Feasibility of Implementing a Breast Reconstruction Database.

OBJECTIVE: To assess whether implementing a breast reconstruction database would be feasible in terms of time commitment, cost, and overall benefits in a tertiary-care hospital. METHODS: A survey was sent to 40 Canadian plastic surgeons who have a practice focused on breast reconstruction. The survey assessed demographics, practice characteristics, database use, and opinions on database construction. Univariate descriptive analyses were performed on all variables. RESULTS: Thirty-one surgeons responded to the survey (77.5%). Most were from Ontario (29.1%) and worked in an academic center (83.9%). Of all, 45.3% of surgeons performed more than 50 breast reconstructions yearly. Six (19.4%) surgeons utilized databases that were all started for quality improvement and research purposes. Databases included variables such as demographics, type of reconstruction, complications, surgeons involved, and type of implants. Data are input by research assistants (50%) for approximately 4.2 hours per month at a cost below 200$CAD per month. Databases are funded by research grants (50%), hospital funds (33.3%), and/or division funds (16.7%). Of the surgeons without databases, 60% have considered starting a database. Barriers include being too busy (72%) and impressions of the cost being too high (32%). Surgeons commonly felt that a database would be beneficial at their practice (80%), provincially (77.4%), and nationally (67.7%). CONCLUSIONS: Plastic surgeons are open to the idea of constructing a breast reconstruction database and that the costs and time required are lower than expected. Grants or integration with existing databases should be pursued on a provincial level first prior to pursuing a national database.

OBJECTIF: Évaluer s'il est possible de créer une base de données de reconstruction mammaire dans un hôpital de soins tertiaires, compte tenu du temps, du coût et des avantages globaux. MÉTHODOLOGIE: Quarante plasticiens canadiens dont la pratique est axée sur la reconstruction mammaire ont reçu un sondage, qui évaluait les données démographiques, les caractéristiques de la pratique, l'utilisation de bases de données et les opinions sur la construction d'une base de données. Les chercheurs ont procédé à des analyses descriptives univariées à l'égard de toutes les variables. RÉSULTATS: Trente et un chirurgiens (77,5 %) ont répondu au sondage. La plupart provenaient de l'Ontario (29,1 %) et travaillaient dans un centre universitaire (83,9 %). Ainsi, 45,3 % des chirurgiens effectuaient plus de 50 reconstructions mammaires par année. Six chirurgiens (19,4 %) utilisaient des bases de données qui avaient toutes été lancées pour favoriser l'amélioration de la qualité et la recherche. Ces bases de données incluent des variables comme les données démographiques, le type de reconstruction, les complications, les chirurgiens en cause et le type d'implants. Les données sont saisies par des assistants de recherche (50 %) qui s'y consacrent environ 4,2 heures par mois, à un coût mensuel inférieur à 200 $CAD. Les bases de données sont subventionnées par des bourses de recherche (50 %), les fonds des hôpitaux (33,3 %) ou les fonds des divisions (16,7 %). De plus, 60 % des chirurgiens ne disposant pas d'une base de données avaient envisagé d'en lancer une. Les obstacles incluaient le fait d'être trop occupé (72 %) et l'impression que le coût serait trop élevé (32 %). Les chirurgiens avaient souvent l'impression qu'une base de données serait utile pour leur pratique (80 %), leur province (77,4 %) et le pays (67,7 %). CONCLUSIONS: Les plasticiens sont ouverts à l'idée de créer une base de données de reconstruction mammaire, et les coûts et le temps nécessaire sont moindres que prévu. Il faudrait chercher à obtenir des subventions ou à intégrer cette base de données à une base de données déjà en place à l'échelle provinciale avant d'en envisager une nationale.

Donor Site Morbidities of Iliac Crest Bone Graft in Craniofacial Surgery: A Systematic Review.

