Efficacy of PECS block in addition to multimodal analgesia for postoperative pain management in patients undergoing outpatient elective breast surgery: A retrospective study.

Background: Pectoralis nerve blocks (PECS) have been shown in numerous studies to be a safe and effective method to treat postoperative pain and reduce postoperative opioid consumption after breast surgery. However, there are few publications evaluating the PECS block effectiveness in conjunction with multimodal analgesia (MMA) in outpatient breast surgery. This retrospective study aims to evaluate the efficacy of PECS's blocks on perioperative pain management and opioid consumption. Methods: We conducted a retrospective study to assess the efficacy of preoperative PECS block in addition to preoperative MMA (oral acetaminophen and/or gabapentin) in reducing opioid consumption in adult female subjects undergoing outpatient elective breast surgery between 2015 and 2020. A total of 228 subjects were included in the study and divided in two groups: PECS block group (received PECS block + MMA) and control Group (received only MMA). The primary outcome was to compare postoperative opioid consumption between both groups. The secondary outcome was intergroup comparisons of the following: postoperative nausea and vomiting (PONV), incidence of rescue antiemetic medication, PACU non-opioid analgesic medication required, length of PACU stay and the incidence of 30-day postoperative complications between both groups. Results: Two hundred and twenty-eight subjects (n = 228) were included in the study. A total of 174 subjects were allocated in the control group and 54 subjects were allocated in the PECS block group. Breast reduction and mastectomy/lumpectomy surgeries were the most commonly performed procedures (48% and 28%, respectively). The total amount of perioperative (intraoperative and PACU) MME was 27 [19, 38] in the control group and 28.5 [22, 38] in the PECS groups (p = 0.21). PACU opioid consumption was 14.3 [7, 24.5] MME for the control group and 17 [8, 23] MME (p = 0.732) for the PECS group. Lastly, the mean overall incidence of postsurgical complications at 30 days was 3% (N = 5), being wound infection, the only complication observed in the PECS groups (N = 2), and hematoma (N = 2) and wound dehiscence (N = 1) in the control group. Conclusion: PECS block combined with MMA may not reduce intraoperative and/or PACU opioid consumption in patients undergoing outpatient elective breast surgery.

Spirituality and Wellness in Plastic Surgery: A Survey of ASPS Members.

Spirituality is an important, yet often overlooked, component of personal well-being. The purpose of this study was to assess whether spirituality plays an important role in the well-being of US plastic surgeons and residents, and whether spirituality is viewed as an important component of patient care. METHODS: An anonymous and voluntary email survey was distributed to 3375 members of ASPS during the months of April through June of 2020. The survey distribution included 2230 active members of ASPS and 1149 resident members, all who practice or train within the United States. The survey consisted of 18 multiple-choice questions with answer choices based on a descriptive five-point Likert scale and ranking by priority. Statistical analysis of the results was performed using StataCorp 2019 software. RESULTS: A total of 431 completed surveys were received for a response rate of 12.7%. The majority of participants (70%) reported that personal spiritual beliefs and faith contribute positively to emotional well-being. In total, 65% agreed or strongly agreed that their spiritual beliefs provide a healthy framework for handling conflict, suffering, and loss. More than half (51%) reported that as a result of the COVID-19 global pandemic, their spiritual beliefs and practices have provided increased support and guidance. CONCLUSIONS: Spirituality is an important component of maintaining wellness for plastic surgeons, and spirituality is recognized by plastic surgeons as an important aspect of the healing process for patients. Efforts should be made to promote spiritual health among the surgical community both during training and in practice.

Incidence of Venous Thromboembolism after Sternal Reconstruction: A Single-center Retrospective Review.

