Time to Radiation After Oncoplastic Reduction.

BACKGROUND: Partial breast reconstruction with reduction mammaplasty is an accepted option for women with breast cancer who wish to receive breast conserving therapy. With additional surgery and potential postoperative complications, the impact this approach has on the timely initiation of adjuvant radiation therapy has been raised as a concern. The purpose of this study was to determine if any postoperative complications after oncoplastic reduction (OCR) are associated with a delay in time to radiation. METHODS: All patients undergoing OCR with postoperative adjuvant radiation at a single institution between 1997 and 2015 were included in the analysis. Women who received adjuvant chemotherapy or experienced delays in radiation therapy due to nonsurgical reasons were excluded from our analysis. Comparisons were made between the time to radiation for patients with surgical complications and those without. RESULTS: One hundred eighteen patients were included. Twenty-six (22.0%) experienced a surgical complication. Complications included cellulitis, delayed healing, seroma, wound breakdown, and wound dehiscence. Postoperative complications resulted in a significantly different median time interval for initiation of radiation (74 days vs 54 days, P < 0.001) compared to those without a complication. Among the entire cohort, 5% of patients required a second operative procedure due to complications. (n = 6/118 patients) including hematoma, infection, seroma, open wounds, wound dehiscence, and nipple necrosis. There was no difference in median time to radiation therapy in those with complications who returned to the operating room (73 days) compared to those who did not (74 days, P = 0.692). CONCLUSION: Postoperative complications following OCR procedures were associated with an increased time to initiation of adjuvant radiation therapy regardless of whether or not the complication required reoperation. This needs to be taken into consideration when planning these combined procedures with every attempt made to minimize complications through patient selection and surgical technique.

Scaling up short-term humanitarian surgery: a global surgery elective for senior medical students.

OBJECTIVES: The proportion of US medical students participating in global health has increased by 24%. These experiences are generally self-directed and lack a formal educational component. This article describes a structured, comprehensive, community-driven global surgery elective for senior-year students. DESIGN: "Surgery and Global Health" is a monthlong elective during which students shadow in the university hospital, lead discussions of an assigned text, attend lectures, and participate in a clinical rotation in rural Haiti. The first week is didactic and takes place in Atlanta, GA. Weeks 2 through 4 are clinical and are conducted in Haiti. Urological and general surgery procedures are performed during weeks 2 and 3, while the final week is reserved for follow-up care. This experience was institutionally supported. SETTING: Emory University Hospital, Atlanta, GA; L'Hôpital St. Thérèse, Hinche, Centre, Haiti. PARTICIPANTS: Emory University School of Medicine students, years 2 through 4, supervised by faculty from the departments of Urology, General Surgery, and Anesthesiology. Senior-year students spent 21 days in central Haiti working in a rural clinical setting. RESULTS: Students participated in all facets of surgical care including preoperative clearance, postanesthesia care, discharge planning, and follow-up. Students felt a level of supervised responsibility that was not afforded at their home institution and were able to take on more advanced clinical roles. CONCLUSIONS: Students planned and executed this innovative experience with multidisciplinary, departmental, and institutional support. Stateside components introduced students to Haitian culture, global surgery ethics, and humanitarian surgical trip logistics. Structured global health experiences such as this give students practical skills and incentive to pursue careers involving global surgery.

The management of abdominal contour defects following TRAM flap breast reconstruction.

BACKGROUND: Incisional hernia can develop following breast reconstruction with abdominal tissue regardless of technique, and the management is often challenging. OBJECTIVES: The authors characterize hernias following transverse rectus abdominis musculocutaneous (TRAM) flap procedures and evaluate outcomes of different strategies for repair. METHODS: All patients who underwent repair of a TRAM-related hernia or bulge between 2003 and 2011 at a single institution were retrospectively reviewed. A minimum of 2 years' follow-up was required for inclusion in this series. Outcomes of different techniques for repair were compared and risk factors for hernia recurrence identified. RESULTS: Forty-three patients underwent repair of a TRAM-related hernia or bulge, most often with mesh (74.4%, n=32). At a mean overall follow-up of 5.2 years, 9 patients (20.9%) developed recurrent hernia or bulge. Compared to primary suture closure, the use of mesh was protective against recurrence (odds ratio, 0.05; 95% confidence interval, 0.00-0.65; P=.02), with the best results observed with fascial closure and underlay mesh reinforcement. CONCLUSIONS: Incisional hernia following TRAM flap breast reconstruction can be a challenging problem. Attention to surgical technique and the use of mesh minimize the risk of recurrence.

Two cases of restavek-related illness: clinical implications of foster neglect in Haiti.

Restaveks, or indentured foster children, are a poorly understood, vulnerable subclass of Haitian society. From 2001 to the present, a partnership between multiple US academic medical centers and Project Medishare for Haiti has held an ongoing series of mobile clinics in rural Haiti. Multiple cases of restavek-related illness were identified. At a recent pair of mobile clinics, the authors identified two restavek cases that were significantly worse off than their communal peer groups and required immediate care. Given the lack of a robust legal support to protect orphaned children in Haiti, clinicians have an important role in advocating for restaveks at the bedside. The plight of Haiti's restaveks is widely reported in the human rights literature but is not publicly recognized as an issue for community health and wellbeing among physicians. To address these health disparities, the health consequences of an entire class of neglected children must be further explored.