51.17 Application of intraoperative ultrasound in complicated laparoscopic cholecystectomy

Posted on January 31, 2019

L. Guowei1, Z. Liaonan1, H. Yaobin1, C. Guobin1, L. Guowei1  1Guangdong hospital of TCM, Zhuhai Campus,Guangzhou, GUANGDONG, China

Introduction: To measure the biliary tract relationship of gallbladder triangle in complicated laparoscopic cholecystectomy, avoiding right hepatic pedicle and common bile duct injury.

Methods: We analyzed 21 patients with different cholecystitis received laparoscopic cholecystectomy between Jun. 2018 and Jul. 2018 in our center. Intraoperative ultrasound was performed on gangrenous cholecystitis, atrophic cholecystitis, and porcelain gallbladder. The shortest distance between the gallbladder bed and the right hepatic pedicle was recorded, and the complications were recorded.

Results:14 cases of all?gangrenous cholecystitis, the average distance was 0.543±0.062cm, 5 cases of all, the average distance of atrophic cholecystitis was 0.372±0.033cm, 2 cases of porcelain gallbladder, the average distance was 0.34±0.02cm, and the average distance of 21 cases was 0.483± 0.094 cm, no postoperative jaundice and postoperative biliary fistula in all cases.

Conclusion: Intraoperative ultrasound for complex laparoscopic cholecystectomy can avoid the right hepatic pedicle injury and increase the safety of cholecystectomy. It may reduce the risk of postoperative complications.

 

51.06 Development of an Automated Digital Surgical Safety Checklist to Reduce Surgical Errors

Posted on January 31, 2019

J. Langell1,2,3, J. Ferraro1, M. Young1, C. Mi1, Y. Deng1, C. Swensen1, J. Langell1,2,3  1University Of Utah,Center for Medical Innovation,Salt Lake City, UT, USA 2University Of Utah,Department Of Surgery,Salt Lake City, UT, USA 3VA Salt Lake City Health Care System,Center of Innovation,Salt Lake City, UT, USA

Introduction:

Preventable surgical errors occur in 3-16% of surgeries worldwide and account for >1 million deaths per year. These include wrong site surgeries, wrong procedure, wrong patient, incorrect implant and other so called “never events”. The use of surgical safety checklists (SSC) as a tool to improve surgical communication and planning have been shown to be effective in reducing preventable surgical errors in numerous research studies. Outside of monitored research studies, the effectiveness of SSC drops substantially due to provider complacency and poor compliance.  

Methods:  

We conducted a literature review on surgical safety checklist efficacy and compliance issues and performed observational checklist usability studies and stakeholder review sessions. Output from these reviews and studies were used as design inputs for the development of an automated, digital surgical safety application.  Iterative usability testing and human factors design analysis were then performed on the completed product with input from multiple surgeons, anesthesiologist, nurses and surgical technicians. 

Results: 

A literature review on surgical checklists noted concerns with team engagement, checklist compliancy, lack of participation, failure to complete the entire checklist and lack of accountability and ownership. Our internal analysis demonstrated similar findings, in addition we found that many checklist items were filled out in advance, especially the post-procedure portions. Stakeholder analysis highlighted a need for 1) automation of patient identification, critical characteristics, procedure performed and operative location verification 2) a need to increase team engagement and accountability 3) prevention of user complacency and compliance errors. Data acquired through these studies were used as design inputs to produce a fully functional automated, digital surgical safety checklist application. The final product provided a user-centered design with automated patient identity feature via scannable QR code technology, provided mistake proof checklist question progression and completion, increased team engagement through large monitor projection, and increased accountability through signature capture and electronic medical record documentation. A final usability analysis of the application received uniformly positive feedback for adoption and use by all clinical team members.

Conclusion:

Current paper-based surgical safety checklists suffer from use complacency, poor compliance, low provider engagement and lack of accountability.  Automated digital surgical safety checklist may provide a solution to overcome these barriers and improve the impact of surgical checklists in reducing surgical errors due to poor communication and planning.  

51.04 Factors Associated with Complications in Medical and Surgical Management of Diverticulitis

Posted on January 31, 2019

S. Wei1, K. M. Mueck1, A. A. Radwan1, C. Wan1, C. E. Wade1, T. C. Ko1, S. G. Millas1, L. S. Kao1  1McGovern Medical School at UTHealth,Acute Care Surgery,Houston, TX, USA

Introduction:  Complications during hospitalization for diverticulitis are difficult to classify using traditional tools such as the Clavien-Dindo system, since only 10% of patients require surgical intervention during the same admission. The Adapted Clavien-Dindo in Trauma (ACDiT) grading system is advantageous over the traditional Clavien-Dindo score because it is applicable to emergent surgeries and to patients managed non-operatively.  We have shown that ACDiT is applicable to acute diverticulitis patients, and we aimed to identify factors associated with ACDiT ≥ grade 2 complications in acute diverticulitis patients managed medically or surgically. ACDiT score of 2 means the complication required pharmacologic treatment (not including antiemetics, antipyretics, analgesics, diuretics, and electrolytes) or unexpected blood transfusions, but did not require unplanned procedures or intensive care unit admission.

Methods:  We performed a retrospective cohort study of patients hospitalized for acute diverticulitis admitted to surgery between 2011 – 2016 at a safety-net hospital. Baseline demographics and hospitalization data were collected. ACDiT scores were assigned; scores range from 0 to 5b, with 0 indicating no deviation from treatment plan and 5b indicating death despite active treatment. Univariate analysis was performed. Inverse probability weighted (IPW) propensity scores were assigned for surgical management, and IPW regression analysis was used to determine factors associated with ACDiT ≥ grade 2.

Results: Of 260 patients, 177 (68%) were managed medically. There were no differences in age, sex, race, Charleston Co-morbidity Index (CCI), or intraabdominal drain placement based on management strategy. On multivariable analysis, percutaneous drainage was associated with higher odds of ACDiT ≥ grade 2 with medical and surgical management. Higher CCI increased the odds of ACDiT ≥ grade 2 with medical management, while open surgery increased the odds of ACDiT ≥ grade 2 with surgical management. On IPW propensity score analysis, Hinchey 3, percutaneous drainage, and surgical management had 11-, 9-, and 3-times higher odds of having a complication of ACDiT ≥ grade 2 (Table).

