Sustainability in surgical practice: a collaborative call toward environmental sustainability in operating rooms.

BACKGROUND: The healthcare system plays a pivotal role in environmental sustainability, and the operating room (OR) significantly contributes to its overall carbon footprint. In response to this critical challenge, leading medical societies, government bodies, regulatory agencies, and industry stakeholders are taking measures to address healthcare sustainability and its impact on climate change. Healthcare now represents almost 20% of the US national economy and 8.5% of US carbon emissions. Internationally, healthcare represents 5% of global carbon emissions. US Healthcare is an outlier in both per capita cost, and per capita greenhouse gas emission, with almost twice per capita emissions compared to every other country in the world. METHODS: The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and the European Association for Endoscopic Surgery (EAES) established the Sustainability in Surgical Practice joint task force in 2023. This collaborative effort aims to actively promote education, mitigation, and innovation, steering surgical practices toward a more sustainable future. RESULTS: Several key initiatives have included a survey of members' knowledge and awareness, a scoping review of terminology, metrics, and initiatives, and deep engagement of key stakeholders. DISCUSSION: This position paper serves as a Call to Action, proposing a series of actions to catalyze and accelerate the surgical sustainability leadership needed to respond effectively to climate change, and to lead the societal transformation towards health that our times demand.

A 2-step remote TUNEL approach for sperm DNA fragmentation assessment. Analysis in donors and patients.

OBJECTIVES: Infertility is a disease of the male or female reproductive systems. Male reproductive workup is based on routine semen analysis, although of limited value. The 2021 WHO Manual incorporated Sperm DNA Fragmentation (SDF) assessment, and highlighted the need for individual laboratories to define suitable thresholds. This study aimed to present an alternative to address this issue, determine an SDF cut-off value with fertile donors, and characterize SDF in a patient cohort and their relationship with semen parameters. STUDY DESIGN: A service unit was established to remotely perform TUNEL assay in a 2 step-process. Semen samples were received at andrology laboratories, subjected to routine semen analysis (WHO, 2010), partially processed and transported to the service unit for SDF evaluation. Using this setting, studies were done in fertile donors (n = 15) to define the cut-off value, and in men undergoing infertility workup (n = 318). RESULTS: A cut-off value of 9.17 % was determined with the fertile donor cohort. With this cut-off, a 64.46 % abnormal SDF incidence was determined in the patient cohort. SDF negatively correlated with sperm number, vitality and motility, and positively with abnormal morphology and male age (P < 0.05). TUNEL-positive cases depicted lower sperm quality and higher male age (P < 0.05). A similar abnormal SDF incidence was determined among patients with semen abnormalities. Asthenozoospermic and ≥40 years patient samples depicted higher (P < 0.05) SDF than those of the general population. SDF incidence was also high in normozoospermic patients. CONCLUSIONS: Using a 2-step remote approach with a standardized procedure and an SDF cut-off value established with fertile donors, high SDF incidence in semen samples depicting normal and abnormal quality were identified in men consulting for infertility, highlighting the relevance of its evaluation as part of the male fertility workup.

Interpectoral nerve blocks may lower postoperative narcotic use after mastectomy.

BACKGROUND: Pain management following mastectomy is a significant challenge often requiring opioids. Nonopioid pain management utilizing nerve blocks has been shown in other fields to reduce postoperative opioid use and may be effective for postoperative pain in mastectomy patients. The primary purpose of this study was to compare postoperative opioid use, measured in morphine milligram equivalents (MME), between mastectomy patients who underwent interpectoral nerve block (IPNB) and a historical control group. Secondary outcomes included length of stay (LOS) and postoperative pain scores. METHODS: This is a single-center, retrospective cohort study. The charts of women who underwent mastectomy for cancer without immediate reconstruction from 10/2017-12/2019 were reviewed. Wilcoxon rank sum test was used for unadjusted analysis and multiple linear regression for adjusted analysis. RESULTS: There were 105 patients included in this study, of which 37 (35%) underwent IPNB. In unadjusted analysis, median MME use was significantly lower in patients that received IPNB compared to the control group (IPNB = 5, controls = 17, p = 0.03). Patients that received IPNB had an observed reduction in LOS and postoperative pain, though these results failed to reach statistical significance. There were no IPNB-related complications. CONCLUSIONS: IPNB may be an effective strategy to decrease postoperative opioid use in mastectomy patients. Larger, prospective studies are needed to further investigate the effectiveness of IPNB.

