Conversion from Alloplastic to Autologous Breast Reconstruction: What Are the Inciting Factors?

Introduction: Failure of alloplastic breast reconstruction is an uncommon occurrence that may result in abandonment of reconstructive efforts or salvage with conversion to autologous reconstruction. The purpose of this study was to identify factors that predict failure of alloplastic breast reconstruction and conversion to autologous reconstruction. Methods: A retrospective chart review was conducted of patients who underwent mastectomy and immediate alloplastic breast reconstruction between 2008 and 2019. Inclusion criteria included patients 18 years or older who underwent initial alloplastic reconstruction with a minimum of 3-year follow-up. Data collected included age, body mass index, cancer type, surgical characteristics, neo/adjuvant treatment details, and complications. Results were analyzed using Fischer's exact test, t-test, and multivariate logistic regression. Results: A total of 234 patients met inclusion criteria. Of those, 23 (9.8%) required conversion from alloplastic to autologous reconstruction. Converted patients had a mean age of 50.1 ± 8.5. The time from initial alloplastic reconstruction to conversion was 30.7 months. The most common reasons for conversion included soft tissue deficiency (48%), infection (30%), and capsular contracture (22%). Patients were converted to deep inferior epigastric perforator flap (DIEP; 52%), latissimus dorsi flap with implant (26%), and DIEP with implant (22%). Multivariate logistic regression modeling identified radiation (OR 8.4 [CI = 1.7-40.1]) and periprosthetic infection (OR 14.6 [CI = 3.4-63.8]) as predictors for conversion. Conclusions: Among patients undergoing mastectomy with immediate alloplastic breast reconstruction, those treated with radiation have 8.4 greater odds of conversion and those with a periprosthetic infection have 14.6 greater odds for conversion to an autologous reconstruction.

Introduction : L'échec d'une reconstruction mammaire alloplastique est un événement peu fréquent qui peut aboutir à un abandon des efforts de reconstruction ou à une solution de secours avec une conversion en reconstruction autologue. L'objectif de cette étude était d'identifier les facteurs prédisant l'échec de la reconstruction mammaire alloplastique et sa conversion en reconstruction autologue. Méthodes : Une étude rétrospective a été menée sur les dossiers de patientes ayant subi une mastectomie suivie d'une reconstruction mammaire alloplastique immédiate entre 2008 et 2019. Les critères d'inclusion étaient notamment des patientes âgées d'au moins 18 ans ayant subi une reconstruction alloplastique initiale avec un suivi minimum de 3 ans. La collecte de données a inclus : l'âge, l'indice de masse corporelle (IMC), le type de cancer, les caractéristiques chirurgicales, les détails sur le traitement adjuvant/néoadjuvant et les complications. Les résultats ont été analysés à l'aide du test t exact de Fischer, un test t et une analyse de régression logistique multifactorielle. Résultats : Un total de 234 patientes a satisfait les critères d'inclusion. Parmi ces patientes, 23 (9,8%) ont nécessité la conversion de la reconstruction alloplastique en reconstruction autologue. Les patientes « converties ¼ avaient un âge moyen de 50,1 ± 8,5 ans. Le délai séparant la reconstruction alloplastique initiale et la conversion était de 30,7 mois. Les motifs les plus fréquents de conversion étaient une déficience des tissus mous (48%), une infection (30%) et la formation d'une coque (22%). Les techniques de conversion utilisées étaient la technique dite DIEP ou AEIP (artère épigastrique inférieure profonde, 52%), un lambeau du grand dorsal avec implant (26%), et la technique DIEP avec implant (22%). Une modélisation d'analyse de régression logistique multifactorielle a identifié les facteurs prédictifs de conversion suivants : irradiation (rapport de cotes = 8,4 [IC = 1,7-40,1]) et l'infection périprothétique (RC = 14,6 [IC = 3,4 à 63,8]). Conclusions : Parmi les patientes subissant une mastectomie avec reconstruction mammaire alloplastique immédiate, celles qui ont reçu une radiothérapie avaient un risque de conversion 8,4 fois plus grand et les patientes ayant une infection périprothétique avaient un risque 14,6 fois plus grand de conversion en reconstruction autologue.

Determinants of Success in Single- and Multi-Digit Replant.