Conclusion: The ACDiT score can be used to grade complications in acute diverticulitis patients managed medically or surgically, and to identify factors contributing to worse outcomes regardless of management strategy. Factors associated with ACDiT ≥ grade 2 include Hinchey 3, percutaneous drainage, and surgical management. ACDiT should be considered as a tool that can be used to benchmark outcomes for acute diverticulitis and to compare the effectiveness of strategies addressing risk factors for complications.

49.15 The Significance of Caudal-to-Cranial Approach in Lymphadenectomy in Laparoscopic Right Colectomy

Posted on January 31, 2019

L. Zou1, B. Zheng2, Y. He1, L. Zou1  1Guangdong Hospital of Traditional Chinese Medicine, Zhuhai,Department Of General Surgery,Zhuhai, GUANGDONG, China 2Brookdale Hospital and Medical Center,Department Of General Surgery,Brooklyn, NEW YORK, USA

Introduction: Currently? the medial-to-lateral approach is widely used in laparoscopic right colectomy. However, this approach is unable to dissect lymph nodes located posterior to the superior mesenteric vessels. Our aim is to discuss the necessity and clinical significance of using the caudal-to-cranial approach in laparoscopic right colectomy.

Methods: This is a prospective cohort study. A total of 78 consecutive patients (between 2014 and 2017) with advanced right colon cancer (TNM stage I: 17; stage II: n = 23; stage III: n = 38) requiring a curative right colectomy were subjected to laparoscopic caudal-to-cranial approach. All patients received preoperative nanocarbon injections around the tumor via colonoscopy. Lymph nodes were then analyzed and the positive rate of the lymph nodes was calculated.

Results: In this follow-up study, 45 male and 33 female patients(age 63.6±10.59 years old ) with mean body mass index of 21.7±2.87 kg/m2. The mean operation time was 153.9±25.36 min, and the mean blood loss was 82.0±19.21 ml. The mean tumor size was 5.3±1.1 cm and the mean number of harvested lymph nodes was 19.68±7.56 with an average of 1.53±2.75(7.8%) positive lymph nodes . Of these positive lymph nodes, 1.1±4.69  were posterior to superior mesenteric vessels, with a positive rate of 1.3%. All procedures were successful without any serious intraoperative complications, conversion to open surgery, or surgical mortalities.

Conclusion: There are positive lymph nodes posterior to the superior mesenteric vessels in progressive right colon cancers. We suggest a complete dissection of these lymph nodes to reach radical treatment by using a caudal- to-cranial approach.

 

49.14 Standardized Laparoscopic Surgery for Diverticular Colovesical Fistula

Posted on January 31, 2019

K. Tomizawa1, S. Matoba1, N. Okazaki1, K. Hiramatsu1, Y. Hanaoka1, S. Toda1, H. Kuroyanagi1, H. Kuroyanagi1  1Toranomon Hospital, Gastroenterological Surgery,Tokyo, Japan

Introduction: Colonic diverticular disease is widespread, and its incidence increases with aging. Patients suffering from diverticulitis and colovesical fistula are also increasing. Diverticular colonic resections are frequently more technically demanding than colon cancer due to inflammation. This study aimed to evaluate the safety and efficacy of our standardized laparoscopic procedure. 

Methods: A retrospective analysis was reviewed of 44 consecutive patients undergoing laparoscopic surgery for colovesical fistula during the period October 2006 to July 2018. 

Results:The median age was 61 years and the patients comprised 40 men and 4 women. Surgical procedures were sigmoidectomy: thirty-eight, Hartmann's operation: four, low anterior resection: two, respectively. The median operating time was 201 minutes and the estimated blood loss was 65.5mL. There were no intraoperative complications and conversion to open surgery. No bladder wall repairs were required. Six patients had minor postoperative complications comprising a postoperative abscess and three cases of superficial wound infection and three cases of anastomotic bleeding. The median length of postoperative stay was 11days. No patients had recurrence of diverticulitis or fistula at median follow-up of 5.6 years. 

Conclusion:We demonstrated that laparoscopic surgery for colovesical fistula can be safely performed. Because of its minimally invasive, laparoscopic approach appears to be the ideal choice especially for the colovesical fistula. To our knowledge, this is the largest study of colovesical fistula treated with laparoscopic procedure.

 

49.07 Quantitative Computed Tomography Image Analysis of Lateral Pelvic Lymph Node Status in Rectal Cancer

Posted on January 31, 2019

A. Usui1, K. Okita1, T. Nishidate1, K. Okuya1, E. Akizuki1, M. Ishii1, T. Satoyoshi1, I. Takemasa1  1Sapporo Medical University Hospital,Sapporo, Hokkaido, Japan

Introduction:
Lateral pelvic lymph node (LPLN) dissection in advanced lower advanced rectal cancer remains a subject of debate, and in order to justify this procedure, a reliable method of nodal characterization to assess preoperative nodal status is essential. Computed tomography (CT) of the pelvis is utilized to determine preoperative lymph node metastasis in rectal cancer, and morphological and internal structure of lymph nodes report to be promising factors. In this study, quantitative analysis of morphological and internal structure of LPLN in lower rectal cancer patients was performed to clarify the diagnostic value of these parameters in terms of metastasis.

Methods:
Data were retrospectively collected for 41 patients who had undergone total mesenteric excision with LPLN dissection for lower advanced rectal cancer from 2007 to 2014 at our institution. None of the patients had any treatment prior to surgery. All patients underwent preoperative enhanced CT. A single LPLN largest in short axis diameter was selected on the enhanced phase CT image for each patient, and the region of interest was manually drawn along the margin of the node. The number of voxels was calculated to determine the size of the lymph node and the mean signal intensity was recorded for the enhancement quality. Internal heterogeneity was quantified using kurtosis, skewness, and standard deviation of the pixel distribution histogram. All factors were compared between LPLN with and without metastasis pathologically proven with surgery.

