"The Uncertainty Principle"- studying immediate lymphatic reconstruction impacts the natural history of breast cancer related lymphedema.

Breast cancer-related lymphedema (BCRL) following axillary lymph node dissection (ALND) is a life-altering sequela for patients and a challenging problem for their surgeons. In order to prevent BCRL, immediate lymphatic reconstruction (ILR) is a surgical technique that has been devised to restore lymphatic drainage to the operative limb. Although ILR is becoming popular in the literature, we have identified several challenges within our own ILR research, including a lack of a clear definition of lymphedema, a lack of common outcome measures and possible alteration of the natural history of lymphedema through early compression therapy. Given these challenges, we must move forward with caution, while striving to develop clear and universally agreed upon definitions and outcomes, so that we can advance the body of evidence in support of ILR.

Effect of Smartphone App Postoperative Home Monitoring After Oncologic Surgery on Quality of Recovery: A Randomized Clinical Trial.

Importance: There has been an increase in health care-focused smartphone apps, including those for encouraging healthy behaviors and managing chronic conditions, but app-assisted postsurgical care has yet to be fully explored. Objective: To compare quality of recovery and patient satisfaction between conventional in-person follow-up and smartphone app-assisted follow-up for patients following Enhanced Recovery After Surgery Society (ERAS) protocols. Design, Setting, and Participants: This randomized clinical trial, conducted from June 2019 to April 2021, included women older than 18 years undergoing oncologic breast reconstruction or major gynecologic oncology surgery following ERAS protocols with the care of 2 surgeons at an academic tertiary care center. Interventions: Patients were randomized 1:1 to receive smartphone app-assisted follow-up or conventional in-person follow-up. The smartphone group used a surgeon-monitored app to record Quality of Recovery 15 (QoR15) scores, European Organisation for Research and Treatment of Cancer-selected adverse events, drain outputs, and surgical site photographs over 6 weeks. Patient satisfaction scores were assessed using validated Patient Satisfaction Questionnaire III (PSQ-III) subscales at 2 and 6 weeks postoperatively. The conventional follow-up group also completed the QoR15 and PSQ-III questionnaires at these intervals. Main Outcomes and Measures: The primary outcomes were quality of recovery and patient satisfaction, as measured by the QoR15 and PSQ-III, respectively. Secondary outcomes were costs of follow-up; the number of contacts with the medical system, complications, and surgeons' contacts with patients; and surgeons' perceptions of app-assisted care. Results: Of 72 patients included in the trial, 36 underwent breast reconstruction (mean [SD] age, 45.30 [9.13] years) and 36 underwent gynecologic oncology surgery (mean [SD] age, 54.90 [11.18] years). Three patients dropped out (2 who underwent breast reconstruction [1 in the app group, 1 in the control group], 1 who underwent gynecologic oncology surgery [control group]). The app group had significantly higher mean (SD) QoR15 scores than the control group (2 weeks: 127.58 [22.03] vs 117.68 [17.52], P = .02; 6 weeks: 136.64 [17.53] vs 129.76 [16.42], P = .03). Patients were equally satisfied between groups in all subsets of the PSQ-III at these intervals. The mean (SD) number of complications was similar in both groups, and a similar number of surgeon contacts per patient occurred (1.6 [1.2] vs 2.1 [2.0], P = .16). Surgeons appreciated early identification of complications with the app. Conclusions and Relevance: In this randomized clinical trial, postoperative follow-up for patients undergoing breast reconstruction and gynecologic oncology surgery using smartphone app-assisted monitoring led to improved quality of recovery and equal satisfaction with care compared with conventional in-person follow-up. Trial Registration: ClinicalTrials.gov Identifier: NCT03456167.

Low Infection Rate for Hand Fractures Managed with Surgical Fixation under Wide-Awake Local Anesthesia with No Tourniquet in Minor Surgery.

BACKGROUND: The purpose of this study was to review the rate and type of infectious complications after surgical fixation of hand fractures managed under wide-awake local anesthesia with no tourniquet (WALANT) in minor procedure rooms outside the main operating room. METHODS: A two-surgeon retrospective chart review was performed of patients who received surgical fixation of hand fractures under WALANT in minor surgery from March of 2014 to March of 2019. RESULTS A TOTAL OF: patients, with distal phalanx ( n = 16), middle phalanx ( n = 7), proximal phalanx ( n = 11), or metacarpal ( n = 26) fractures, were included in the study. The average patient age was 37 years, with a higher proportion of male patients (51:7). Two patients had two fractures each. Thirty of the 58 cases were already open fractures. Fixation was performed using either plates and screws (25 of 58) or nonburied Kirschner wires (31 of 58). Thirty-six percent of patients (21 of 58) were treated with prophylactic antibiotics. One patient developed postoperative cellulitis. The only case of osteomyelitis occurred in a patient with risk factors known to increase rates of infectious complications (open fracture, smoking history, and >24 hours from injury to treatment). No infectious complications occurred in those who sustained closed fractures. CONCLUSIONS: Although the minor surgery environment varies significantly from that of the main operating room, infection rates after surgical fixation of hand fractures using WALANT in this setting remain low (3.4 percent), with no documented infections in fractures that were referred closed and opened surgically for operative fixation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.