Purpose: Understanding the variables that influence success in digital replant surgery is essential to guide clinical decision-making and to counsel patients. The purpose of this study was to determine the replant success rate and identify predictors of success at our tertiary care centre. Methods: This was a single centre, retrospective cohort study of consecutive patients who underwent digital replantation from January 2000 to September 2018. Adult patients with flexor zone I to III amputations were included. Patient demographics, comorbidities, injury pattern, operative data, and post-operative care were reviewed. The primary outcome was survival of the replanted digit at discharge. Results: A total of 146 patients met inclusion criteria. Of these, 100 had single-digit replants and 46 underwent multi-digit replants for a total of 220 digits. The success rate was 71%. Predictors of success included sharp mechanism of injury (P < .01), incomplete amputation (P < .01), amputation proximal to zone I flexor level (P = .02), post-operative acetylsalicylic acid use (P < .01), absence of leech use (P = .05), and absence of operative re-exploration (P < .01). Daytime replants had similar outcome compared to nighttime replants despite having increased ischemia time (7.9 ± 3.9 hours vs 6.8 ± 2.6 hours, P = .02). However, daytime operative time (7.8 ± 3.7 hours) was significantly shorter than nighttime replant time (9.6 ± 5.9 hours, P = .01). Conclusion: Sharp amputation, intact venous drainage, proximal amputation, and acetylsalicylic acid use were associated with replant survival and are factors to consider when managing patients for digital replantation. Leech therapy and operative re-exploration were associated with poor outcome. Nighttime replants required significantly longer operative time than daytime replants despite similar survival outcome.

Objectif: Il est essentiel de comprendre les variables qui influent sur la réussite de la réimplantation digitale par voie chirurgicale pour orienter les décisions et conseiller les patients. La présente étude visait à déterminer le taux de réussite des réimplantations et à déterminer les prédicteurs de réussite au centre de soins tertiaires des chercheurs. Méthodologie: Cette étude de cohorte monocentrique et rétrospective portait sur des patients consécutifs qui avaient subi une réimplantation chirurgicale entre janvier 2000 et septembre 2018. Les patients adultes ayant subi des amputations des zones I à III des fléchisseurs ont été retenus. Les chercheurs ont évalué les caractéristiques démographiques des patients, leurs maladies associées, leur type de blessures, les données opératoires et leurs soins postopératoires. La survie du doigt réimplanté au congé était le résultat primaire. Résultats: Au total, 146 patients ont respecté les critères d'inclusion. De ce nombre, 100 avaient fait réimplanter un seul doigt et 46, plusieurs doigts, pour un total de 220 doigts. Le taux de réussite s'élevait à 71%. Les prédicteurs de réussite incluaient un mécanisme franc de blessure (p<0,01), une amputation incomplète (p<0,01), une amputation proximale au fléchisseur de la zone I (p=0,02), la prise d'acide acétylsalicylique après l'opération (p<0,01), la non-utilisation de sangsues (p=0,05) et l'absence de réexploration opératoire (p<0,01). Les réimplantations effectuées le jour donnaient des résultats semblables à celles qui étaient effectuées la nuit, malgré une durée d'ischémie plus longue (7,9±3,9 h par rapport à 6,8±2,6 h, p=0,02). Cependant, les opérations exécutées le jour (7,8±3,7 h) était beaucoup plus courtes que celles effectuées la nuit (9,6±5,9 h, p=0,01). Conclusion: Une amputation franche, un drainage veineux intact, une amputation proximale et la prise d'acide acétylsalicylique étaient liés à la survie de la réimplantation et représentent des facteurs à considérer dans la prise en charge des patients qui doivent subir une réimplantation digitale. La thérapie par les sangsues et la réexploration opératoire étaient associées à un mauvais pronostic clinique. Les réimplantations opératoires effectuées la nuit étaient beaucoup plus longues que celles effectuées le jour, malgré un taux de survie semblable.

Acute Thumb Reconstruction With Medial Femoral Condyle and Radial Forearm Free Flaps: A Case Report.

