a means of avoiding drainage following breast surgery. This study compares outcomes following flap fixation or routine drain placement and uniquely considers the economic implications of each technique. PATIENTS AND METHODS: Data on seroma formation and wound infection following mastectomy and axillary clearance were recorded prospectively. Patients underwent either routine drain placement or flap anchoring using subcutaneous tacking sutures without drainage. Equipment and surgical bed costs were provided by our finance department. RESULTS: Data was available for 135 patients. 76 underwent flap anchoring without drainage and 59 had routine drainage. There was no difference in seroma rates between the two groups: 49% vs. 59% (p = 0.22). However, the length of hospital stay was reduced in the flap fixation group: 1.88 vs. 2.67 days (p < 0.0001). Per patient, flap suturing equated to an estimated financial saving of £ 240. CONCLUSIONS: Flap anchoring resulted in a significantly shorter hospital stay than routine drainage, with a comparable rate of seroma formation. This technique presents a viable alternative to drain placement and could lead to a considerable economic savings.

Perioperative fluid restriction reduces complications after major gastrointestinal surgery.

The physiologic response to surgical trauma promotes sodium and water retention AND weight gain owing to perioperative fluid loading increases morbidity SO perioperative fluid restriction should reduce postoperative complications after gastrointestinal surgery.

Serum calcium slope predicts hypocalcaemia following thyroid surgery.

BACKGROUND: Hypocalcaemia is the single commonest complication of thyroid surgery. Typically, serial calcium levels are performed post-operatively in order to detect hypocalcaemia, often requiring at least a 48-h stay. Our practice is to measure serum corrected calcium pre-operatively, 6 h post-operatively and 24 h post-operatively. Patients are discharged if they have a normal serum calcium value at 24 h. METHODS: We performed a retrospective review to determine if the calcium slope from pre-operatively to 6 h post-operatively predicts serum calcium levels at 24 h, thus allowing early discharge. RESULTS: Fifty-two patients who underwent total or subtotal thyroidectomies were studied. Hypocalcaemia developed in 19 patients within 24 h of surgery (serum adjusted calcium less than 2.15 mmol/dL) within 24 h of surgery. There were no significant differences between the hypocalcaemic and normocalcaemic groups with respect to Graves' disease (p=0.17), total thyroidectomy (p=0.39), number of parathyroids identified (p=0.66), or parathyroid autotransplantation (p=0.29). The serum calcium slope from baseline to 6 h post-operatively correlated with serum calcium values at 24 h (p=0.008). CONCLUSION: Serum calcium slope may be useful in identifying patients suitable for early discharge following thyroid surgery.

Early management of atrial fibrillation in general surgical in-patients.

BACKGROUND: It has been suggested that new-onset atrial fibrillation (AF) in non-cardiac surgical patients should trigger a thorough search for other morbidity. We reviewed our unit's management of new-onset AF to determine whether this target is achieved. METHODS: Patients under the care of a general surgeon who developed new-onset AF during their inpatient stay were identified from a prospectively maintained database of surgical in-patients. Their case-notes were reviewed to determine whether a precipitating cause for the AF was sought or identified. RESULTS: Thirty-one patients developed new-onset AF. Almost half had positive findings on cardiovascular or respiratory system examination and assessment. However, 35% of patients had no respiratory examination, 58% had no cardiovascular examination and 55% had no abdominal examination performed. Eighty-one percent had another underlying complication diagnosed within 24h of the AF. Twenty-six percent had an intra-abdominal collection. Of those with an underlying complication, 52% were not diagnosed at the time of initial assessment for AF. Twenty percent of patients died within 30 days of the AF. CONCLUSIONS: New-onset AF in general surgical patients is associated with considerable morbidity. A thorough clinical evaluation and early involvement of senior surgical staff are recommended.