Results:
An average of 16.9 LPLN was identified histopathologically for each patient (range: 2 to 39). Of the 41 patients, the LPLN detected on CT in 9 patients were too small for quantitative evaluation. Nine patients were histologically positive for LPLN metastasis. Compared to those without metastasis, the LPLN in these patients had a significantly increased number of voxels and significantly low mean signal intensity. Regarding heterogeneity, skewness was significantly higher and standard deviation was significantly lower in positive LPLN status. No significant difference was observed in kurtosis.

Conclusion:
LPLN with pathologically proven metastasis are presented on enhanced CT as larger in size, less enhanced, and CT enhancement was less heterogenous, compared to non-metastatic lymph nodes. Quantitative analysis with enhance CT using number of voxels, mean signal intensity, skewness, and standard deviation of the pixel distribution histogram are promising for discriminating metastatic lateral pelvic lymph nodes in lower rectal cancer.
 

49.06 Impact of Hospital Volume on Outcomes of Robotic versus Laparoscopic Resection for Rectal Cancer

Posted on January 31, 2019

N. Kim1, S. W. De Geus2, A. D. Geary2, S. Ng2, J. F. Hall1, J. F. Tseng2, U. Phatak1  1Boston Medical Center,Department Of Colorectal Surgery,Boston, MA, USA 2Boston Medical Center,Department Of General Surgery,Boston, MA, USA

Introduction: Robotic surgery for colorectal disease is rapidly gaining popularity. However, the impact of hospital volume on the outcomes of robotic surgery (RS) versus laparoscopic surgery (LS) remains unclear. This study investigates from the National Cancer Database whether hospital volume is a factor in determining the short- and long-term outcomes of RS versus LS for rectal cancer.

 

Methods:  Patients with stage I-III rectal cancer who underwent RS or LS between 2011 and 2014 were identified from the National Cancer Database. Institutions were defined as being either low-volume hospitals (LVH: 15 operations/year) or high-volume hospitals (HVH> 15 operations/year). Propensity-scores for the probability of undergoing RS were created within each volume group. Patients were matched based on propensity-score. Within each group, conversion rates, positive margin rates, readmission rates, 30-day and 90-day mortality, length of stay, number of lymph nodes dissected and overall survival were compared between patients who had RS vs LS. Survival analysis was performed using the Kaplan-Meier method.

Results: 8,235 patients underwent minimal invasive surgery for rectal cancer. Overall, 28.8% (n=2,374) of resections were performed robotically. Rectal cancer surgery at a HVH was associated with lower positive resection margins (5.0% vs. 6.3%; p=0.0080), lower rates of conversion to open (11.2% vs. 15.7%; p<0.0001), and 90-day (1.7% vs. 2.7%; p=0.0009) mortality. After matching, conversion rates were significantly lower after RS compared to LS (LVH: 10.1% vs. 18.8%; p<0.0001; HVH: 6.3 vs. 13.4; p<0.0001). There following factors were not significant for patients that received either RS or LS; positive margins rates (LVH: 5.5% vs. 6.9%; p=0.2014; HVH: 5.1% vs. 4.8%; p=0.7211), number of lymph nodes resected (LVH: 14 vs. 15 nodes; p=0.4129; HVH: 16 vs. 16 nodes; p=0.5739), median length of stay (LVH: 5 vs. 5 months; p=0.1324; HVH: 5 vs. 5 months; p=0.1324), readmission (LVH: 9.3% vs. 7.3%; p=0.0936; HVH: 8.9% vs. 8.9%; p=0.9460), 90-day mortality (LVH: 2.3% vs. 2.7%; p=0.5742; HVH: 1.2% vs. 1.9%; p=0.1567) and overall 3 year survival (LVH: 86.9% vs. 86.7%; log-rank p=9148; HVH: 88.6% vs. 88.6%; log-rank p=0.5114).

Conclusion: Although outcomes after major operations are influenced by various factors beyond hospital volume alone, the results of this study suggest that patients with rectal cancer are at higher risk of having positive resection margins, higher rates of conversion to open and 90-day mortality if they are treated at LVH as opposed to at HVH.  However, for both high- and low-volume hospitals, robotic resections of rectal cancer were associated with surgical and oncologic outcomes that were similar to those for laparoscopic operations. Although residual selection bias regarding RS vs LS must be acknowledged, our data suggest that robotic colorectal resections when feasible is a reasonable approach across hospital volume strata.

49.04 Two-stage Complete Fistulotomy Approach for Horseshoe Fistula does not Affect Continence

Posted on January 31, 2019

A. Usui1, Y. Ishiyama1, A. Nishio1, M. Kawamura1, Y. Kono1, G. Ishiyama1  1Sapporo Ishiyama Hospital,Sapporo, HOKKAIDO, Japan

Introduction: Horseshoe fistulas are deep posterior anal fistulas which extend into the ischiorectal space in the shape of a horseshoe, involving muscle structure associated with continence. Surgical management is challenging due to its complex configuration and sphincter involvement. Failures in surgery for horseshoe fistulas often are attributed to insufficient drainage of the fistula or unsuccessful eradication of the fistula. These issues can be resolved with complete fistulotomy, which has been discredited for its high rate of incontinence, but recent studies have shown severance of the superficial external sphincter does not affect continence. We have chosen complete fistulotomy as the initial procedure of choice for horseshoe fistulas and divided the procedure in two stages to avoid impairment of sphincter function.

Methods: A retrospective review of 139 patients who underwent surgery for horseshoe fistula using this method between 2014 and 2017 was conducted. Incisions for the initial surgery were placed along the extended fistula arms so that the lateral tracts of the horseshoe were deroofed. The large open wound allowed a wider view enabling the eradication of fistula walls with a direct vision of the sepsis origin, as well as easier drainage. A loose seton was placed in the primary tract through the fistula origin which was laid open in the second surgery after the lateral wound was partially healed.

Results:

Fistula tracts extended into the supralevator space in 14 of the patients. An upward intersphincteric extension to the submucosa of the rectum was observed in 15. Twenty-one patients (15.1%) had undergone previous surgery intended to cure a lower anal fistula, implying the difficulty in accurate diagnosis for deep posterior anal fistulas.