BACKGROUND: Deep sternal wound infection and mediastinitis following sternotomy are associated with significant morbidity and mortality, and often require sternal reconstruction by plastic surgeons. Despite this patient population having a substantial risk of venous thromboembolism, there are no reports of the incidence of venous thromboembolism in patients undergoing sternal reconstruction. The authors sought to evaluate the incidence of venous thromboembolism in sternal reconstruction patients and to identify common risk factors for venous thromboembolism in this patient population. METHODS: A single-center retrospective review was completed of all patients who underwent sternal reconstruction by plastic surgeons between January 2012 and July 2020. Demographic data, antiplatelet and anticoagulant use, 2005 Caprini score, operative time, bleeding events, and postoperative venous thromboembolism events were recorded. RESULTS: A total of 44 patients were identified for analysis. The average 2005 Caprini score for the cohort was 10.9. In total, 93.2% of patients received perioperative antiplatelet and anticoagulant therapy (either chemoprophylaxis or systemic). Two patients developed postoperative venous thromboembolism events, for a total venous thromboembolism rate of 4.6%. Four patients had bleeding events requiring reoperation. No deaths were reported from either of these complications. CONCLUSIONS: Patients undergoing sternal reconstruction are at a high risk for venous thromboembolism and postoperative bleeding events. Despite the growing body of literature on venous thromboembolism in various surgical populations, the optimal management of thromboembolic risk in patients with high Caprini scores undergoing sternal reconstruction requires additional investigation.

Congenital Symmastia: A Comprehensive Review and Proposed Treatment Algorithm.

ABSTRACT: Congenital symmastia is a relatively uncommon condition and poorly described in the literature. Although numerous studies have evaluated iatrogenic symmastia including its prevention and treatment, considerably less has been studied with regard to congenital symmastia. In this review, the authors seek to consolidate the literature published thus far and provide techniques and principles of management that may guide surgeons treating patients with this condition.

Negative pressure wound therapy: device design, indications, and the evidence supporting its use.

Introduction: Negative pressure wound therapy (NPWT) has become a mainstay in the armamentarium for wound care. Since the initial commercial vacuum-assisted closure device became available in 1995, subsequent research has confirmed the positive physiological effects of negative pressure on wound healing. Traditionally, NPWT has been used to improve healing of open nonsurgical wounds by secondary intention. However, the clinical applications of NPWT have significantly broadened, and now also include use in open surgical wounds, closed surgical incisions, and skin graft surgery. In addition, devices have evolved and now include functionality and features such as instillation, antimicrobial sponges, and portability.Areas covered: This article reviews the history, background, and physiology underlying NPWT, as well as the most commonly used devices. In addition, an evidence-based discussion of the current clinical applications of NPWT is presented, with a focus on those with high levels of evidence.Expert opinion: Future directions for device development include modifications to increase ease of use by patients and to allow its use in a broader array of anatomic areas. Lastly, more research with high levels of evidence is needed to better define the outcomes associated with NPWT, including in relation to specific clinical applications and cost.

Surgical Residents' Perceptions of the Impact of Productivity-Based Faculty Compensation at an Academic Medical Center.

BACKGROUND: Academic medical centers have increasingly adopted productivity-based compensation models for faculty. The potential exists for conflict between financial incentives and the quality of surgical resident education. This study aims to examine surgical residents' perceptions regarding the impact of productivity-based compensation on education. METHODS: Following implementation of a productivity-based compensation plan, a survey of surgical residents (general surgery, plastic surgery, otolaryngology, urology, orthopedic surgery, and neurosurgery) was conducted to examine perceptions of its impact on didactics, patient care, surgical technique, teaching in the operating room, and financial considerations. Survey data were prospectively collected and analyzed. A retrospective analysis of relative value units (RVUs) was also performed. RESULTS: Following implementation of the productivity-based compensation plan, annual work RVUs increased by 8.9% in surgery as a whole, with increases observed within all surgical subspecialties. A total of 100 surveys were sent and 35 were completed (35% response rate and at least 30% within each surgical subspecialty). Forty-nine percent of participants perceived an increased focus on clinical productivity by faculty. Thirty-seven percent reported learning more about RVUs and Current Procedural Terminology coding. Most residents reported that the compensation plan did not have an impact on their education with respect to didactics (77%), patient care (94%), surgical technique (97%), and teaching in the operating room (83%). CONCLUSIONS: Increased clinical productivity in the setting of an RVU-based compensation plan was not perceived by most surgical residents to have impacted their education. In some cases, this model may enhance education in relation to RVUs, Current Procedural Terminology coding, and the financial aspects of surgery.