Traumatic thumb injuries often result in significant functional disability. With segmental bone loss, reconstructive options include antibiotic cement with delayed bone graft, revision amputation with webspace deepening, metacarpal distraction osteogenesis, index pollicization, bone flap, and free toe transfer. We present a case of a subtotal thumb amputation just distal to the metacarpal phalangeal joint resulting in loss of both soft tissue and a segmental bone defect of the proximal and distal phalanx. Reconstruction was initially performed with a chimeric bone free flap from the medial femoral condyle with a vastus medialis muscle cuff to provide soft tissue coverage. A revision soft tissue coverage procedure was required and a radial forearm free flap was utilized. His reconstruction restored his missing bone and soft tissue, and provided stability with sufficient grip strength and metacarpophalangeal function resulting in a satisfactory functional outcome.

Safety and Cost-Effectiveness of Outpatient Surgery in Acute Burn Care.

Outpatient burn surgery is increasingly used in acute burn care. Reports of its safety and efficacy are limited. This study aims to evaluate the safety and cost reduction associated with outpatient burn surgery and to describe our center's experience. This was a single-center, retrospective cohort study of consecutive patients who underwent outpatient burn surgery requiring split-thickness skin graft or dermal regenerative template from January 2010 to December 2018. Patient demographics, comorbidities, burn etiologies, operative data, and postoperative care were reviewed. The primary outcome is complications involving major graft loss requiring reoperation. One hundred and sixty-five patients and 173 procedures met the inclusion criteria. The average age was 44 years and 60.6% (100/165) were male. Annual outpatient procedure volume increased 48% from 23 to 34 cases over the 9-year period. The median (interquartile range) grafted percentage total body surface area was 1.0 (1.0)%. Rate of major graft loss requiring reoperation was 5.2% (9/172) and the most common site was the lower extremity (8/9, 88.9%). Age, sex, comorbidities, total body surface area, and procedure types were not significantly associated with postoperative complication rates. The outpatient burn surgery model was estimated to save CA$8170 per patient from inpatient costs. Demonstration of the safety and cost savings associated with outpatient acute burn surgery is compelling for further utilization. Our experience found the adoption of improved dressing care, appropriate patient selection, increased patient education, adequate pain control, and regimented outpatient multidisciplinary care to be fundamental for effective outpatient surgical burn care.

Medico-legal Closed Case Trends in Canadian Plastic Surgery: A Retrospective Descriptive Study.

To enhance patient safety and prevent medico-legal complaints, we need to understand current trends and impacts. We aimed to characterize Canadian plastic surgery medico-legal patterns in many dimensions. METHOD: This retrospective descriptive analysis of Canadian Medical Protective Association data between January 1, 2013 and December 31, 2017 included closed regulatory body complaints and civil-legal actions involving plastic surgeons. We excluded class action legal cases and hospital complaints. We collected data on patient allegations, procedure types, healthcare-related patient harms, and peer expert criticisms. The primary outcome of interest was physician medico-legal outcome. RESULTS: We found 414 cases that met the inclusion criteria: 253 (61.1%) cases involved cosmetic procedures and 161 (38.9%) noncosmetic procedures. The annual incidence among plastic surgeon members of regulatory body complaints and civil-legal actions was 12.1% and 6.7%, for a combined incidence of 18.8%. The most common allegations were deficient clinical assessment, inadequate informed consent, delayed or misdiagnosis, and inadequate monitoring. Leading contributing factors were physician-patient communication breakdown, deficient clinical judgments, and inadequate documentation. The top procedural complications included cosmetic deformity, poor scarring, upper extremity stiffness or deficit, major structural injury, and mental health disorder. Less than half of cases (198/414, 47.8%) had unfavorable medico-legal outcomes for the surgeon. Patients were compensated in 86/198 (43.4%) of civil-legal cases. CONCLUSIONS: Plastic surgeons experience more medico-legal complaints for cosmetic versus noncosmetic procedures. To minimize medico-legal risks, plastic surgeons should focus on strong physician-patient communication, patient education/consent, thorough clinical assessment, minimizing potentially preventable complications, and maintaining relevant documentation.

Canadian Postoperative Dependency Protocols Following Lower Limb Microvascular Reconstruction: A National Survey and Literature Review.