All patients were followed up for a median of 22 months (range 3-53) and recurrence was observed in 12. In all but 1 patient, recurrence occurred as a superficial residual infection with the sepsis origin cured. Recurrence rate was 5.41% in those with tracts extending only to the ischiorectal fossa. Those with fistula extending higher intersphincterically had a significantly higher recurrence rate. Furthermore, patients who resided further than 50km from the hospital and could not visit the outpatient clinic frequently also had a significantly higher recurrence rate, indicating wound observation for premature closure is crucial in preventing recurrence. In regard to anal sphincter function, no patient had any continence issues including minor problems at the end of the follow up period.

Conclusion:Managing horseshoe fistula with the two-stage complete fistulotomy approach allows for complete eradication of the fistula tract without compromising anal sphincter function.
 

49.03 Impact of Primary Tumor Resection in Colorectal Cancer with Unresectable Metastasis

Posted on January 31, 2019

N. Ichikawa1, S. Homma1, T. Yoshida1, F. Kawamata1, T. Mitsuhashi2, H. Iijima3, S. Shibasaki1, H. Kawamura1, K. Ogasawara4, K. Kazui5, Y. Kamiizumi6, A. Taketomi1  1Hokkaido University,Department Of Gastroenterological Surgery 1,Sapporo, HOKKAIDO, Japan 2Hokkaido University Hospital,Department Of Surgical Pathology,Sapporo, HOKKAIDO, Japan 3Hokkaido University Hospital,Clinical Research And Medical Innovation Center,Sapporo, HOKKAIDO, Japan 4Kushiro Rosai Hospital, Japan Labour Health and Welfare Organization,Department Of Surgery,Kushiro, HOKKAIDO, Japan 5Hokkaido Hospital, Japan Community Healthcare Organization,Department Of Surgery,Sapporo, HOKKAIDO, Japan 6Iwamizawa Municipal Hospital,Department Of Surgery,Iwamizawa, HOKKAIDO, Japan

Introduction: The prognostic benefit of primary tumor resection in colorectal cancer patients with unresectable distant metastasis remains unclear. We aimed to assess whether palliative primary tumor resection in colorectal cancer patients with unresectable metastasis is associated with improved survival.

Methods: The survival period of 123 colorectal cancer patients diagnosed from January 2010 to December 2015 in 4 Japanese hospitals was analyzed. Sixty-four patients with and 59 without primary tumor resection were compared, retrospectively. In the patients with primary tumor resection, the survival period of 39 patients with lymphocyte:monocyte ratio (LMR) increase after primary tumor resection (LMR-increase) and 25 patients with LMR decrease (LMR-decrease) was also compared.

Results: Eighty nine colon cancer and 34 rectal cancer patients were eligible for the analysis. The mean age was 63 years old and male to female ratio was 63: 60. In the resection group, more patients were accompanied by non-differentiated adenocarcinoma (36% vs 15%, p <0.01), obstructive symptom (80% vs 51%, p <0.01), high serum albumen (3.8 vs 3.6 mg/dL, p =0.02) and no lymph node metastasis (20% vs 2%, p <0.01) than the non-resection group. The patients who underwent primary tumor palliative resection had prolonged median survival compared with patients never resected (24.5 vs 14.5 months, p =0.01). Multivariate analysis identified possible independent prognostic variables as the pathology containing non-differentiated adenocarcinoma (Hazard Ratio, 3.7), non-resection of primary lesion (2.7), and no use of irinotecan (2.6). Moreover, in the patients with primary tumor resection, the median survival times of the LMR-increase and LMR-decrease groups were 27.3 and 20.8 months, respectively (p =0.02, Figure). The preoperative lymphocyte population and LMR in peripheral blood of the LMR-increase group were significantly less than those of LMR-decrease group. There were no differences in any other patient characteristics and the extent of metastases between the 2 groups. When assessed the resected specimen in available cases, there were more CD163+ and CD8+ cells invaded into tumor stroma, significantly. (n=5)

Conclusion: Palliative primary tumor resection in colorectal cancer patients with unresectable metastasis is possibly associated with improved survival, especially in the case with lymphocyte:monocyte ratio  increase after primary tumor resection.

 

49.02 Chasing Zero Cuff: Robotic Distal Dissection Superior to Laparoscopy in Ileal Pouch Anal Anastomosis

Posted on January 31, 2019

A. W. Elias1, R. G. Landmann2  1Mayo Clinic – Florida,General Surgery,Jacksonville, FL, USA 2MD Anderson Cancer Center, Baptist Health,Colon & Rectal Surgery,Jacksonville, FL, USA

Introduction: Improved rectal dissection allows more distal transection and minimization of the rectal cuff during pouch procedures. Data is limited comparing robotic versus laparoscopic ileal J pouch-anal anastomosis (IPAA) procedures. Herein, we sought to compare robotic versus laparoscopic ileal pouch-anal anastomosis outcomes.

Methods: A prospectively maintained database was utilized to perform a retrospective matched cohort study. 44 consecutive patients who underwent ileal pouch-anal anastomosis between 2008-2017 at a US tertiary care hospital via robotic approach were matched to 72 laparoscopic controls by surgeon, age, gender, BMI, comorbidities, and operative history. Distal extent of dissection, intraoperative, and postoperative outcomes were analyzed.

Results: 116 patients (58% male) with median age 37.8 years [range 1716-68], BMI 24.5 [range 16.1-40.7], ASA score II [range I-III] underwent restorative ileal pouch-anal anastomosis (44 robotic, 72 laparoscopic), predominantly (90%) for ulcerative colitis. Distal extent of dissection (distance from dentate line) was significantly improved robotically (0 versus 1.3cm) (p<0.001). There were no significant differences in blood loss, complications, number of bowel movements at 30-days, 1 and 2 years, or use of pre-operative immunomodulators, steroids, ASA-derivatives, or TPN; however, more robotic patients utilized biologics (p = 0.007). Robotic procedure length was 20 minutes longer. Robotic median time to diet resumption was shorter (1 versus 2 days) (p<0.001). Despite equal medians, robotic admission length (4 days) and time until ostomy function (1 day) was significantly shorter (p = 0.02 and p=0.005, respectively). There were no reoperations or mortalities.

