Breast Trauma: A United States-Based Epidemiological Study From 2016 to 2019.

Background  Breast trauma is an often under-recognized injury, especially in female polytrauma patients. The purpose of this study was to assess the prevalence of breast injuries and their association with injury severity score (ISS) in trauma patients nationally.  Method A retrospective review was performed using data from the National Trauma Data Bank® (NTDB®) from 2016 to 2019, using all applicable International Classification of Diseases (ICD) codes for three outlined subgroups (abrasions, contusions, and open wounds/punctures/lacerations) with minors excluded. All continuous variables were tested as non-normally distributed, and all test results for continuous variables used the Kruskal-Wallis test. All categorical variables were tested using a chi-squared test. Results  Patients with traumatic breast abrasions and contusions had a higher rate of intensive care unit (ICU) admissions (23.8%; n=395 and 25.3%; n=48, respectively) compared to patients with open wounds/punctures/lacerations (13.6%; n=205). Patients with abrasions and contusions to the breast had a significantly higher ISS compared to those with visible open wounds/punctures/lacerations (9 and 9, vs 5, p <0.001). Mortality rates were highest among patients with breast abrasions and contusions, 15% (n=213) and 14% (n=23), respectively, compared to patients with open wounds/punctures/lacerations at 11% (n=132), p<0.017. Conclusion  Traumatic breast abrasions and contusions were associated with higher rates of ICU admission, elevated ISS, and overall mortality compared to open breast wounds, punctures, or lacerations. This indicates the importance of traumatic breast injuries as a prognostic indicator in the standard workup of a trauma patient.

Enhanced Recovery after Surgery (ERAS) Protocols Expanded over Multiple Service Lines Improves Patient Care and Hospital Cost.

Enhanced recovery after surgery (ERAS) may improve patients' postoperative course. Our center implemented the ERAS protocol for the colorectal service in 2016, and then expanded to multiple service lines over the course of 1.5 years. Our aim was to determine whether broad implementation of ERAS protocols across different service lines could improve patient care. All ERAS patients from 2018 were captured prospectively. For each service line using ERAS, one full year of data preceding ERAS was compared. ERAS service lines included colorectal, gynecology laparoscopic, gynecology open, hepatopancreaticobiliary, urology - nephrectomy and cystectomy, spinal fusion, cardiac surgery-coronary artery bypass grafting. ERAS and pre-ERAS services were compared based on length of stay (LOS), complications, readmission, and mortality rates. In addition, hospital costs were collected during this time frame. ERAS protocols significantly decreased LOS for colorectal, gynecology, and spine. Complications were significantly decreased in colorectal, gynecology, urology, and spine. Readmissions did not significantly increase in any service line except spine. There was no significant change in mortality. ERAS proved to save the hospital 1847 days and cost saving of almost $5 million in 2018. Implementing ERAS broadly improved patient outcomes (LOS, complications, readmission, and mortality) while providing cost savings to the hospital.

Healthcare Costs Reduced After Incorporating the Results of the American College of Surgeons Oncology Group Z0011 Trial into Clinical Practice.

The purpose of our study was to quantitate the changes in axillary lymph node dissection (ALND), frozen section (FS), and the impact on costs after the publication of the American College of Surgeons Oncology Group (ACOSOG) Z0011 trial. We compared axillary nodal management and cost data in breast cancer patients who met Z0011 criteria and were treated with lumpectomy and sentinel lymph nodes (SLN) biopsy from 2007 to July 2013. Of 800 patients, 67 (13.5%) and 34 (12.5%) patients in the pre- and post-Z0011 era had 1-2 positive SLN. ALND decreased from 78% to 21% (p < 0.001) after publication of Z0011. The mean overall cost of SLN biopsy was $41,059 per patient, while SLN biopsy with completion ALND was $50,999 (p < 0.001). Intraoperative FS use decreased from 95% to 66% (p = 0.015). Omitting the FS decreased mean costs from $4,319 to $2,036. The application of Z0011 resulted in an overall mean cost savings of $571,653 from 2011 to July 2013. ACOSOG Z0011 significantly impacted axillary management resulting in a 20% reduction in the mean overall cost per patient by omitting ALND. In these patients, intraoperative FS analysis had poor sensitivity (56%) and doubled the cost of pathologic examination. Fewer ALND and intraoperative FS were performed after the publication of ACOSOG Z0011. Eliminating FS and ALND in patients who met Z0011 criteria, results in significant cost savings.

The effect of multiple wire localization in breast conservation.

Variability exists regarding the surgical technique in breast conservation therapy. The purpose of this project was to determine differences between single (SH) or flanking (FH) hooked needle localization wires used for nonpalpable breast lesions. We retrospectively reviewed 201 female patients at a single institution from 2004 to 2008. All patients had biopsy-proven ductal carcinoma in situ or invasive disease. Comparisons were made in regard to margin status, reoperation, completion mastectomy, size of lesion, and breast specimen volume. SH was placed in 122 patients (61%) and FH in 79 patients (39%). In SH, 23 patients (18%) had positive margins and 31 patients (25%) had reoperations as compared with 31 patients (25%) with positive margin and 36 patients (44%) in the FH cohort (P = 0.039 and 0.0037). Average lesion size and volume resected was 1.5 cm and 137 cm(3) in SH and 2.85 cm and 188 cm(3) in FH, respectively (P = 0.0001 and 0.006). Positive margins were associated with lesion size and not volume of tissue excised. The FH technique was associated with more positive margins, reoperation, and completion mastectomy.