Background For the last decade, there has been a significant reduction in hospital length of stay (LOS) after breast cancer surgery, and the last few years there is a tendency of early discharge (ED) rates following mastectomy. We defined same-day surgery (SDS) as admission, surgery and discharge on the same day and ED as hospital length of stay less than 36 hours. Studies show clear benefits with breast cancer patients having SDS such as reduction of hospital and patient costs, faster patient psychological recovery, lower rates of surgical complications and significant reduction of surgical site infection. However, concerns about performing more invasive procedures in an outpatient basis, such as immediate breast reconstruction (BR) is noticeable and few articles addresses this subject. At our institute our goal is to have an early and safely discharge for every patient with low complication rate, independently of the procedure (except for microvascular BR). We sought to describe our early discharge BR program in terms of complication rate and analyze risk factors for one-night hospitalization. Methods IRB approval was obtained for a retrospective review of all BR procedures performed from 2017- 2019 in the National Cancer Institute of Mexico. We selected patients who underwent BR surgeries with or without associated oncologic procedure in a basis of ED mode. Exclusion criteria were microvascular BR and patients who were not admitted the same day of surgery. We analyzed immediate and delayed BR (alloplastic or autologous), oncoplastic procedures and revision surgeries (complications). Demographic, clinical and surgical variables were analyzed in the bivariate analysis. And a logistic regression was used to determine possible risk factors for > 24 hours length of stay (LOS). Results A total of 456 patients were submitted to 692 total breast reconstruction surgeries. We categorized surgical events into 2 groups according to LOS: 419 (61%) in the SDS group with < 24 hours LOS and 273 (39%) in the > 24 hours group. The SDS group had a higher median age (46.7 years versus 44.8; p=0.0265), similar rates of diabetes, systemic hypertension, other comorbidities and ASA class. There is a greater proportion of patients with overweight in the SDS group (47.7% versus 33.7%; p=0.004). SDS group had a median LOS of 9.2 ±2.6 hours versus 33.1± 17.5 hours in the > 24 hours group (p=0.000). In the > 24 hours group the proportion of bilateral surgeries was 29.6% versus 36.8% (p=0.457), MT with alloplastic BR 59.7% versus 24.6% (p=0.000), and axillary lymph node surgery 55% versus 24.5% (p=0.000). Among all surgeries, 131 (18.9%) presented postoperative complications, 14.6% in the SDS group versus 25.6% (p=0.000). The quantity of reconstruction failures was 16 (4.8%). Most common complications were: 10.7% surgical site infection (9.1% in the SDS group versus 13.2%), 9.4 reintervention (7.4% SDS group versus 12.5%),13.6% of emergency room consultation (12.4% SDS group versus 14.3%), 0.6% hematoma. In the multivariate analysis we found significant risk factors for >24 hours LOS were a low educational level, low hemoglobin level, quantity of drains, length of surgery and certain types of surgery such as MT with immediate BR, oncoplastic surgery and autologous BR and presence of axillary lymph node surgery. Conclusions These results demonstrate that an ED breast cancer reconstruction program is safe and effective at our institution. The complication rate for our population is similar to other reported. We also found very positive that although there is no significant difference in complications, reinterventions or readmissions between >24 hours group and patients discharged the same day, there is a slight difference towards less complications in the SDS group which support continue reinforcing our SDS BR program. Citation Format: Juan Enrique Bargallo-Rocha, Daniela Vargas-Salas, Luz M Gutiérrez-Zacarías, Juan A Torres-Domínguez, Judith Acosta-Violante, Erick H Rubio-Arroyo. Effectiveness of a breast reconstruction program with early discharge [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P6-14-03.
