RESUMEN
BACKGROUND AND AIM: Traditional visualization techniques in microsurgery require strict positioning in order to maintain the field of visualization. However, static posturing over time may lead to musculoskeletal strain and injury. Three-dimensional high-definition (3DHD) visualization technology may be a useful adjunct to limiting static posturing and improving ergonomics in microsurgery. In this study, we aimed to investigate the benefits of using the 3DHD technology over traditional techniques. METHODS: A total of 14 volunteers consisting of novice and experienced microsurgeons performed femoral anastomoses on male Sprague-Dawley retired breeder rats using traditional techniques as well as the 3DHD technology and compared the two techniques. Participants subsequently completed a questionnaire regarding their preference in terms of operational parameters, ergonomics, overall quality, and educational benefits. Efficiency was also evaluated by mean times to complete the anastomosis with each technique. RESULTS: A total of 27 anastomoses were performed, 14 of 14 using the traditional microscope and 13 of 14 using the 3DHD technology. Preference toward the traditional modality was noted with respect to the parameters of precision, field adjustments, zoom and focus, depth perception, and overall quality. The 3DHD technique was preferred for improved stamina and less back and eye strain. Participants believed that the 3DHD technique was the better method for learning microsurgery. Longer mean time of anastomosis completion was noted in participants utilizing the 3DHD technique. CONCLUSIONS: The 3DHD technology may prove to be valuable in improving proper ergonomics in microsurgery. In addition, it may be useful in medical education when applied to the learning of new microsurgical skills. More studies are warranted to determine its efficacy and safety in a clinical setting.
Asunto(s)
Actitud del Personal de Salud , Imagenología Tridimensional , Microcirugia/métodos , Microvasos/cirugía , Enfermedades Musculoesqueléticas/etiología , Enfermedades Profesionales/etiología , Procedimientos Quirúrgicos Vasculares/métodos , Anastomosis Quirúrgica/educación , Anastomosis Quirúrgica/métodos , Animales , Ergonomía , Arteria Femoral/cirugía , Cirugía General , Humanos , Internado y Residencia , Masculino , Microcirugia/educación , Postura , Ratas , Ratas Sprague-Dawley , Estudiantes de Medicina , Cirugía Plástica , Encuestas y Cuestionarios , Procedimientos Quirúrgicos Vasculares/educaciónRESUMEN
BACKGROUND: It has been previously reported that the indigent patient population is less likely to seek breast reconstruction. It has also been reported that lower income women who do chose to undergo reconstruction are less satisfied with the results. This study assesses the level of breast reconstruction satisfaction in women treated at Los Angeles County Medical Center (LAC). For those women with lower satisfaction, we seek to identify the root source of this dissatisfaction. METHODS: Patients who underwent breast reconstruction at LAC from 2007 to 2012 were identified by Current Procedural Terminology codes. Eligible participants were administered the BREAST-Q postreconstruction module. Demographic data were obtained from the patient and/or their medical records. RESULTS: A total of 65 patients completed the surveys. The satisfaction scores for the appearance of the breast were 61 (24) and satisfaction with overall outcome was 80 (26). The occurrence of major complications was associated with lower satisfaction scores with respect to the appearance of the breast (P<0.0001) and overall outcome (P=0.02). In addition, patients with delayed reconstruction were also noted to be more satisfied with respect to appearance of the breast (P=0.03). CONCLUSIONS: Despite suggestions that the indigent and the underserved patient population are less satisfied with the results of their breast reconstruction procedures, patients at LAC demonstrated comparable satisfaction levels to other published reports. The occurrence of major complications and immediate reconstruction were significantly associated with lower levels of satisfaction.
Asunto(s)
Hospitales de Condado , Mamoplastia , Satisfacción del Paciente/estadística & datos numéricos , Adulto , Anciano , Neoplasias de la Mama/cirugía , Carcinoma Ductal de Mama/cirugía , Carcinoma Intraductal no Infiltrante/cirugía , Femenino , Encuestas de Atención de la Salud , Humanos , Los Angeles , Mastectomía , Persona de Mediana Edad , Estudios Retrospectivos , Poblaciones VulnerablesRESUMEN
The field of reconstructive microsurgery is experiencing tremendous growth, as evidenced by recent advances in face and hand transplantation, lower limb salvage after trauma, and breast reconstruction. Common to all of these procedures is the creation of a nutrient vascular supply by microsurgical anastomosis between a single artery and vein. Complications related to occluded arterial inflow and obstructed venous outflow are not uncommon, and can result in irreversible tissue injury, necrosis, and flap loss. At times, these complications are challenging to clinically determine. Since early intervention with return to the operating room to re-establish arterial inflow or venous outflow is key to flap salvage, the accurate diagnosis of early stage complications is essential. To date, there are no biochemical markers or serum assays that can predict these complications. In this study, we utilized a rat model of flap ischemia in order to identify the transcriptional signatures of venous congestion and arterial ischemia. We found that the critical ischemia time for the superficial inferior epigastric fasciocutaneus flap was four hours and therefore performed detailed analyses at this time point. Histolgical analysis confirmed significant differences between arterial and venous ischemia. The transcriptome of ischemic, congested, and control flap tissues was deciphered by performing Affymetrix microarray analysis and verified by qRT-PCR. Principal component analysis revealed that arterial ischemia and venous congestion were characterized by distinct transcriptomes. Arterial ischemia and venous congestion was characterized by 408 and 1536>2-fold differentially expressed genes, respectively. qRT-PCR was used to identify five candidate genes Prol1, Muc1, Fcnb, Il1b, and Vcsa1 to serve as biomarkers for flap failure in both arterial ischemia and venous congestion. Our data suggests that Prol1 and Vcsa1 may be specific indicators of venous congestion and allow clinicians to both diagnose and successfully treat microvascular complications before irreversible tissue damage and flap loss occurs.