BACKGROUND: The iliac crest bone graft (ICBG) is criticized for high donor site morbidity. Recent research suggests this morbidity is related to the patient population for which the ICBG is harvested. This systematic review is the first to delineate the type and incidence of ICBG donor site complications in craniofacial surgery. METHODS: Two independent reviewers conducted a systematic review of multiple databases (MEDLINE, EMBASE, CINAHL, PEDRO, and Cochrane Central Register of Controlled Trials) from 1917 to 2017. All studies utilizing the ICBG for craniofacial indications were included. Donor site morbidities, including immediate and chronic pain, hematoma, seroma, infection, hypertrophic/painful scarring, nerve injury, muscle herniation, iliac crest fracture, and gait disturbance, were recorded. A weighted incidence for each morbidity, excluding immediate pain, was calculated. An average visual analog scale score was calculated for immediate pain. RESULTS: Forty-four studies, with 2801 patients, were included. Oral and maxillofacial (50%) and cleft reconstruction (40%) were the primary indications for surgery. Average immediate pain visual analog scale scores on postoperative days 1 and 14 were 6.3 and 1.3, respectively. The incidence of donor site morbidities was as follows: acute (45.7%) and chronic (1.5%) gait disturbance, acute (17.8%) and chronic nerve changes (1.4%), hypertrophic/painful scar (9.1%), chronic pain (3.1%), hematoma (2.2%), seroma (2.0%), infection (1.0%), iliac crest fracture (1.2%), and muscle herniation (0%). CONCLUSIONS: Chronic morbidity was lower than previously documented. Rare chronic morbidity illustrates that the ICBG remains a viable surgical option. The authors hope this review will facilitate surgical planning and informed consent.

Is main operating room sterility really necessary in carpal tunnel surgery? A multicenter prospective study of minor procedure room field sterility surgery.

BACKGROUND: Over 70% of Canadian carpal tunnel syndrome (CTS) operations are performed outside of the main operating room (OR) with field sterility and surgeon-administered pure local anesthesia [LeBlanc et al., Hand 2(4):173-8, 14]. Is main OR sterility necessary to avoid infection for this operation? This study evaluates the infection rate in carpal tunnel release (CTR) using minor procedure room field sterility. METHODS: This is a multicenter prospective study reporting the rate of infection in CTR performed in minor procedure room setting using field sterility. Field sterility means prepping of the hand with iodine or chlorhexidine, equivalent of a single drape, and a sterile tray with modest instruments. Sterile gloves and masks are used, but surgeons are not gowned. No prophylactic antibiotics are given. RESULTS: One thousand five hundred four consecutive CTS cases were collected from January 2008 to January 2010. Six superficial infections were reported and four of those patients received oral antibiotics. No deep postoperative wound infection was encountered, and no patient required admission to hospital, incision and drainage, or intravenous antibiotics. CONCLUSIONS: A superficial infection rate of 0.4% and a deep infection rate of 0% following CTR using field sterility confirm the low incidence of postoperative wound infection using field sterility. This supports the safety and low incidence of postoperative wound infection in CTR using minor procedure field sterility without prophylactic antibiotics. The higher monetary and environmental costs of main OR sterility are not justified on the basis of infection for CTR cases.

A detailed cost and efficiency analysis of performing carpal tunnel surgery in the main operating room versus the ambulatory setting in Canada.

BACKGROUND: Our goals were to analyze cost and efficiency of performing carpal tunnel release (CTR) in the main operating room (OR) versus the ambulatory setting, and to document the venue of carpal tunnel surgery practices by plastic surgeons in Canada. METHOD: A detailed analysis of the salaries of nonphysician personnel and materials involved in CTR performed in these settings was tabulated. Hospital statistical records were used to calculate our efficiency analysis. A survey of practicing plastic surgeons in Canada documented the venue of CTR performed by most. RESULTS: In a 3-h surgical block, we are able to perform nine CTRs in the ambulatory setting versus four in the main OR. The cost of CTR in the ambulatory setting is $36/case and $137/case in the main OR in the same hospital. Only 18% of Canadian respondents use the main OR exclusively for CTR, whereas 63% use it for some of their cases. The ambulatory setting is used exclusively by 37%, whereas 69% use it for greater than 95% of their cases. The majority of CTR cases (>95%) are done without an anesthesia provider by 73% of surgeons. Forty-three percent use epinephrine routinely with local anesthesia and 43% avoid the use of a tourniquet for at least some cases by using epinephrine for hemostasis. CONCLUSION: The use of the main OR for CTR is almost four times as expensive, and less than half as efficient as in an ambulatory setting. In spite of this, many surgeons in Canada continue to use the more expensive, less efficient venue of the main OR for CTR.