Background: Breast cancer (BC) is the most common malignancy in Mexico, and although many Mexican women need breast reconstruction, this is not covered by most public insurance schemes. The National Cancer Institute of Mexico (INCan), located in southern Mexico City provides care to uninsured individuals with all types of malignancies, including BC. In 2012, INCan received a grant from the Mexican federal government in order to establish the “Post-Mastectomy Program” (PMP), aimed at providing free breast reconstruction to women after mastectomy. Here, we describe the implementation and outcomes of our microsurgical breast reconstruction program. Methods: We retrospectively reviewed medical records of all patients undergoing microsurgical breast reconstruction after mastectomy at INCan between the establishment of the PMP in 01/2013 and until 12/2017. Sociodemographic, clinical and surgical characteristics were collected. We also recorded for the presence of complications directly related to the reconstructive procedures, including local complications (infections, necrosis, thrombosis etc.), flap loss, need for reoperation and hospitalization time. Data were analyzed using descriptive statistics such as means, medians and proportions. Results: 161 microsurgical breast reconstructions were conducted at INCan between 01/2013 and 01/2017, ranging from 23 in 2013 to 41 in 2016. Median patient age was 45 years (y) (21-66), and 57% had < high school education. 2.5% had diabetes, 9.9% hypertension, and 2.5% rheumatologic diseases. Median body mass index was 26.8 (18.2-39), 82.6% were non-smokers and 46.5% (n = 108) had previous abdominal scars. Regarding reasons for mastectomy, 67.7% were due to invasive BC, 11.8% to ductal carcinoma in situ, and 5.6% to BRCA mutations. Of the 109 invasive carcinomas, 21.8% were stage I, 57.3% stage II, and 20% stage III; 21.7% received neoadjuvant chemotherapy. 125 patients underwent immediate reconstruction, of which 89 used unilateral deep inferior epigastric perforator flaps (DIEP), 35 bilateral DIEPs, and 1 other technique. Mean preoperatory albumin was 4.2g/dL (SD 0.35), while mean preoperatory hemoglobin was 14.2g/dL (SD 1.2). 41.6% of the patients (n = 67) had at least one surgical complication, with the most common being delayed wound healing in 17% and fat necrosis in 14%. 26% of patients had to be reoperated, and flap loss occurred in 13% (n = 21). No differences were noted in the clinical or surgical characteristics of patients with or without flap loss. Median length of stay was 6 days (range 2-17). Conclusions:This is the first detailed description of the outcomes of a microsurgical reconstruction program in a country with limited resources. Developing and implementing such a program is feasible, and may provide access to breast reconstruction to women who would normally be unable to obtain it. Citation Format: Vargas-Salas D, Figueroa-Padilla J, Soto-Perez-de-Celis E, Maciel-Miranda A, Santamaria E, Zacarías-Gutiérrez LM, Cabrera-Galeana P, Bargallo-Rocha E. Implementation and outcomes of a microsurgical breast reconstruction program at a public cancer center in Mexico [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-16-12.
Background: As life expectancy improves in women with breast cancer (BC), all efforts to enhance patients´ quality of life (QOL) have gained great importance. It is known that breast reconstruction (BR) surgery has a big impact in QOL and consequently it has become a valuable element in the multidisciplinary approach of BC patients. It is clear that as long as it does not suppose an interference for their oncologic treatment, patients must have offered immediate breast reconstruction as part of their surgical treatment. However, concerns about delay in oncologic therapy, especially because of postoperative complications may influence oncologic specialists to discourage patients to take this option in certain scenarios. In this study we evaluated the association between immediate BR and delay in time to oncologic treatment (TOT), defined as number of days between surgery and the initiation of oncologic adjuvant therapy (chemotherapy, endocrine and radiotherapy). Methods: IRB approval was obtained for a retrospective review of all patients undergoing BC surgery with immediate BR and received adjuvant oncologic therapy at the National Cancer Institute of Mexico from 2017 to 2019. We performed a 2:1 statistical matching with randomly selected patients from an institutional database who underwent only oncologic surgery and adjuvant therapy using year of surgery (2014-2016) and clinical stage as selection criteria. Demographic, tumor and surgical variables were analyzed in the bivariate analysis. According to the variable TOT, we categorized patients into 3 groups: <20, 20 to 50, and >50 days. We performed a quantile regression to identify the association with delay in TOT. A logistic regression was used to analyze postoperative complications in reconstructed patients as possible risk factors for delay. Results: We analyzed 456 patients undergoing BC surgery, of which 152 (33.3%) underwent immediate BR. Clinical Stage II was the most prevalent in all grousps. Among all patients 60% underwent total mastectomy (TM), 23.5% TM and alloplastic BR, 6.6% TM and autologous BR, 6.6% breast conservative surgery and 3.3% oncoplastic surgery. Patients not reconstructed had a higher median age (53.4 years versus 45.4; p=0.000), higher rates of diabetes (12.5% versus 5.9%; p=0.029) and higher rates of systemic hypertension (23.6% versus 10.5%; p=0.001). In the reconstructed group, the median TOT was 29 days (12 to 179) versus 29.5 days (6 to 188) in the not reconstructed (p=0.43). Among the 21% of reconstructed patients who experienced postoperative complications, we found 16 (10.5%) surgical site infections, 24 (15%) reinterventions, 4 (2.6%) hematoma and 1 (0.65%) flap loss. The complication group did not show delay in the TOT (p=0.09) with a median TOT of 41.5 days. There is a global BR failure rate of 11.8% and it has no association with delay in TOT (p=0.842). Conclusions: In our series, we found a median TOT of 29 days in both groups. There is no difference in TOT between the reconstructed and the not reconstructed groups in terms of delay of TOT. When analyzing the reconstructed group by incidence of postoperative complications, which is one of the main concerns, we also found they did not have a significant impact in delay of therapy. We considered that a multidisciplinary approach, an effective communication between the plastic and the oncologic team and careful patient education are of major importance to get an early detection of complications, prompt management and recanalization of patient to continue their oncologic therapy as planned. Our results support previous findings that breast reconstruction should continue to be encouraged in order to provide good QOL for BC patients without interfering with oncologic outcomes. Citation Format: Juan Enrique Bargallo-Rocha, Daniela Vargas-Salas, Luz M Gutiérrez-Zacarías, Juan Alejandro Torres-Domínguez, Luis Erick Juárez-Cabello, Paula Anel Cabrera-Galeana. Does immediate breast reconstruction delay oncologic therapy? [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P6-14-02.