Bridging Acellular Dermal Matrix in Abdominal Wall Repair following Radical Resection of Recurrent Endometrioma.

The patient is a 31-year-old woman with a history of prior resection of a presumed keloid scar around her Pfannenstiel incision found to be endometrial tissue on final pathology. She presented 5 years later with recurrence of pain and a mass associated with menses despite maximal medical therapy for endometriosis. Computed tomography of her abdomen and pelvis demonstrated an infiltrative soft tissue mass measuring 8.8 cm × 4.0 cm. Surgical oncology conducted an en bloc resection of the mass and obstetrics and gynecology performed a concomitant total abdominal hysterectomy and bilateral salpingo-oophorectomy. Plastic and reconstructive surgery completed the repair of the final 23 cm × 10 cm full-thickness abdominal wall defect with bridging biologic mesh, complex layered closure, and incisional negative-pressure wound therapy. Final pathology confirmed a diagnosis of endometriosis. Patient's hospital course was uncomplicated, and follow-up at 6 months does not demonstrate clinical or radiographic evidence of bulge or hernia recurrence. Abdominal wall endometrioma is a well-documented occurrence in prior cesarean scars; plastic surgeons can contribute to a multidisciplinary approach in reconstruction when resection compromises abdominal wall integrity, necessitating expertise in complex repairs.

Instillation negative pressure wound therapy: An effective approach for hardware salvage.

Wound infection involving hardware can be notoriously difficult to treat, often requiring the removal of the infected implant. The goal of this study was to determine the utility of instillation negative pressure wound therapy to help eradicate infection and allow for definitive wound closure in patients without removing the infected hardware. A retrospective review was performed on the outcomes of 28 patients who presented with open wounds with exposed or infected hardware and who were treated with a combination of surgical debridement and negative pressure wound therapy with instillation (NPWTi). Eleven patients were treated for infected spinal hardware, 12 for extremity, and 5 for sternal hardware. Twenty-five of 28 (89%) patients had successful retention or replacement of hardware, with clearance of infection and healed wounds. Original hardware was maintained in 17 of 28 (61%) patients. In 11 patients, original hardware was removed, with subsequent replacement in eight of those patients after a clean wound was achieved. Average time to definitive closure was 12.6 days. Average follow-up was 135 days. This series supports NPWTi as an effective adjunct therapy to help expeditiously eradicate hardware infection, allowing for hardware retention.

Instillation Negative Pressure Wound Therapy: A Role for Infected LVAD Salvage.

Objective: To determine the utility of instillation negative pressure wound therapy (NPWT) in achieving eradication of infection and definitive wound closure in patients with infected left ventricular assist device (LVAD). Approach: A retrospective review was performed in a series of patients with infected and exposed LVADs who were treated with instillation NPWT in conjunction with surgical debridement. Results: Three consecutive patients were included who developed periprosthetic infection subsequent to LVAD implantation. In all cases, the utilization of a vacuum-assisted closure with instillation (VACi) along with surgical debridement and IV antibiotics eradicated infection resulting in successful retention of hardware. Cases 1 and 2 received definitive wound closure within 3 and 12 days of starting treatment, respectively. Case 3 initially deferred surgery in favor of local wound care. Eventually the patient elected for surgical treatment and underwent closure 164 days after initial presentation. All three patients healed completely without residual evidence of infection. Flap reconstruction with a pedicled rectus flap was used to achieve definitive closure in all patients. One patient subsequently required pump replacement secondary to thrombosis and mechanical pump failure. Innovation: LVAD infections are met with high morbidity and mortality rates, and timely salvage is critical. In this initial series, VACi has proven a viable therapy option to help control and eradicate infection without LVAD removal. Conclusion: This series illustrates the value of newer techniques such as VACi in combination with surgical debridement and antibiotic therapy in effectively salvaging LVADs that were infected.