Synthetic computed tomography for low-field magnetic resonance-only radiotherapy in head-and-neck cancer using residual vision transformers.

Background and purpose: Synthetic computed tomography (sCT) scans are necessary for dose calculation in magnetic resonance (MR)-only radiotherapy. While deep learning (DL) has shown remarkable performance in generating sCT scans from MR images, research has predominantly focused on high-field MR images. This study presents the first implementation of a DL model for sCT generation in head-and-neck (HN) cancer using low-field MR images. Specifically, the use of vision transformers (ViTs) was explored. Materials and methods: The dataset consisted of 31 patients, resulting in 196 pairs of deformably-registered computed tomography (dCT) and MR scans. The latter were obtained using a balanced steady-state precession sequence on a 0.35T scanner. Residual ViTs were trained on 2D axial, sagittal, and coronal slices, respectively, and the final sCTs were generated by averaging the models' outputs. Different image similarity metrics, dose volume histogram (DVH) deviations, and gamma analyses were computed on the test set (n = 6). The overlap between auto-contours on sCT scans and manual contours on MR images was evaluated for different organs-at-risk using the Dice score. Results: The median [range] value of the test mean absolute error was 57 [37-74] HU. DVH deviations were below 1% for all structures. The median gamma passing rates exceeded 94% in the 2%/2mm analysis (threshold = 90%). The median Dice scores were above 0.7 for all organs-at-risk. Conclusions: The clinical applicability of DL-based sCT generation from low-field MR images in HN cancer was proved. High sCT-dCT similarity and dose metric accuracy were achieved, and sCT suitability for organs-at-risk auto-delineation was shown.

What a Waste! The Impact of Unused Surgical Supplies in Hand Surgery and How We Can Improve.

BACKGROUND: The US health care system is the second largest contributor of trash. Approximately 20% to 70% of waste is produced by operating rooms, and very few of this waste is recycled. The purpose of this study is to quantify the opened but unused disposable supplies and generate strategies to reduce disposable waste. METHODS: A single-center prospective study to evaluate the cost of opened but unused single-use operating room supplies was completed by counting the number of wasted disposable products at the end of hand surgery cases. We used χ2 test, t test, Wilcoxon rank-sum test, and simple linear regression to assess the associations between patient and case variables and the total cost of wasted items. Environmentally Extended Input Output Life Cycle Assessment methods were used to convert the dollar spent to kilograms of carbon dioxide equivalent (CO2-e), a measure of greenhouse gas emissions. RESULTS: Surgical and dressing items that were disposed of and not used during each case were recorded. We included 85 consecutive cases in the analysis from a single surgeon's practice. Higher cost from wasted items was associated with shorter operative time (P = .010). On average, 11.5 items were wasted per case (SD: 3.6 items), with a total of 981 items wasted over the 85 cases in the study period. Surgical sponges and blades were 2 of the most unused items. Wasted items amounted to a total of $2193.5 and 441 kg of CO2-e during the study period. CONCLUSIONS: This study highlights the excessive waste of unused disposable products during hand surgery cases and identifies ways of improvement.

Hand Function Following Simulated Fusion of Thumb Metacarpophalangeal and Interphalangeal Joints.

