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Background: The enhanced recovery after surgery pathway was introduced in 1997 as a multimodal approach to reduce preventable postoperative harm and shorten hospital length of stay. However, there is yet no widely accepted enhanced recovery after surgery protocol for microsurgical breast reconstruction. The authors conducted a systematic review and meta-analysis of the current literature on enhanced recovery after surgery for microsurgical breast reconstruction with regard to postoperative length of stay and morbidity. Methods: The PubMed, Embase, Cochrane, Scopus, and Web of Science databases were searched for all studies published before June of 2016 containing original data on enhanced recovery after surgery in microsurgical breast reconstruction in relation to postoperative length of stay and morbidity. Studies were screened using eligibility criteria. Meta-analysis, odds ratio, and 95 percent confidence interval were used to pool acquired data. Results: The initial search identified 86 studies. Two independent screeners identified four original articles with a total of 676 patients. Length of stay was significantly shorter for patients on an enhanced recovery after surgery pathway (mean difference, −1.23; 95 percent CI, −1.50 to −0.96; p < 0.001; I 2 = 0 percent; random effects model). Enhanced recovery was not associated with changes in 30-day postoperative morbidity; specifically, no significant difference was observed in rates of partial flap loss (p = 0.44), total flap loss (p = 0.91), breast hematoma (p = 0.69), donor-site infection (p = 0.53), urinary tract infection (p = 0.29), and pneumonia (p = 0.42). Conclusion: The authors’ review suggests that enhanced recovery after surgery in microsurgical breast reconstruction is associated with a reduced length of stay, and is not associated with increased postoperative morbidity.

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stablished in 1966 under the Social Security Administration, Medicare is the primary health insurance for many Americans older than 65 years. 1 In 2018, Medicare represented more than 61.5 million individuals, and its budget was approximately $750 billion. 2 Medicare reimburses physicians based on a national fee schedule. 1 To establish this fee schedule, each medical procedure or service is represented by a CPT code and linked to an International Classification of Diseases, Tenth Revision, diagnosis. This represents the relative resources required to provide a particular service and forms the basis for physician and hospital reimbursement. 3 These relative value units are updated annually by the Centers for Medicare and Medicaid Services and effectively set the standard by which hospitals and/or physicians are reimbursed. Relative value units consider expenses related to physician work, practice expenses, and malpractice insurance. The final fee schedule for each procedure/service is then determined by applying the conversion factor to the relative value units. The conversion factor is a number selected by Centers for Medicare and Medicaid Services every year based on complex formulas that take into consideration the Medicare charges the year prior, the number of Medicare enrollees, the overall status of the U.S. economy, and any expected regulations that may affect Medicare services. The goal of the conversion factor is to limit potential increases in the Medicare budget higher than 20 percent from the last year's budget. 4 Growth in the aging population, steadily rising health care costs, and increased demand for health care services combined with fluctuations in the national political and financial landscape lead to financial unpredictability in the health

Background Keloid disease treatment continues to be unsatisfactory with high recurrence rates. We evaluated the literature regarding the effectiveness of keloid excision with various adjuvant treatments following surgery and assessed recurrence rates. Methods We systematically searched databases through November 2016. We performed pairwise meta-analyses and Bayesian network meta-analyses on the number of recurrences. Results Following screening, 14 studies including 996 patients with various types of keloids were eligible for inclusion. Patients were categorized based on the receipt of surgery and the type of adjuvant treatment employed afterward. Paired meta-analysis (6 meta-analyses) showed that “excision + 1 adjuvant drug” led to statistically significantly higher odds of recurrence compared to “excision + radiation” (odds ratio [OR], 3.22; 95% confidence interval [CI], 1.35–7.67). Based on the network meta-analyses, the ORs of keloid recurrence following various treatments compared to no excision were as follows: “excision + pressure, 0.18 (95% CI, 0.01–7.07); excision + 2 adjuvants drugs, 0.47 (95% CI, 0.02–12.82); excision + radiation, 0.39 (95% CI, 0.04–3.31); excision + skin grafting, 0.58 (95% CI, 0.00–76.10); excision + 1 adjuvant drug, 1.76 (95% CI, 0.17–21.35); and excision only, 2.17 (95% CI, 0.23–23.95). Conclusions According to our results, “excision + radiation” had significantly better outcomes than excision alone. “Excision + pressure” had better outcomes than excision + any other treatment modality, and excision + nonradiation adjuvant therapies were also better than “excision only,” although these findings did not reach statistical significance.

According to our meta-analysis, abdominal wound characteristics following cesarean section can predict the presence of adhesions. However, given the small number of published studies, further research is needed to corroborate our findings.

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.

Because UE transplantation is not a life-saving procedure, much ethical debate has accompanied its evolution. It is important for UE surgeons considering referring patients for evaluation to be aware of this discussion to fully educate patients and help them make informed treatment decisions.