Conclusion: Robotic surgery enables superior total mesorectal excision and distal transection with elimination of the at-risk rectal cuff with improved postoperative outcomes in patients undergoing IPAA for ulcerative colitis and familial adenomatous polyposis. This technique can be applied to inflammatory and oncologic operations to improve negative margin rates and improve rates of sphincter preservation/intestinal continuity.

 

49.01 Robotic Natural orifice IntraCorporeal anastomosis and transrectal Extraction (NICE) procedure

Posted on January 31, 2019

R. O. Minjares-Granillo1, B. Dimas1, J. P. LeFave1,2, E. M. Haas1,2  1University of Texas Medical School at Houston,Department Of Surgery, Division Of Minimally Invasive Colon And Rectal Surgery,Houston, TEXAS, USA 2Houston Methodist Hospital,Division Of Colon And Rectal Surgery,Houston, TEXAS, USA

Introduction: Numerous studies have confirmed significant benefits of intracorporeal anastomosis (ICA) following colorectal procedures however technical challenges have limited this approach following conventional laparoscopic surgery.

The robotic Xi platform serves as an enabling technology and has resulted in a surge of reports for right-sided intracorporeal anastomosis, however, there are no reports involving more complex left-sided procedures such as for diverticulitis. Furthermore, there are no reports of natural orifice assisted techniques using robotic Xi in which the specimen can be removed and the anvil can be placed thereby completely eliminating the need for an abdominal wall incision other than the port sites. 

We present a pilot study to investigate the safety, feasibility and short term outcomes of robotic Natural orifice-assisted IntraCorporeal anastomosis with transrectal Extraction of specimen, called the robotic NICE procedure.

Methods:  Consecutive patients presenting for elective resection for diverticulitis with formation of a colorectal anastomosis were entered into an IRB database.  All patients underwent the robotic NICE procedure.  Demographic data, intraoperative data and outcomes data were assessed and analyzed.  

Results: Ten patients (5 male and 5 female) underwent resection. The mean age, ASA and BMI was 56 (range 43-66), II (I-III) and 29 (21-35).  All procedures were successfully completed including transrectal extraction of the specimen and formation of an ICA.  The mean operative time was 198 min (146–338) and mean EBL was 35 ml (15 –50). Mean time to first flatus was 16 hours (10-22) and mean length of stay was 1.9 days (1.6 – 2.6).  There were no intraoperative or post-operative complications.  There were no unexpected ICU stay, reoperation or readmission. 

Conclusion:  Colorectal left-sided resections such as for diverticulitis can be safely accomplished using natural-orifice assisted extraction of the specimen as well as complete intracorporeal anastomosis in this pilot study.  The NICE procedure resulted in early return of bowel function, short length of stay and low complications. The complete elimination of abdominal wall incision likely accounts for these findings and larger cohorts of patients are to be investigated to explore this promising approach afforded by robotic technology.

47.20 Implant Sparing Nipple Sparing Mastectomy

Posted on January 31, 2019

E. E. Burke1, C. Laronga1, W. Sun1, S. J. Hoover1, N. Khakpour1, J. V. Kiluk1, M. C. Lee1  1Moffitt Cancer Center,Breast Oncology,Tampa, FL, USA

Introduction: Nipple sparing mastectomy has become an option for the treatment and prevention of breast cancer in selected women. Our experience with implant sparing mastectomy suggests that this is a safe and effective option for women with previous retropectoral implant augmentation. We aimed to explore outcomes of patients that underwent concurrent implant and nipple sparing mastectomy (ISNSM) at our institution.

Methods:  A retrospective review of patients undergoing ISNSM for either prevention or treatment of breast cancer from 2009 until 2017 was performed at a single institution. Data including patient and tumor characteristics, stage, systemic and radiation therapy use, 90-day complication rates, additional reconstruction, and disease recurrence was collected.

Results: A total of 11 patients were identified after ISNSM; the average BMI was 22.8kg/m2 (range 18.6-30.9). Four (36.4%) had breast cancer in the breast undergoing ISNSM, 3 (27.3%) had a known pre-operative diagnosis of invasive breast cancer or ductal carcinoma in situ (DCIS) in the contralateral breast for which the nipple was excised, and 4 (36.4%) had no disease in either breast. The mean age of the cohort was 48 years, with mean of 52.1 years in those with breast cancer and 41 years in those without breast cancer. Average tumor size was 15mm in breasts treated with ISNSM; all had negative margins of resection, negative analysis of nipple base, and none had disease recurrence after average follow up of 34.9 months (range 0.4-80 months). Final pathological stage was stage 0 for 1 patient, Ia for 3 patients, IIa for 1 patient and IIb for 1 patient. In the 4 disease free patients, 2 were BRCA1+, 1 was BRCA2+, and 1 had a PALB2 mutation. There have been no diagnoses of breast cancer in the 7 patients that pursued implant and nipple sparing mastectomy in breasts without cancer after an average of 33.5 months (range 7-63 months). Ninety-day complication rates in this group were low overall. There was no nipple necrosis, 1 patient developed wound dehiscence with skin flap loss requiring operative intervention, 1 patient required takeback to OR for hematoma and 1 patient had a wound infection requiring antibiotics. Of the 11 patients, 9 (81.8%) have undergone delayed reconstruction requiring only implant exchange. One has not required implant exchange and one has not yet undergone implant exchange. Average time to exchange was 12.5 months (range 3-52 months).  None of these patients required delayed flap reconstruction. 

Conclusion: ISNSM was effective and well tolerated in this highly selected group of patients with acceptable oncologic outcomes and low complication rates. Patients undergoing this procedure pursued delayed reconstruction and none required flap reconstruction. Further investigation into this option for the treatment and prevention of breast cancer is warranted.   
 

47.03 Implant Sparing Mastectomy: A Novel and Safe Surgical Approach for Breast Cancer

Posted on January 31, 2019

E. E. Burke1, C. Laronga1, W. Sun1, B. J. Czerniecki1, S. J. Hoover1, N. Khakpour1, J. V. Kiluk1, M. C. Lee1  1Moffitt Cancer Center,Breast Oncology,Tampa, FL, USA

Introduction:   In women undergoing mastectomy for breast cancer with prior retropectoral implant-based augmentation, implant sparing mastectomy has been reported. In this study, the safety and feasibility of this novel surgical approach was evaluated.