Background: There is poor understanding regarding functional limitation of thumb strength and dexterity following thumb metacarpophalangeal (MCP) and interphalangeal (IP) arthrodesis. The purpose of this investigation was to quantitatively evaluate the functional limitations of MCP and IP joint fusion using an orthosis to simulate fusion. Methods: Thirty-two healthy volunteers underwent simulated MCP and IP thumb arthrodesis using custom-molded orthoses. Each volunteer was independently assessed for hand and thumb function using the Jebsen-Taylor Hand Function test, lateral pinch strength, tip pinch strength, and Grooved Pegboard test. Comparisons between the 3 groups in all functional tests were carried out. Results: The mean lateral pinch strength was significantly greater in the unsplinted group (8.3 kg) compared with the MCP- (6.3 kg) and IP-splinted (5.7 kg) groups. Mean tip pinch strength was also significantly higher in the unsplinted group than in MCP- and IP-splinted thumbs (4.6 kg vs 4.1 and 3.9 kg). There was no difference in the Jebsen-Taylor or Grooved Pegboard test between the 3 groups. Conclusion: Our study suggests that with a fused MCP joint the lateral and tip pinch strength will decrease by 24% and 10%, respectively, compared with a healthy nonsplinted thumb. A fused IP joint will decrease lateral and tip pinch by 31% and 16%, respectively. This information does not take into account an arthritic thumb. We found that the Jebsen-Taylor test and Grooved Pegboard test were not affected by simulated thumb MCP and IP fusion.

Association between meteorological variables and semen quality: a retrospective study.

Spermatogenesis is a temperature-dependent process, and high summer temperatures have been linked to lower sperm concentration and count. However, reports describing the association between other meteorological variables and semen quality are scarce. This study evaluated the association between semen quality and temperature, humidity, pressure, apparent temperature (AT), temperature-humidity index (THI), simplified wet-bulb global temperature (sWBGT), and sunshine duration. Semen samples were obtained at the Laboratorio de Andrología y Reproducción (LAR, Argentina), from men undergoing routine andrology examination (n=11657) and computer-assisted sperm analysis (n=4705) following WHO 2010 criteria. Meteorological variables readings were obtained from the Sistema Meteorológico Nacional. Sperm quality parameters were negatively affected in summer when compared to winter. Additionally, there was a significant decrease in sperm kinematics between winter and spring. Branch and bound variable selection followed by multiple regression analysis revealed a significant association between semen quality and meteorological variables. Specifically, changes in sunshine duration and humidity reinforced the prognosis of semen quality. Highest/lowest sunshine duration and humidity quantiles resulted in decreased sperm concentration, count, motility, vitality and membrane competence, nuclear maturity, and sperm kinematics associated to highest sunshine duration and lowest humidity. Findings from this report highlight the relevance of environmental studies for predicting alterations in male reproductive health associated to variations in meteorological variables, especially considering the current climate changes around the planet due to global warming and its consequences for human health.

Comparison of mastectomy and breast reconstruction outcomes using low thermal dissection versus traditional electrocautery: a blinded randomized trial.

INTRODUCTION: PlasmaBlade® is a thermal dissection device that may allow for improved perfusion of the mastectomy flap by limiting thermal injury. In this study we aim to compare the mastectomy flap perfusion using PlasmaBlade® versus traditional electrocautery. METHODS: Patients undergoing bilateral mastectomy with immediate breast reconstruction were recruited. The right and left breasts of each patient were randomized to dissection with PlasmaBlade® or standard electrocautery. Randomization was performed using random sequences on the day of surgery and was blinded to the plastic surgeon. Mastectomy flap perfusion was assessed following completion of the mastectomy using intra-operative fluoroscopy and plastic surgeon review. Surgical site drainage and pain score were measured. Sign tests were employed to assess differences in perfusion and Wilcoxon paired test for the secondary outcomes. RESULTS: Twenty patients were enrolled in the study with median age of 40.5 years and median BMI of 26 kg/m2. In 18 patients (90%), perfusion was assessed to be better on the side of the PlasmaBlade® dissection. Median daily drainage over a 7-day period was 51 cc (IQR 35-61) on the PlasmaBlade® side and 44 cc (IQR 31-61) on the control side. Median pain score on the PlasmaBlade® side was 4.0 (IQR 2.3-5.9) and 4.4 (IQR 2.9-6) on the control side. No skin necrosis was noted in either groups. CONCLUSION: Use of PlasmaBlade® appears to be a safe and reliable technique to perform mastectomy and breast reconstruction with equivalent outcomes to traditional electrocautery. Although, mastectomy skin flap perfusion was rated better intra-operatively for the PlasmaBlade® group, both cohorts had comparable outcomes. ClinicalTrials.gov Identifier: NCT03711916 Level of Evidence: I (Randomized trial).