INTRODUCTION: Microsurgical free tissue transfer for lower limb reconstruction presents unique challenges in the postoperative period where dependency promotes interstitial fluid diffusion and reduced tissue perfusion. Management of flap edema, venous congestion, and ischaemic conditioning is critical for flap survival. Little evidence exists to guide postoperative protocols in the initiation and progression of lower extremity dangle, monitoring, and anticoagulation. We aim to describe current trends for postoperative dependency protocols by surveying Canadian microsurgeons. METHODS: Plastic surgeons performing lower limb microvascular reconstruction at Fellow of The Royal College of Surgeons of Canada approved teaching institutions were administered a 17-question anonymous electronic survey. A literature review was conducted to identify protocols and consensus opinions in other jurisdictions. RESULTS: All respondents (n = 16) monitored flaps clinically, with conventional Doppler used by 13 respondents. Anticoagulation was employed by 15 of 16 respondents, and 9 of 16 used 2 or more agents. The most common agents were aspirin, followed by low-molecular-weight heparin. Significant variability existed in dangling protocols. Dependency was initiated at postoperative day (POD) 3 to 10 (mean POD: 6 ± 1.64 standard deviation), with intervals ranging from 5 to 20 minutes and frequencies ranging from 1 to 6 times per day. Nearly half allowed both increasing duration and frequency of dependency. Flap success rates were above 90%, and the median length of stay was 10 to 12 days. CONCLUSION: While flap success rates across the country are similar, no consensus exists for postoperative dependency protocols amongst Canadian microsurgeons. Prospective randomised controlled trials are warranted to evaluate early aggressive dependency protocols to reduce length of stay and cost.

INTRODUCTION: Le transfert microchirurgical de tissus libres pour la reconstruction des membres inférieurs comporte des défis particuliers pendant la période postopératoire, où la dépendance entraîne la diffusion de liquide interstitiel et une perfusion réduite des tissus. Il est essentiel de prendre en charge l'œdème du lambeau, la congestion veineuse et le conditionnement ischémique pour assurer la survie du lambeau. Il existe peu de données probantes pour orienter les protocoles postopératoires sur l'initiation et la progression du ballottement, la surveillance et l'anticoagulation des extrémités inférieures. Les chercheurs ont décrit les tendances actuelles des protocoles de dépendance postopératoire après avoir sondé les microchirurgiens canadiens. MÉTHODOLOGIE: Les plasticiens qui effectuent des reconstructions microvasculaires des membres inférieurs aux établissements universitaires approuvés par le CRMCC ont reçu un sondage électronique anonyme de 17 questions. Les chercheurs ont effectué une analyse bibliographique pour établir les protocoles et les opinions consensuelles des autres territoires de compétence. RÉSULTATS: Tous les répondants (n=16) surveillaient les lambeaux en clinique. Treize répondants utilisaient le Doppler classique, 15, l'anticoagulation et neuf, au moins deux agents. Les agents les plus utilisés étaient l'aspirine, suivie de l'héparine de bas poids moléculaire. Les protocoles de ballotement variaient considérablement. La dépendance postopératoire se manifestait entre trois et dix jours après l'opération (dépendance postopératoire moyenne de 6 ± 1,64 d'écart-type), les intervalles se situant entre cinq et 20 minutes et la fréquence, entre une et six fois par jour. Près de la moitié favorisait à la fois une plus longue durée et une plus grande fréquence de dépendance. Le taux de réussite des lambeaux dépassait les 90%, et l'hospitalisation médiane était de dix à 12 jours. CONCLUSION: Le taux de succès des lambeaux est semblable partout au pays, mais il n'y a pas de consensus sur les protocoles de dépendance postopératoire chez les microchirurgiens canadiens. Il faudra procéder à des essais aléatoires et contrôlés prospectifs pour évaluer des protocoles énergiques précoces qui réduiront la durée de l'hospitalisation et le coût.

Correction to: Postoperative Adverse Events are Associated with Oncologic Recurrence Following Curative­intent Resection for Lung Cancer.

The original version of this article unfortunately contained a mistake in author names. The given and family names of all the authors was transposed. The author names are corrected with this correction. The original article has been corrected.

Postoperative Adverse Events are Associated with Oncologic Recurrence Following Curative-intent Resection for Lung Cancer.