Methods:  A retrospective review of all patients undergoing implant sparing mastectomy from 2006 to 2018 for either breast cancer treatment or prevention at a single institution was performed. Data including patient and tumor characteristics, stage, use of systemic therapy and radiation therapy, 90-day complication rates, type of reconstruction, and recurrence of disease was collected.  

Results: A total of 74 women were identified with implant sparing mastectomy from 2006 to 2018.  Of these, 49 (66.2%) underwent bilateral mastectomy. A total of 66 (89.2%) received mastectomy after diagnosis of invasive breast cancer or ductal carcinoma in situ (DCIS) while 8 (10.8%) elected mastectomy for prophylaxis. Among 66 breast cancer patients, resection margins were negative in 53 (80.3%), negative but close (DCIS < 2mm) in 10 (15.2%), and positive in 3 (4.5%). Five (7.6%) of these breast cancer patients had a documented recurrence; 4 at distant sites, and 1 local recurrence in the chest wall despite adjuvant chemotherapy and radiation therapy in the setting of node positive disease for which axillary lymph node dissection was declined. No new breast cancer diagnoses were reported in the 8 patients that underwent implant sparing mastectomy for prophylaxis alone. Ninety-day complication rates for all patients were low; 1 patient (1.4%) had a seroma requiring aspiration, 1 patient (1.4%) had a wound infection requiring antibiotics, and 4 (5.4%) had a hematoma requiring operative intervention. Three patients (4.1%) had wound dehiscence and 8 (10.8%) had flap loss. Of those patients with flap loss, 6 required debridement in the operating room (OR), and 1 of these patients required OR for free flap loss that was performed immediately after implant sparing mastectomy. The only complication rate higher than expected based on the literature was that of hematoma requiring operative intervention.  The vast majority, 64 (86.5%) underwent delayed reconstruction. Of these, only 7 required flap reconstruction, the remainder of patients underwent implant exchange only. 

Conclusion: For patients with previous implant-based augmentation pursuing mastectomy for breast cancer treatment or prevention, implant sparing mastectomy is a novel surgical approach with local recurrence and overall complication rates comparable to skin-sparing mastectomy with the exception of a slightly increased hematoma rate.  Finally, delayed reconstruction for these patients often requires no more than implant exchange with a low rate of need for flap reconstruction. As such this study suggests that implant sparing mastectomy is a safe and reasonable approach for selected patients.

 

33.10 Technical Innovation in Transoral Endoscopic Endocrine Surgery: A Modified “Scarless” Technique

Posted on January 31, 2019

I. Suh1, C. Viscardi1, Y. Chen1, I. Nwaogu1, R. Sukpanich1, J. E. Gosnell1, W. T. Shen1, C. D. Seib1, Q. Duh1  1University Of California – San Francisco,Department Of Surgery, Endocrine Surgery Section,San Francisco, CA, USA

Introduction:  The transoral endoscopic approach for thyroid and parathyroid surgery is the latest remote-access endocrine surgical technique aiming to eliminate a visible anterior neck incision in selected patients. The early experience in North America has demonstrated promising safety and efficacy results, but as expected has uncovered unique challenges and drawbacks.  We present a case series of our institutional experience and evolution in the technique in response to our perceived challenges.

 

Methods:  We reviewed all patients who successfully underwent transoral endoscopic thyroid and parathyroid surgery at our institution from 4/2017-6/2018.  A technical innovation to the technique was introduced midway in the experience.  Demographics, surgical indications, technical details, and perioperative outcomes were recorded in a prospective database and analyzed retrospectively. 

 

Results: 13 patients underwent transoral endoscopic thyroid and parathyroid surgery, with mean follow-up of 23 weeks.  Mean age was 39 years, and all but one were female. Eleven patients underwent thyroidectomy and 2 patients underwent focused parathyroidectomy.  Of the ten patients who underwent thyroidectomy for nodular disease or papillary thyroid carcinoma, the FNA cytology and mean nodule size were as follows: 1) Bethesda II nodules: 3.1 cm (n=6); 2) indeterminate nodules: 3.3cm (n=1), and 3) papillary thyroid carcinoma: 1.2cm (n=3).  There were no injuries to the recurrent laryngeal or mental nerves.  One patient undergoing total thyroidectomy had transient hypocalcemia which resolved within 1 month.  

The first 5 cases were performed with the traditional transoral endoscopic technique with 3 incisions in the oral vestibule.  Amongst these cases, 3 patients complained of pain at the midline of the chin that lasted for 3 months.  The capsules of two specimens for benign or indeterminate nodules were disrupted in the specimen retrieval bag during extraction through the mouth.  In response, we developed a hybrid transoral and submental technique (TOaST) in which the 1cm middle incision is placed in a hidden submental location (Figure).  The subsequent 8 cases were performed with this hybrid approach.  There were no differences in technique-specific complications between the traditional and TOaST approaches.  The TOaST approach had no instances of significant chin pain or specimen disruption, and cosmetic outcomes remained excellent.

 

Conclusion: We present a pilot series of our institution’s evolution in the transoral endoscopic approach to thyroid and parathyroid surgery, incorporating a technical innovation that addresses unique challenges that we identified in this procedure and population.

 

33.08 Intraoperative Autofluorescence Parathyroid Localization in MEN1 Patients

Posted on January 31, 2019

M. H. Squires1, R. Jarvis1, L. A. Shirley1, J. E. Phay1  1Ohio State University,Division Of Surgical Oncology,Columbus, OH, USA

Introduction:  Intrinsic near-infrared (NIR) autofluorescence (AF) of the parathyroid gland enables intraoperative gland identification and localization, without the need for contrast agent injection. Whether real-time AF imaging is useful in patients with multiple endocrine neoplasia type 1 (MEN1) and primary hyperparathyroidism, however, is unknown.