Establishing a Culture of Patient Safety, Quality, and Service in Plastic Surgery: Integrating the Fractal Model.

PROBLEM: There are obstacles to effective nationwide implementation of a culture of patient safety. Plastic surgery faces unique challenges in this area because quality measures are not as well-established as in other fields. Plastic surgery may also require emphasis on patient-reported outcomes as a quality-of-life specialty with distinct concomitant analytical methods. APPROACH: We devised a dynamic framework, based on our 3-year experience using a Comprehensive Unit-Based Safety Program-a formal quality improvement committee structure, literature review, and work from The Johns Hopkins Armstrong Institute for Patient Safety and Quality. This framework is specific and exportable to the field of plastic surgery. Monthly patient safety, quality, and service committee meetings encourage multilevel participation in a bottom-up fashion, while connecting with other departments and entities in Johns Hopkins Medicine. Our model focuses our work in the following four domains: (1) safety, (2) external measures, (3) patient experience, and (4) value. Our framework identifies and communicates clear goals, creates necessary infrastructure, identifies opportunities and needs, uses robust performance to develop and implement interventions, and includes analytics to track improvement plans and results. OUTCOMES: We have gradually implemented this quality improvement structure into the Johns Hopkins Department of Plastic and Reconstructive Surgery successfully since 2012. Outcomes have improved in externally reported measures of patient safety, quality, and service. We have demonstrated exemplary National Surgical Quality Improvement Program performance for morbidity, return to operating room, and readmission rates. Patient satisfaction surveys show improvement related to the high-level patient experience.

Identification of early stage recurrence endometrial cancer biomarkers using bioinformatics tools.

Endometrial cancer (EC) is the sixth most common cancer in women worldwide. Early diagnosis is critical in recurrent EC management. The present study aimed to identify biomarkers of EC early recurrence using a workflow that combined text and data mining databases (DisGeNET, Gene Expression Omnibus), a prioritization algorithm to select a set of putative candidates (ToppGene), protein­protein interaction network analyses (Search Tool for the Retrieval of Interacting Genes, cytoHubba), association analysis of selected genes with clinicopathological parameters, and survival analysis (Kaplan­Meier and Cox proportional hazard ratio analyses) using a The Cancer Genome Atlas cohort. A total of 10 genes were identified, among which the targeting protein for Xklp2 (TPX2) was the most promising independent prognostic biomarker in stage I EC. TPX2 expression (mRNA and protein) was higher (P<0.0001 and P<0.001, respectively) in ETS variant transcription factor 5­overexpressing Hec1a and Ishikawa cells, a previously reported cell model of aggressive stage I EC. In EC biopsies, TPX2 mRNA expression levels were higher (P<0.05) in high grade tumors (grade 3) compared with grade 1­2 tumors (P<0.05), in tumors with deep myometrial invasion (>50% compared with <50%; P<0.01), and in intermediate­high recurrence risk tumors compared with low­risk tumors (P<0.05). Further validation studies in larger and independent EC cohorts will contribute to confirm the prognostic value of TPX2.

Comparing Operative Performance between Independent and Integrated Plastic Surgery Residents.