Five-step Correction of Congenital Symmastia.

Congenital symmastia is distressing and difficult to treat, and traditional surgical modalities have met with limited success. We present a novel approach for a patient that failed all traditional surgical options. The anatomic deformity is analyzed using a modified version of Blondeel's 3-step analysis (conus, footprint, and skin envelope, to which we added a fourth element "intermammary web"). Combining operative principles from breast cancer reconstruction, we describe 5 operative steps that help correct the deformity, followed by a new postoperative splinting regimen that addresses the common pitfalls that could lead to recurrence.

Inpatient mortality and length of stay comparison of percutaneous endoscopic gastrostomy and percutaneous endoscopic gastrojejunostomy.

INTRODUCTION: Percutaneous endoscopic gastrostomy (PEG) and percutaneous endoscopic gastrojejunostomy (PEGJ) are endoscopic procedures often performed by surgeons. No recent population-based study has compared inpatient mortality or length of stay between patients who undergo PEG or PEGJ placement during their hospitalization. METHODS: Patients undergoing inpatient PEG or PEGJ placement and who were at least 18 years old were identified from the 2006 Nationwide Inpatient Sample (NIS) database. Baseline characteristics of each group were compared, and outcomes of risk-adjusted inpatient mortality and length of stay were determined. Means were compared from using a complex sample t-test, and proportions were compared from using a complex sample chi-square test, with an alpha level of 0.05 for significance. Bivariate logistic regression was used to evaluate PEG or PEGJ placement as a risk factor for mortality. RESULTS: In the 2006 NIS, 187,597 discharges were identified, during which a PEG or PEGJ was placed. Ninety-six percent (179,587) of patients underwent PEG placement, and 4% (8010) had PEGJ tubes placed. Fifty-one percent were men, with the mean age for PEG and PEGJ placement of 71.3 +/- 0.3 (mean +/- standard error) and 64.8 +/- 0.8 years (P < 0.05). In the PEG group, 86% of admissions were nonelective, compared to 79% in the PEGJ group (P < 0.05). The primary discharge diagnoses for both groups of patients included acute cerebrovascular disease, aspiration pneumonitis, septicemia, respiratory failure, and intracranial injury. PEG patients had a higher cumulative incidence of congestive heart failure, chronic lung disease, and diabetes. Crude in-hospital mortality for death was 11% for both PEG and PEGJ patients. No difference in mortality was observed in risk-adjusted analyses accounting for patient severity. Mean length of stay was similar for both groups (PEG 20.9 +/- 0.4 days; PEGJ 22.5 +/- 1.1 days). Neither PEG nor PEGJ was identified as a risk factor for inpatient mortality. CONCLUSIONS: Comparative analyses of patients undergoing PEG versus PEGJ revealed no detectable difference between inpatient mortality and hospital length of stay in this large observational study. Both procedures can be performed safely in high-risk populations, with no increased mortality or length of stay incurred by jejunal feeding access. However, further analysis is required to compare more specific short-term outcomes between these populations as well as their respective cost-effectiveness.

Light-mediated inhibition of protein synthesis.

The regulation of protein synthesis is vital for a host of cell biological processes, but investigating roles for protein synthesis have been hindered by the inability to selectively interfere with it. To inhibit protein synthesis with spatial and temporal control, we have developed a photo-releasable anisomycin compound, N-([6-bromo-7-hydroxycoumarin-4-yl]methyloxycarbonyl)anisomycin (Bhc-Aniso), that can be removed through exposure to UV light. The area of protein synthesis inhibition can be restricted to a small light-exposed region or, potentially, the volume of two-photon excitation if a pulsed IR laser is the light source. We have tested the compound's effectiveness with an in vitro protein-translation system, CHO cells, HEK293 cells, and neurons. The photo-released anisomycin can inhibit protein synthesis in a spatially restricted manner, which will enable the specific inhibition of protein synthesis in subsets of cells with temporal and spatial precision.