BACKGROUND: Up to 50% of patients suffer short-term postoperative adverse events (AEs) and metastatic recurrence in the long-term following curative-intent lung cancer resection. The association between AEs, particularly infectious in nature, and disease recurrence is controversial. We sought to evaluate the association of postoperative AEs on risk of developing recurrence and recurrence-free survival (RFS) following curative-intent lung resection surgery. METHODS: All lung cancer resections at a single institution (January 2008-July 2015) were included, with prospective collection of AEs using the Thoracic Morbidity & Mortality System. Cox proportional hazards models were used to estimate the effect of AEs on recurrence, with results presented as hazard ratio (HR) with 95% confidence interval (CI). An a priori, clinically driven approach to predictor variable selection was used. Kaplan-Meier curves were used examine the relationship between AE and RFS. p < 0.05 was considered statistically significant. RESULTS: 892 patients underwent curative-intent resection. 342 (38.3%) patients experienced an AE; 69 (7.7%) patients developed infectious AEs. 17.6% (n = 157) of patients had disease recurrence after mean follow-up of 26.5 months. Severe (Grade IV) AEs were associated with increased risk of recurrence (3.40; 95% CI 1.56-7.41) and a trend to decreased RFS. Major infectious AEs were associated with increased risk of recurrence (HR 1.71; CI 1.05-2.8) and earlier time to recurrence (no infectious AE 66 months, minor infectious 41 months, major infectious 54 months; p = 0.02). CONCLUSION: For patients undergoing curative-intent lung cancer resection, postoperative AEs associated with critical illness or major infection were associated with increased risk of oncologic recurrence.

Evaluation of Intrinsic Hand Musculature Reinnervation following Supercharge End-to-Side Anterior Interosseous-to-Ulnar Motor Nerve Transfer.

Supercharge end-to-side anterior interosseous-to-ulnar motor nerve transfer is commonly performed in the authors' institution to augment intrinsic hand function. Following observations of recovery patterns, the authors hypothesized that despite its more distal innervation, the first dorsal interosseous muscle recovers to a greater extent than the abductor digiti minimi muscle. The objective of this work was to evaluate the clinical and electrodiagnostic pattern of reinnervation of intrinsic hand musculature following supercharge end-to-side anterior interosseous-to-ulnar motor nerve transfer. A retrospective cohort of prospectively collected data included all patients who underwent a supercharge end-to-side anterior interosseous-to-ulnar motor nerve transfer. Two independent reviewers performed data collection. Reinnervation was assessed with two primary outcome measures: (1) clinically, with serial Medical Research Council strength assessments; and (2) electrodiagnostically, with serial motor amplitude measurements. Statistical analysis was performed using nonparametric statistics. Seventeen patients (65 percent male; mean age, 56.9 ± 13.3 years) were included with a mean follow-up of 16.7 ± 8.5 months. Preoperatively, all patients demonstrated clinically significant weakness and electrodiagnostic evidence of denervation. Postoperatively, strength and motor amplitude increased significantly for both the first dorsal interosseous muscle (p = 0.002 and p = 0.016) and the abductor digiti minimi muscle (p = 0.044 and p = 0.015). Despite comparable preoperative strength (p = 0.098), postoperatively, the first dorsal interosseous muscle achieved significantly greater strength when compared to the abductor digiti minimi muscle (p = 0.023). Following supercharge end-to-side anterior interosseous-to-ulnar motor nerve transfer, recovery of intrinsic muscle function differs between the abductor digiti minimi and the first dorsal interosseous muscles, with better recovery observed in the more distally innervated first dorsal interosseous muscle. Further work to elucidate the underlying physiologic and anatomical basis for this discrepancy is indicated. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, IV.

Clinicopathological overlap of neurodegenerative diseases: A comprehensive review.

Clinical and neuropathological overlap of two or more neurodegenerative diseases (ND) is not an uncommon occurrence yet is still underdiagnosed in clinical neurological and neuropathological. The authors present a clinicopathological overview of the current understanding of overlapping ND's with the hope that this review will encourage further studies that are required to investigate the effect of such overlaps on clinical presentations and how often clinical presentations raise the suspicion of multiple ND's. The authors suggest that as more patients with overlapping ND's come to light, traditional classification system of ND's may need to be modified.

Determining postoperative outcomes after cleft palate repair: A systematic review and meta-analysis.

