Something to Dye For: Toward Better Breast Lumpectomy Margins.

The development of fluorescence imaging in oncology led to the possibility of using intraoperative devices to improve the precision of surgical techniques.1 In this issue of NEJM Evidence, Smith et al.2 report results from a prospective multicenter trial evaluating the ability of intravenous pegulicianine with an optical head device and software to intraoperatively identify lumpectomy margins with residual cancer and excise them immediately. Identifying these margins intraoperatively avoids the need for a second surgery, which is required when margins are positive on the final pathology.

Keeping tabs: Reducing postoperative opioid prescriptions for patients after breast surgical procedures.

BACKGROUND: As the opioid crisis continues, it is critical that health care providers ensure they are not overprescribing opioid medications. At our institution (Walter Reed National Military Medical Center, Bethesda, MD), postoperative patients after breast surgeries are discharged with variable amounts of opioid medications. However, many patients report minimal opioid use. The objectives of this study were to characterize postoperative opioid usage and prescribing practices for patients undergoing various breast surgeries and to recommend the number of opioid pills for discharge for each procedure. METHODS: This was a prospective, single-institution study of all patients undergoing breast surgery from October 2018 to 2019. All patients were enrolled in our institution's enhanced recovery after surgery protocol. Patients were given questionnaires at their 2-week postoperative clinic appointment that evaluated perioperative pain and use of pain medications. The electronic medical record was reviewed to obtain additional information. Appropriate parametric and nonparametric tests were used for analysis. RESULTS: A total of 190 breast surgery patients completed the survey. We observed no significant differences in pain scores except between re-excision and mastectomy. Of these patients, 99% were prescribed opioids; however, only 53% of patients used them. Of those patients who were prescribed opioids, on average, all were prescribed more pills than were used. CONCLUSION: Our study demonstrates that it is possible to discharge all breast surgery patients with fewer than 10 opioid pills, except for special circumstances. This is the first study to provide a set of specific recommended discharge medications. Utilization of an enhanced recovery after surgery protocol with standardized discharge opioids can be used successfully to reduce the number of opioids prescribed to patients.