Asunto(s)
Arterias/cirugía , Biomarcadores/metabolismo , Isquemia/cirugía , Microvasos/cirugía , Colgajos Quirúrgicos/irrigación sanguínea , Colgajos Quirúrgicos/patología , Venas/cirugía , Animales , Arterias/metabolismo , Arterias/patología , Perfilación de la Expresión Génica , Regulación de la Expresión Génica , Ontología de Genes , Hiperemia/cirugía , Isquemia/genética , Isquemia/patología , Masculino , Microcirugia , Microvasos/patología , Análisis de Secuencia por Matrices de Oligonucleótidos , Fenotipo , Ratas , Ratas Sprague-Dawley , Reproducibilidad de los Resultados , Reacción en Cadena de la Polimerasa de Transcriptasa Inversa , Transducción de Señal/genética , Factores de Tiempo , Transcriptoma/genética , Venas/metabolismo , Venas/patologíaRESUMEN
BACKGROUND: To date, few large-scale studies have reported the incidence of surgical-site infection in women undergoing mastectomy with respect to the various methods of immediate breast reconstruction. This study assessed whether the reconstruction method was associated with the risk of surgical-site infection in these patients. METHODS: Using the National Surgical Quality Improvement Program database, 9230 female patients undergoing mastectomy with immediate reconstruction from 2005 to 2009 were identified. Reconstruction was classified as autologous, prosthetic, or hybrid. The primary outcome was the incidence of surgical-site infection within 30 days of operation. Univariate and multivariate analyses were performed to derive the unadjusted and adjusted risk of surgical-site infection according to reconstruction method. RESULTS: The overall rate of surgical-site infection was 3.53 percent (95 percent CI, 3.15 to 3.94 percent), with individual rates of 3.33 percent (95 percent CI, 2.93 to 3.76 percent) for prosthetic reconstruction, 4.88 percent (95 percent CI, 3.48 to 6.11 percent) for autologous reconstruction, and 2.19 percent (95 percent CI, 0.88 to 4.45 percent) for hybrid reconstruction. The adjusted odds ratio of surgical-site infection was 1.14 (95 percent CI, 0.83 to 1.58; p = 0.42) for autologous versus prosthetic methods and 0.59 (95 percent CI, 0.27 to 1.27; p = 0.18) for hybrid versus prosthetic methods. CONCLUSIONS: Although the risk of surgical-site infection in patients undergoing immediate reconstruction is highest with autologous and lowest with hybrid methods of reconstruction, the difference in infection risk was not statistically significant after adjustment for confounding factors. Thus, all methods of reconstruction are viable options with regard to risk for surgical-site infection. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.
Asunto(s)
Mamoplastia/efectos adversos , Mamoplastia/métodos , Medición de Riesgo/métodos , Infección de la Herida Quirúrgica/epidemiología , Implantes de Mama , Neoplasias de la Mama/cirugía , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Mastectomía , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Riesgo , Infección de la Herida Quirúrgica/etiología , Factores de Tiempo , Estados Unidos/epidemiologíaRESUMEN
Venous thromboembolism (VTE) is a potentially preventable disease that carries significant morbidity and mortality. Although malignancy is associated with increased risk for VTE, it varies according to cancer type. Despite the fact that breast cancer is the most common form of cancer in women, the incidence and risk factors associated with VTE in patients undergoing mastectomy have not been well characterized. To address this we utilized the ACS-NSQIP database to identify and characterize independent risk factors for VTE in 49,028 mastectomy patients. We identified 116 cases of VTE in the 49,028 cases analyzed (0.23%). Obesity (BMI > 30, OR = 1.91, p < 0.001), inpatient status (OR = 3.75, p < 0.001), venous catheterization (OR = 2.67, p = 0.012), prolonged operative time >3 h (OR = 4.36, p < 0.001), and immediate reconstruction (OR = 3.23, p < 0.001) were found to be independent risk factors for VTE. While the incidence of VTE is rare in mastectomy patients, the heightened awareness and increased VTE prophylaxis should be considered in high risk groups.
Asunto(s)
Neoplasias de la Mama/epidemiología , Mastectomía , Complicaciones Posoperatorias/epidemiología , Embolia Pulmonar/epidemiología , Trombosis de la Vena/epidemiología , Adulto , Anciano , Neoplasias de la Mama/cirugía , Cateterismo Venoso Central/estadística & datos numéricos , Femenino , Humanos , Mamoplastia , Persona de Mediana Edad , Obesidad/epidemiología , Tempo Operativo , Factores de Riesgo , Tromboembolia Venosa/epidemiologíaRESUMEN
BACKGROUND: The Centers for Disease Control and Prevention reported that surgical site infections (SSIs) create a significant hospital burden. To date, few multi-institutional studies have been performed to evaluate the risk factors for SSIs in mastectomy patients. METHODS: By using the American College of Surgeons' National Surgical Quality Improvement Program database, all patients undergoing mastectomy from 2005 to 2009 were identified. The outcome was to determine the incidence rate and identify significant independent risk factors of SSIs. RESULTS: The incidence of SSI was 2.3% (891 of 38,739; 95% confidence interval, 2.2%-2.5%) in patients undergoing mastectomy without reconstruction. Significant (P < .05) risk factors for SSI included a body mass index greater than 25, American Society of Anesthesiology classification of 3 or higher, diabetes mellitus, surgical time of 2 hours or longer (75th percentile), and current smoking status. CONCLUSIONS: Before this study, there was wide variation in the incidence rate of surgical site infections in this patient population. This was a large-scale study to address these inconsistencies.