BACKGROUND: A lack of high-level evidence exists on the outcomes of different cleft palate repair techniques. A critical appreciation for the complication rates of common repair techniques is paramount to optimize cleft palate care. METHODS: A literature search was conducted for articles on the measurement of fistula and velopharyngeal insufficiency (VPI) rates following cleft palate repair. Study quality was determined using validated scales. The heterogeneity between studies was evaluated using the I2 statistic. Random-effect model analysis and forest plots were used to report pooled relative risks (RRs) with 95% confidence intervals for treatment effect. P-values of 0.05 were considered statistically significant. RESULTS: Of 2386 studies retrieved, 852 underwent screening and 227 met inclusion criteria (130 studies (57%) on fistulas and 122 studies (54%) on VPI). Meta-analyses were performed using 32 studies. The Furlow technique was associated with less postoperative fistulae than the von Langenbeck and Veau/Wardill/Kilner techniques (RR = 0.56 [0.39-0.79], p < 0.01 and RR = 0.25 [0.12-0.52], p < 0.01, respectively). One-stage repair was associated with less fistulae compared to two-stage repair (RR = 0.42 [0.19-0.96], p = 0.04). The Furlow repair was also associated with a less VPI than the Bardach palatoplasty (RR = 0.41 [0.23, 0.71], p < 0.01), and the one-stage repair was associated with a reduction in VPI rates compared to two-stage repair (RR = 0.55 [0.32, 0.95], p = 0.03). CONCLUSION: The Furlow repair is associated with less risk of fistula formation than the von Langenbeck and Veau/Wardill/Kilner techniques and less VPI compared to the Bardach repair. One-stage repair is associated with less risk of fistula formation and VPI than two-stage repair.

Students working against tobacco: A novel educational program to improve Canadian medical students' tobacco counselling skills.

BACKGROUND: Medical professionals should be appropriately trained in the field of smoking cessation counseling and be familiar with related tobacco-control issues. Sadly, Canadian medical students receive little education regarding smoking cessation. METHODS: University of Ottawa medical students created Students Working Against Tobacco (SWAT), a program that provides its members with tobacco education and opportunities to discuss tobacco use, smoking prevention and cessation with elementary-school students. Surveys assessing student knowledge and confidence in addressing tobacco issues were administered to the participating students at the start of the program and following their delivery of a school presentation. RESULTS: Students initially lacked knowledge, skills and experience in addressing tobacco issues and discussing smoking prevention and cessation counselling. Following their involvement in the SWAT program, students' smoking cessation counselling knowledge and skills improved, and they expressed confidence in becoming more engaged in this important preventive health issue. CONCLUSION: Until smoking cessation is incorporated into undergraduate medical education programs, gaps will remain in the preparation of tomorrow's physicians regarding the provision of effective smoking cessation counselling and their broader understanding of this important health issue. Currently, there are constraints limiting the number of medical undergraduates that SWAT is able to involve and influence.

All grades of severity of postoperative adverse events are associated with prolonged length of stay after lung cancer resection.

OBJECTIVE: To determine whether all grades of severity of postoperative adverse events are associated with prolonged length of stay in patients undergoing pulmonary cancer resection. METHODS: This was a retrospective cohort study of all patients who underwent pulmonary resection with curative intent for malignancy at The Ottawa Hospital, Division of Thoracic Surgery (January 2008 to July 2015). Postoperative adverse events were collected prospectively with the Thoracic Morbidity & Mortality System, based on the Clavien-Dindo severity classification. Patient demographics, comorbidities, preoperative investigations, cardiopulmonary assessment, pathologic staging, operative characteristics, and length of stay were retrospectively reviewed. Prolonged hospital stay was defined as >75th percentile for each procedure performed (wedge resection 6 days, segmentectomy 6 days, lobectomy 7 days, extended lobectomy 8 days, pneumonectomy 10 days). Univariable and multivariable logistic regression analyses were conducted to identify factors associated with prolonged hospital stay. RESULTS: Of 1041 patients, 579 (55.6%) were female, 610 (58.1%) were >65 years old, 232 (22.3%) experienced prolonged hospital stay, and 416 (40.0%) patients had ≥1 postoperative adverse event. Multivariable analyses identified significant (P < .05) factors associated with prolonged hospital stay to be (odds ratio; 95% confidence interval): lower diffusion capacity of the lung for carbon monoxide (0.99; 0.98-0.99), surgical approach: open thoracotomy (1.8; 1.3-2.5), and presence of any postoperative adverse event: Grade I (5.8; 3.3-10.2), Grade II (6.0; 4.0-8.9), Grade III (11.4; 7.0-18.7), and Grade IV (19.40; 7.1-55.18). CONCLUSIONS: Lower diffusion capacity of the lung for carbon monoxide, open thoracotomy approach, and the development of any postoperative adverse event, including minor events that required no additional therapy, were factors associated with prolonged hospital stay.