BACKGROUND: Anecdotally, faculty report that independent residents' operative skills differ from those of their integrated peers. This study compared operative competency between integrated (postgraduate years 4 to 6) and independent plastic surgery residents. METHODS: The authors compared independent (postgraduate years 1 to 3) and integrated (postgraduate years 4 to 6) plastic surgery residents at their institution using operative performance data from the Operative Entrustability Assessment, a validated five-point assessment tool that provides residents with real-time feedback about their operative performance, documenting performance at the point of care. Independent postgraduate year 1, 2, and 3 residents were categorized as postgraduate year 4, 5, and 6 residents, respectively, for comparison. The authors analyzed attending physician (evaluator) Operative Entrustability Assessment scores over time using the independent t test. RESULTS: From July 1, 2013, to June 30, 2018, Operative Entrustability Assessments were completed at one training program for residents in postgraduate years 4 to 6: 1886 (47.4 percent) by independent [n = 12 (37.5 percent)] and 2094 (52.6 percent) by integrated [n = 20 (62.5 percent)] residents. Evaluator scores were lower for independent track residents throughout the first two quarters of postgraduate year 4 (quarter 1 delta, -0.49 point, p < 0.001; quarter 2 delta, -0.36 point, p < 0.001). However, this difference was no longer statistically significant during the third and fourth quarters of postgraduate year 4 (p = 0.192 and p = 0.228, respectively). No difference was detectable at postgraduate year 5 (p = 0.095) or postgraduate year 6 (p = 0.877). CONCLUSIONS: Operative Entrustability Assessment data demonstrate that differences between independent and integrated plastic surgery residents regarding operative skills (0.49 of 5 points) and amount of time needed for independent residents to catch up (6 months) is minimal and resolves during the third quarter of independent postgraduate year 1. Programs can design curricula to facilitate independent residents' plastic surgery skill acquisition during their first two quarters.

Determinants of receiving immediate breast reconstruction: An analysis of patient characteristics at a tertiary care center in the US.

BACKGROUND: Breast reconstruction is an option for women undergoing mastectomy for breast cancer. Previous studies have reported underutilization of reconstructive surgery. This study aims to examine the role demographic, clinical and socio-economic factors may have on patients' decisions to undergo breast reconstruction. METHODS: We analyzed data from our institutional database. Using multivariable and multinomial logistic regression, we compared breast cancer patients who had undergone mastectomy-only to those who had immediate breast reconstruction (overall and by type of reconstruction). RESULTS: We analyzed data on 1459 women who underwent mastectomy during the period 2003-2015. Of these, 475 (32.6%) underwent mastectomy-only and 984 (67.4%) also underwent immediate breast reconstruction. After adjusting for potential confounders, older age (OR = 0.18, 95%CI:0.08-0.40), Asian race (OR = 0.29, 95%CI:0.19-0.45), bilateral mastectomy (OR = 0.71, 95%CI:0.56-0.90), and higher stage of disease (OR = 0.44, 95%CI:0.26-0.74) were independent risk factors for not receiving immediate breast reconstruction. Furthermore, patients with Medicare or Medicaid insurance were less likely than patients with private insurance to receive an autologous reconstruction. There was no evidence for changes over time in the way socio-demographic and clinical factors were related to receiving immediate breast reconstruction after mastectomy. CONCLUSIONS: Clinical characteristics, sociodemographic factors like age, race and insurance coverage affect the decision for reconstructive surgery following mastectomy.

Patient-Related Risk Factors for Worsened Abdominal Well-Being after Autologous Breast Reconstruction.

BACKGROUND: Patient-reported lower satisfaction with the abdomen preoperatively is a strong predictor of undergoing DIEP flap surgery. The authors evaluated physical well-being of the abdomen before and after flap-based breast reconstruction to determine potential predictors for decreased postoperative abdominal well-being. METHODS: The authors retrospectively analyzed an institutional breast reconstruction registry, selecting patients who underwent abdominally based autologous flap breast reconstruction from 2010 to 2015. The authors' primary outcome was the Physical Well-being of the Abdomen domain from the BREAST-Q, measured preoperatively and at 6- and 12-month follow-up visits after final reconstruction. The authors classified two patient groups: those who experienced a clinically important worsening of Physical Well-being of the Abdomen score and those who did not. The authors used the chi-square test, t test, and Wilcoxon rank sum test, and multivariable logistic regression to identify potential predictors. RESULTS: Of 142 women identified, 74 (52 percent) experienced clinically important worsening of physical well-being of the abdomen, whereas 68 (48 percent) did not. The first group experienced a 25-point (95 percent CI, 22 to 28) decrease and the latter an 8-point (95 percent CI, 5 to 10) decrease in score compared to baseline. Multivariable analysis showed an association between higher baseline score and race, with higher odds of decreased score at the 12-month follow-up. A higher baseline RAND-36 general health score, bilateral reconstruction, and a lower body mass index demonstrated a trend for clinically important worsening of physical well-being of the abdomen. CONCLUSIONS: More than half of flap-based breast reconstruction patients experienced clinically important worsening of abdominal well-being after final breast reconstruction. Clinicians may use these findings to identify patients at higher risk of worsened postoperative abdominal well-being. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Computer-Assisted Design and Manufacturing Assists Less Experienced Surgeons in Achieving Equivalent Outcomes in Cranial Vault Reconstruction.

