Background: Cannabis use is increasingly prevalent. Cannabinoid receptors regulate pro-inflammatory cytokines, and compounds in marijuana exert diverse physiologic effects. As more patients use cannabis, clinicians should recognize implications of perioperative cannabis use. Although the role of cannabis use in perioperative pain control has been explored, little is known about its effect on perioperative wound healing or on hematologic, pulmonary, and cardiovascular physiology. Methods: We searched PubMed for English-language articles related to cannabis (ie, marijuana, cannabidiol oil, and tetrahydrocannabinol) and wound healing, cardiovascular, pulmonary, or hematologic outcomes, and surgery. Titles and abstracts were reviewed, and relevant articles were analyzed. Human, animal, and pathology studies were included. Editorials, case reports, and review articles were excluded. Results: In total, 2549 wound healing articles were identified; 5 human studies and 8 animal/pathology studies were included. Results were conflicting. An estimated 2900 articles related to cardiovascular effects were identified, of which 2 human studies were included, which showed tetrahydrocannabinol and marijuana caused tachycardia. A total of 142 studies regarding pulmonary effects were identified. Three human studies were included, which found no difference in respiratory complications. In total, 114 studies regarding hematologic effects were identified. The 3 included human studies found conflicting venous thromboembolism risks. The overall study quality was poor. Information about dose/duration, administration route, and follow-up was reported with variable completeness. Conclusions: Surgeons should consider effects of cannabis in the perioperative setting. Little is known about its perioperative effects on wound healing, or on cardiovascular, pulmonary, and hematologic physiology. Further research should elucidate the effects of administration route, dose, and timing of cannabis use among surgical patients.
When given options for pain control in breast augmentation, intraoperative ketorolac should be considered, because its inclusion was significant in decreasing use of narcotics and pain upon discharge. Addition of other costly drugs such as liposomal bupivacaine may not provide additional benefit in the immediate postoperative setting for procedures with a short recovery period such as breast augmentation.
Surgical site infection after breast reconstruction is associated with increased length of hospital stay, readmission rates, cost, morbidity, and mortality. Identifying methods to reduce surgical site infection without the use of antibiotics may be beneficial at reducing antimicrobial resistance, reserving the use of antibiotics for more severe cases. Quaternary ammonium salts have previously been shown to be a safe and effective antimicrobial agent in the setting of in vitro and in vivo animal experiments. A retrospective study was conducted to investigate the antimicrobial properties of a quaternary ammonium salt, 3-trimethoxysilyl propyldimethyloctadecyl ammonium chloride (QAS-3PAC; Bio-spear), at reducing surgical drain site colonization and infection after breast reconstruction (deep inferior epigastric perforator flap reconstruction or tissue expander placement). Twenty patients were enrolled, with 14 surgical drains covered with nonimpregnated gauze and 17 surgical drains covered with QAS-3PAC impregnated gauze, for the purposes of investigating bacterial colonization. Antibiotic sensitivity analysis was also conducted when bacterial cultures were positive. The overall incidence of bacterial colonization of surgical drains was lower in the treatment group compared with the control group (17.6% vs 64.3%, respectively; P = 0.008). QAS-3PAC impregnated gauze reduced the incidence of bacterial colonization of surgical drains during the first (0.0% vs 33.3%) and second (33.3% vs 87.5%; P = 0.04) postoperative week. Furthermore, no enhanced antibiotic resistance was noted on drains treated with QAS-3PAC impregnated gauze. The results of this study suggest that QAS-3PAC impregnated gauze applied over surgical drains may be an effective method for reducing the incidence of bacterial colonization.
Gender-Affirming Surgery G ender-affirming care requires a multidisciplinary clinical approach. Some transfeminine patients may undergo a complex and highly individualized transition process. Medical transition can include feminizing hormone therapy like conjugated estrogens and antiandrogens. 1 However, prolonged estrogen hormone exposure and genetic mutations are known risk factors for breast cancer. There have only been 21 reports of breast cancer in transgender female patients since 1968. It remains unclear whether the use of feminizing hormone therapy augments this risk in transgender women in the setting of genetic predisposition.There is a lack of literature addressing the approach to breast cancer treatment and reconstruction in transgender women. We aim to contribute our findings to the small data set by presenting the second ever reported case of BRCA2 associated invasive ductal carcinoma in a transgender woman. We then discuss the shared decision-making process that led to bilateral nipple-sparing mastectomy (NSM) and prosthetic implantation. Finally, we explore the challenges associated with reconstructing a transfeminine chest. CASE REPORTFull informed consent for participation and photography was obtained from the patient. A 70-year-old transgender woman of Ashkenazi Jewish descent began taking 1.8 mg estradiol and 50 mg spironolactone daily in 2018 as part of her gender-affirmation transition. Baseline mammography done 1 year after beginning hormone therapy was normal. Six months later, she developed prominent asymmetry in the right breast (Fig. 1). Repeat mammography revealed a 1.8 cm lobulated spiculated mass in the right retroareolar region and no axillary adenopathy. Pathology showed estrogen and progesterone receptor positive (ER/ PR+), human epidermal growth factor receptor 2 negative (HER2-) invasive ductal carcinoma.Estrogen and spironolactone were discontinued. Orchiectomy was recommended to decrease peripheral testosterone conversion to estrogen. However, the patient declined orchiectomy because she did not wish to undergo any genital operations before vaginoplasty. She was agreeable to neoadjuvant endocrine therapy with tamoxifen. Following 3 months of therapy, the patient underwent bilateral NSM with ipsilateral sentinel lymph node biopsy and immediate subpectoral tissue expander and acellular dermal matrix placement.Surgical pathology revealed a 1.8 cm high grade invasive ductal carcinoma with less than 1 mm nipple margin and lymphovascular invasion. One sentinel node was positive with 1 mm nodal deposit. In the setting of her pathologic findings, adjuvant chemotherapy and radiation were recommended. 2 Genetic evaluation revealed both sets of grandparents were of Eastern European Ashkenazi Jewish descent. Family history was notable for both lung and breast cancer. The patient met National Comprehensive Cancer Network
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