Background: Multiple advances are ongoing on breast cancer surgery, however it is still frequently associated with postoperative acute and chronic pain, nausea and vomiting. This is a major concern in immediate breast reconstruction patients which usually report higher pain levels. Acute post-surgical pain leads to delayed discharge, impaired immune functions, higher risk of cardiovascular complications and chronic pain. Hence, the importance of an appropriate perioperative pain management in these patients. Regional nerve blocks have demonstrated to be a good modality for pain control, with an opioid-sparing effect, which allows early discharge and reduced postoperative analgesic requirements. This is particularly relevant, since the reduced use of opioids, not only limits opioid-related side effects as nausea and constipation but may also prevent the risk of recurrence associated to the immunosuppressive effect of opioids on the breast cancer microenvironment. The aim of this study is to analyze the effect of regional block usage in perioperative adjuvant pain and nausea management aswell as its influence in early discharge and postoperative complications. Methods: After obtaining IRB, we retrospectively review medical and anesthetic reports of patients who underwent immediate and delayed breast reconstruction from 2017 to 2019 at the National Cancer Institute of Mexico. Surgical events were categorized according to the use of a regional nerve block as complement for general balanced anesthesia. Sociodemographic, clinical, surgical and anesthesiologic variables were collected. Data were analyzed using descriptive statistics such as means and deviated standards for quantitative variables; and medians and proportions for qualitative variables. A bivariate analysis was made taking as dependent variable the usage of regional nerve block. T-test or Mann-Whitney U test were used for quantitative variables, chi-square or Fisher exact test for qualitative variables. Results: A total of 692 breast reconstructive procedures, of which 106 (15.3%) had regional nerve blocks. We found no differences in age, diabetes mellitus, systemic hypertension and other comorbidities between both groups. Tumor characteristics, smoking and BMI were similar between the non-blocked and blocked groups. When analyzing surgical variables there were no differences in type of surgery (immediate or delayed breast reconstruction), presence of axillary lymph node dissection and drainage device usage. There were no significant differences in overall complications in the non-blocked group versus the blocked group (18.94% versus 18.87%, p=0.99). We found no significant differences in specific complications in the blocked group: cardiovascular (1.02% versus 0.94%, p=0.94); no hypertensive crisis; pneumothorax (0.17% versus 0.94%, p=0.17); hematoma (0 versus 0.68%, p=0.39); thrombosis (0 versus 0.85%, p=0.34); reintervention (9.22% versus 9.57%, p=0.94), nausea/vomiting (1.89% versus 0.17, p=0.01) and uncontrolled pain (1.37% versus 0.94%, p=0.72). When analyzing anesthetic variables, we found less steroid use in the blocked group (82.1% versus 91.3%, p=0.004); less doses of antiemesis drugs (5-HT3 antagonist) (4.6±4.45mg versus 5.9±4.55mg, p=0.002), less opioid need (tramadol) (42.5% versus 66.8%, p=0.000) and less fentanyl doses (355.4±184.7 mg versus 289.7 ± 148.0 mg, p=0.0012). Conclusions: Based on our results, we consider that the use of regional blocks as a perioperative pain management in breast reconstruction procedures is a safe intervention, which reduces the use of steroids, doses of antiemetics and opioid use. These findings suggest that further studies need to be performed to confirm which type of regional block has more benefits in terms of recovery time, opioid use and patient satisfaction. Citation Format: Juan Enrique Bargallo-Rocha, Daniela Vargas-Salas, Luz M Gutiérrez-Zacarías, Juan A Torres-Domínguez, Judith Acosta-Violante, Horacio Vázquez-Morales. The role of regional blocks in an early discharge breast reconstruction program [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P6-14-04.
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