PURPOSE: The purpose of this study was to assess whether long-term outcomes were equivalent between computer-assisted design and manufacturing (CAD/CAM) -assisted cranial vault reconstruction performed by an inexperienced surgeon, with fewer years of surgical experience, and traditional reconstruction performed by senior surgeons with many decades of experience. METHODS: An Institutional Review Board-approved retrospective cohort study was performed for all patients with nonsyndromic craniosynostosis between the ages of 1 month to 18 years who received primary, open calvarial vault reconstruction at the Johns Hopkins Hospital between 1990 and 2017. The primary outcome variable was the Whitaker category (I-IV) for level of required revision at the 2-year follow-up visit. Secondary outcomes included estimated blood loss, length of stay, operative time, and postoperative complications. CAD/CAM-assisted surgery was considered noninferior if the proportion of cases requiring any revision (Whitaker II, III, or IV) was no more than 10% greater than the proportion in the traditional surgery group with multivariate logistic regression analysis. t tests and fisher exact tests were used for secondary outcomes. RESULTS: A total of 335 patients were included, with 35 CAD/CAM-assisted reconstructions. CAD/CAM-assisted reconstruction was noninferior to traditional after accounting for patient demographics, type of surgery, and experience level of the plastic surgeon. The traditional group required revision more frequently at 29.0% compared to CAD/CAM at 14.3%. Secondary outcomes were not significantly different between groups, but CAD/CAM had significantly longer average operative times (5.7 hours for CAD/CAM, 4.3 hours for traditional, P < 0.01). CONCLUSION: CAD/CAM technology may lower the learning curve and assist less experienced plastic surgeons in achieving equivalent long-term outcomes in craniofacial reconstruction.

Survival and Disease Recurrence Rates among Breast Cancer Patients following Mastectomy with or without Breast Reconstruction.

BACKGROUND: Concerns have been expressed about the oncologic safety of breast reconstruction following mastectomy for breast cancer. This study aimed to evaluate the association of breast reconstruction with breast cancer recurrence, and 5-year survival among breast cancer patients. METHODS: The authors analyzed data from The Johns Hopkins Hospital comprehensive cancer registry, comparing mastectomy-only to postmastectomy breast reconstruction in breast cancer patients to evaluate differences in breast cancer recurrence and 5-year survival. Kaplan-Meier curves were used to compare unadjusted estimates of survival or disease recurrence. Data were modeled through Cox proportional hazards regression, using as outcomes time to death from any cause or time to cancer recurrence. RESULTS: The authors analyzed data on 1517 women who underwent mastectomy for breast cancer at The Johns Hopkins hospital between 2003 and 2015. Of these, 504 (33.2 percent) underwent mastectomy only and 1013 (66.8 percent) underwent mastectomy plus immediate breast reconstruction. Women were followed up for a median of 5.1 years after diagnosis. There were 132 deaths and 100 breast cancer recurrences. A comparison of Kaplan-Meier survival estimates demonstrated a survival benefit among patients undergoing mastectomy plus reconstruction. After adjusting for various clinical and socioeconomic variables, there was still an overall survival benefit associated with breast reconstruction which, however, was not statistically significant (hazard ratio, 0.78; 95 percent CI, 0.53 to 1.13). Patients who underwent reconstruction had a similar rate of recurrence compared to mastectomy-only patients (hazard ratio, 1.08; 95 percent CI, 0.69 to 1.69). CONCLUSION: This study suggests that breast reconstruction does not have a negative impact on either overall survival or breast cancer recurrence rates. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Increased Incidence of Symptomatic Venous Thromboembolism following Pedicled Lower Extremity Flap Harvest for Abdominal and Perineal Reconstruction in Patients Receiving Mechanical Prophylaxis and Chemoprophylaxis: A Case for Heightened Awareness.