Methods:  Patients undergoing surgery for primary hyperparathyroidism by two experienced endocrine surgeons were enrolled in a prospective clinical trial. Intraoperative imaging was performed with a handheld NIR AF device and images were captured for analysis. Representative areas of greatest AF from the parathyroid, thyroid, and adjacent soft tissue were quantified by Image J software and reported as mean values with standard deviation. Rates of false negative (lack of significant parathyroid gland AF compared to background AF, defined as parathyroid AF:background AF ratio <1.10) and false positive AF (aberrant AF of non-parathyroid tissue confirmed by pathology) were analyzed.

Results: Seventy-one consecutive patients with primary hyperparathyroidism underwent parathyroidectomy from 2017-2018. These included 6 patients with MEN1 diagnosed either genetically or clinically and 65 non-MEN1 patients. No significant differences in serum preoperative parathyroid hormone level or parathyroid gland size or weight on pathology were observed between the two cohorts (all p>0.2).

 

The mean absolute value of in situ parathyroid AF was significantly lower for MEN1 patients than non-MEN1 patients (55.2 +/- 9.5 vs. 76.7 +/- 21.4; p=0.001), as was the ratio of parathyroid to background AF (0.99 vs. 1.64; p=0.005). Three of six MEN1 patients (50%) had falsely negative non-fluorescent parathyroid adenomas (Fig D) versus a false negative rate of 12% (8 of 65) among non-MEN1 patients. The fibroadipose and lymphatic tissue of MEN1 patients exhibited greater background AF (Fig F), leading to high false positive rates (5 of 6 patients; 83%) versus only 3 of 65 (5%) false positive AF non-parathyroid specimens among non-MEN1 patients. 

Conclusion: Intraoperative identification of parathyroids using their intrinsic autofluorescence by real-time NIR imaging appears to have utility in patients with primary hyperparathyroidism. In this cohort of MEN1 patients, decreased parathyroid AF and increased background AF of non-parathyroid tissue led to high rates of false negative and false positive fluorescence, potentially limiting the utility of this intraoperative imaging adjunct in this specific subset of patients.
 

29.09 Postoperative Analgesia after Iliac Crest Bone Graft Harvest using Liposomal Bupivacaine

Posted on January 31, 2019

R. Patel1, M. R. Borrelli1, K. Rustad1, B. Pridgen1, A. Momeni1, H. P. Lorenz1, S. Virk1, D. C. Wan1  1Stanford University,Palo Alto, CA, USA

Introduction: Bone grafting of alveolar clefts is routinely performed using cancellous bone harvested from the iliac crest. Graft site morbidity, however, is common, with many patients experiencing early post-operative pain. Conventional intraoperative use of local anesthetics such as Marcaine is often insufficient and requires additional opioid-based medications to achieve adequate postoperative analgesia. Marketed under the name Exparel®, liposomal bupivacaine has been demonstrated to provide significant improvement in post-operative pain for patients undergoing bunionectomy or hemorrhoidectomy, and this medication may similarly provide relief of donor site pain in patients requiring bone graft harvest. In this study we assessed the efficacy of a single dose of intraoperatively administered liposomal bupivacaine in children undergoing iliac crest bone graft harvest for repair of alveolar clefts.

Methods: 10 patients undergoing iliac crest bone graft from June 2017 to October 2017 were included in the study, which was performed under IRB approval. 5 patients underwent open iliac crest bone graft harvest, with administration of 0.25% Marcaine in Gelfoam at the hip donor site. The other 5 patients underwent open iliac crest bone graft harvest with direct infiltration of 1.3% liposomal bupivacaine around the osteotomy site. Post-operative measures included: patient-reported pain score, total narcotic use (in oral morphine equivalent) during hospitalization, length of stay, postoperative steps, as measured by a Fitbit Activity Tracker, and thigh numbness.

Results: There were no significant differences in age, weight, or distribution of clefts between the two groups. Patients receiving 0.25% Marcaine were discharged on average 1.4 ± 0.55 days after surgery and patients receiving Exparel discharged on average 1.2±0.45 days after surgery. However, differences were noted in average postoperative pain scores (4.25 ±2.15 vs. 2.50 ±1.51), oral morphine equivalents administered (7.08 ± 1.05 vs. 4.82 ± 1.55), and postoperative steps (498 ± 32 vs. 786 ± 157) for patients receiving 0.25% Marcaine vs. Exparel, respectively. Of note, two patients receiving liposomal bupivacaine did report transient thigh numbness lasting three days. No other complications were noted with these patients.

Conclusion: Liposomal bupivacaine may provide reliable and long-acting post-operative analgesia which contributes to a reduction in pain scores and need for additional narcotic administration. This is also reflected in improved post-operative activity, as measured by patient steps. Importantly, there are no recommendations for pediatric dosing of Exparel, and no studies exist in the literature describing use in this patient population. Nonetheless, safe use was observed in this study, highlighting the promise of this analgesic to improve postoperative pain management in children undergoing alveolar bone grafting.

 

29.04 Radiation Following Autologous Breast Reconstruction – Is It Safe Practice?

Posted on January 31, 2019

L. A. Gamble1, S. Sha2, J. L. Kelly1, L. A. Jarvis4, G. L. Freed3, K. M. Rosenkranz1, C. V. Angeles1  2Stony Brook University,School Of Medicine,Stony Brook, NEW YORK, USA 3Dartmouth-Hitchcock Medical Center,Plastic Surgery,Lebanon, NEW HAMPSHIRE, USA 4Dartmouth-Hitchcock Medical Center,Radiation Oncology,Lebanon, NEW HAMPSHIRE, USA 1Dartmouth-Hitchcock Medical Center,General Surgery,Lebanon, NEW HAMPSHIRE, USA

Introduction:  The incidence of immediate breast reconstruction (IBR) following mastectomy for breast cancer has steadily been on the rise while the indications for post mastectomy radiation therapy (PMRT) have broadened. Current literature demonstrates conflicting data regarding surgical complications and timing of PMRT, while the safety of PMRT following autologous breast reconstruction (ABR) is still considered controversial. We sought to investigate the safety of PMRT in breast cancer patients who undergo ABR.

Methods:  Retrospective chart review was performed on all patients treated with mastectomy between 2000-2006 at a single, academic institution. Data collected included patient demographics, PMRT, and postoperative complications including seroma, infection, fat necrosis, and contracture documented from the time of surgery until one year post surgery. Median follow-up was 6.19 years. Chi-square analysis was performed with significance set at p <0.05.