Impact of Adverse Events and Length of Stay on Patient Experience After Lung Cancer Resection.

BACKGROUND: Postoperative adverse events (AEs), prolonged length of stay (PLOS), and patient experience are common quality measures after thoracic surgical procedures. Our objective was to investigate the relationship of postoperative AEs on patient experience and hospital length of stay (LOS) after lung cancer resection. METHODS: AEs (using Thoracic Morbidity and Mortality system based on Clavien-Dindo schema) and LOS were prospectively collected for all patients undergoing lung cancer resection. A 21-item questionnaire, retrospectively asking about patient experience, was mailed to patients twice (October 2015 and January 2016). The impact of AEs on experience was investigated and stratified by hospital LOS, with PLOS defined as the 75th percentile. Univariate analysis used parametric (t test) and nonparametric (Mann-Whitney) tests according to test conditions. RESULTS: Of 288 patients who responded to the survey (70% response rate), 175 (61%) had no AEs, 113 (39%) had experienced at least one AE, and 52 (18%) had experienced PLOS. Lung cancer patients who experienced PLOS showed significantly decreased experience on several questionnaire items, including their impression of comprehensiveness of surgeons information provision during inpatient period (p = 0.008), inpatient recovery from operation (p = 0.001), quality of life 30 days after operation (p = 0.032), follow-up care, (p = 0.022), and satisfaction with outcome 1 year after operation during follow-up care (p = 0.022). The presence of postoperative AEs led only to reduced impression about inpatient recovery from the operation (p = 0.01). CONCLUSIONS: In this cohort, postoperative AEs were minimally associated with negative patient experience. However, patients who experienced PLOS demonstrated a marked reduction in experience after thoracic surgical procedures.

Post-operative outcomes after cleft palate repair in syndromic and non-syndromic children: a systematic review protocol.

BACKGROUND: There is a lack of high-level evidence on the surgical management of cleft palate. An appreciation of the differences in the complication rates between different surgical techniques and timing of repair is essential in optimizing cleft palate management. METHOD: A comprehensive electronic database search will be conducted on the complication rates associated with cleft palate repair using MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials. Two independent reviewers with expertise in cleft pathology will screen all appropriate titles, abstracts, and full-text publications prior to deciding whether each meet the predetermined inclusion criteria. The study findings will be tabulated and summarized. The primary outcomes will be the rate of palatal fistula, the incidence and severity of velopharyngeal insufficiency, and the rate of maxillary hypoplasia with different techniques and also the timing of the repair. A meta-analysis will be conducted using a random effects model. DISCUSSION: The evidence behind the optimal surgical approach to cleft palate repair is minimal, with no gold standard technique identified to date for a certain type of cleft palate. It is essential to appreciate how the complication rates differ between each surgical technique and each time point of repair, in order to optimize the management of these patients. A more critical evaluation of the outcomes of different cleft palate repair methods may also provide insight into more effective surgical approaches for different types of cleft palates.

The Use of Neuronavigation as an Adjunct in Facial Reconstructive Surgery.

Neuronavigation, a ubiquitous tool used in neurosurgery, is rarely used in maxillofacial reconstructive surgery despite it offering many advantages without any disadvantage to the patient. The present report describes one patient with complex gun-shot wound facial injury and one patient with a rare malignant peripheral nerve sheath tumor involving the skull base, in which neuronavigation was used to improve the accuracy of bony reduction and minimize surgical invasiveness. Although neuronavigation is not necessary for all maxillofacial surgery, it can be a useful adjunct in complex maxillofacial reconstruction and maxillofacial tumor resection.