BACKGROUND: Postsurgical venous thromboembolism remains a leading cause of hospital morbidity. Data to support venous thromboembolism prophylaxis guidelines in lower extremity flap surgery are lacking. The purpose of this study was to explore the effect of pedicled lower extremity flap harvest on venous thromboembolism development in the setting of abdominal or perineal reconstruction. METHODS: One hundred twenty-six patients undergoing unilateral lower extremity flap harvest for abdominal or perineal reconstruction were included. The contralateral leg served as an internal control. Sixty comorbidity-matched patients who underwent abdominal/perineal resection without flap reconstruction provided an external control. Bivariate analyses included chi-square and t tests; logistic regression adjusted for confounding variables on venous thromboembolism development. RESULTS: All patients underwent flap reconstruction for an oncologic defect of the abdomen or perineum, with 80 percent undergoing perineal reconstruction. Most patients underwent anterolateral thigh (41 percent) or gracilis flap (40 percent) harvest. Eleven patients developed deep venous thromboses in one or more legs (9 percent): 10 of 11 (90.9 percent) in the donor extremity and five (45.5 percent) contralaterally (p = 0.022). Patients who underwent flap harvest had a 10-fold higher odds of venous thromboembolism formation when compared to comorbidity-matched controls without flap reconstruction (OR, 10.64; 95 percent CI, 1.11 to 102.34; p = 0.041). CONCLUSIONS: The rate of venous thromboembolism is higher than previously appreciated for reconstructive procedures of the abdomen and/or perineum that use pedicled lower extremity flaps-particularly in the operative extremity. Additional research can clarify the role for further prophylaxis or screening. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Mitral Valve Repair Versus Replacement in Elderly With Degenerative Disease: Analysis of the STS Adult Cardiac Surgery Database.

BACKGROUND: It has been postulated that mitral valve repair in the elderly does not confer short-term benefits over mitral valve replacement with complete preservation of the chordal apparatus. Our purpose was to test this hypothesis using data from The Society of Thoracic Surgeons Adult Cardiac Surgery Database (STS ACSD). METHODS: Patients aged 70 years or more undergoing primary isolated elective mitral valve repair or mitral valve replacement for degenerative disease were obtained from the STS ACSD versions 2.73 and 2.81. Patients with a concomitant tricuspid procedure, atrial fibrillation surgery, or atrial septal defect/patent foramen ovale repair were included. The two treatment groups were further stratified by age in years (70 to 74, 75 to 79, and 80 or more). Adjusted 30-day mortality rates were analyzed by mitral procedure and chordal preservation strategy. RESULTS: The study included 12,043 patients, of whom 71% underwent mitral valve repair. Observed 30-day mortality after repair was lower than after replacement (2.2% versus 4.8%, respectively; p < 0.0001). Using repair as reference, adjusted operative mortality was higher for replacement in the overall cohort (odds ratio 1.83, 95% confidence interval: 1.45 to 2.31). There was no significant difference in mortality between complete versus partial chordal preservation in repair (odds ratio 1.24, 95% confidence interval: 0.80 to 1.93). Mitral valve replacement with chordal preservation remained inferior to repair (odds ratio 1.66, 95% confidence interval: 1.28 to 2.14). The failed repair rate was 7.9%, with a 30-day mortality of 6%. CONCLUSIONS: In patients aged 70 years or more, degenerative mitral repair was associated with lower operative mortality compared with replacement, irrespective of chordal preservation strategy. Failed repairs reduced this short-term benefit compared with chordal-sparing replacement as evidenced by the similar operative mortality on an intention to treat analysis.