Results: 592 patients underwent mastectomy for breast cancer treatment or prophylaxis. Only half of these patients (49%; 292/592) underwent reconstruction. The majority (83%; 240/292) received ABR, and 95% (228/240) were done at the time of mastectomy (IBR). The most common flap performed was the transverse rectus abdominis (TRAM) flap at 72.1%, followed by 24.2% latissmus dorsi (LD), and 3.7% other flaps (including superior and inferior gluteal artery perforators, and transverse upper gracilis). Of the immediate ABR patients, 57/228 received PMRT. Of these, 54% (31/57) suffered any surgical complication and 23% (13/57) were classified as Clavien-Dindo grade IIIb (CD IIIb). Comparatively, 171/228 patients did not receive PMRT with almost half (84/171) having complications, but only 26% (45/171) were classified as CD IIIb. There was no statistically significant difference in overall complication rate or CD IIIb complications between ABR patients with or without PMRT (p=0.742 and p=0.357, respectively). Additionally, we found no significant difference in overall complication rate in patients who underwent PMRT when comparing between those who had no reconstruction versus those who had ABR (p=0.0623).

Conclusion: Our data shows no statistically significant difference in the complication rate between breast cancer mastectomy patients who received PMRT after ABR versus no reconstruction.  Additionally, there is no difference in the rate of complications between ABR patients who did or did not receive PMRT. This study supports the idea that it is safe to radiate a reconstructed breast.

 

22.02 The Impact of Prehospital Whole Blood on Arrival Physiology, Shock, and Transfusion Requirements

Posted on January 31, 2019

N. Merutka1, J. Williams1, C. E. Wade1, B. A. Cotton1  1McGovern Medical School at UT Health,Acute Care Surgery,Houston, TEXAS, USA

Introduction: Several US trauma centers have begun incorporating uncrossmatched, group O whole blood into civilian trauma resuscitation. Our hospital has recently added this product to our aeromedical transport services. We hypothesized that patients receiving whole blood in the field would arrive to the emergency department with more improved vital signs, improved lactate and base deficit, and would receive less transfusions following arrival when compared to those patients receiving pre-hospital component transfusions. 

Methods: In Novemeber 2017, we added low-titer group O whole blood (WB) to each of our helicopters, alongside that of existing RBCs and plasma. We collected information on all trauma patients receiving prehospital uncrossed, emergency release blood products between 11/01/17 and 07/31/18. Patients were divided into those who received any prehospital WB and those who received only RBC and or plasma (COMP). Initial field vital signs, arrival vital signs, arrival lbaoratory values, and ED and post-ED blood products were captured. Statistical analysis was performed using STATA 12.1. Continuous data are presented as medians (25th-75th IQR) with comparisons performed using Wilcoxon ranksum. Categorical data are reported as proportions and tested for significance using Fisher’s exact test. Following univariate analyses, a multivariate model was created to evaluate post-arrival blood products, controlling injury severity score, field vital signs, and age. 

Results: 174 patients met criteria, with 98 receiving prehospital WB and 63 receiving COMP therapy. 116 WB units were transfused in the prehospital setting. Of those receiving WB prehospital, 84 (82%) received 1 U, 14 (12%) received 2U. There was no difference in age, sex, race, or injury severity scores between the two groups. While field pulse was similar (WB: median 117 vs. COMP: 114; p=0.649), WB patients had lower field systolic pressures (median 101 vs. 125; p=0.026) and were more likely to have positive field FAST exam (37% vs. 20%; p=0.053). On arrival, however, WB patients had lower pulse and higher systolic pressures than COMP patients (TABLE). There was no difference in arrival base excess and lactate values (TABLE). However, WB patients had less ED and post-ED blood transfusions than the COMP group. A multivariate linear regression model demonstrated that field WB was associated with a reduction in ED blood transfusions (corr. coef. -10.8, 95% C.I. -19.0 to -2.5; p=0.018).

Conclusion: Prehospital WB transfusion is associated with improved arrival physiology with similar degrees of shock compared to COMP treated pateints. More importantly, WB pateints received less transfusions after arrival than their COMP counterparts. 

15.19 Methotrexate Use In Patients With Granulomatous Mastitis

Posted on January 31, 2019

B. Caballero2, J. Sugandi1,2, R. K. Viscusi1,2  1Banner- University of Arizona,Department Of Surgery,Tucson, AZ, USA 2University Of Arizona,College Of Medicine,Tucson, AZ, USA

Introduction:  Granulomatous mastitis (GM) is a rare, benign, chronic inflammatory disease of the breast that usually affects women of child bearing age. The most common clinical symptoms are a palpable breast mass associated with overlying erythema, induration, pain or drainage. Imaging is non-specific and histopathology is needed for confirmative diagnosis. The etiology is unclear, but an autoimmune reaction is favored and it has been linked to prior contraceptive use, a history of pregnancy and breastfeeding. Given the limited knowledge of etiology, initial treatment of this benign, yet locally aggressive disease remains controversial. Observation alone, antibiotics, surgical excision, steroids alone, and immunosuppressive agents have all been described in the literature. There is no consensus on treatment but knowing GM is generally a self-limited disease and surgery can be associated with poor cosmetic outcomes, a non-invasive alternative such as methotrexate (MTX) is a viable option. 

Methods:  A retrospective chart review of patients with histologically confirmed GM between January 2013 and December 2017 was analyzed to identify response to MTX treatment. Eight adult female patients, age range 29-57, were diagnosed with GM via excisional or core breast biopsy. Methotrexate treatment was planned for all 8 patients with confirmed GM. Liver function tests and a full blood count were evaluated during treatment course. Treatment protocol included MTX administered at 2.5-10 mg orally together with folic acid in one dose, once a week. 

 

Results: On physical exam, a palpable breast mass was detected on 8 patients. All patients underwent ultrasound examination and after diagnosis of GM was confirmed, MTX + folic acid treatment was initiated. Treatment was administered for 3-15 months. One patient discontinued MTX due to plans to conceive. None of the patients developed complications from MTX and no recurrence was observed during follow up periods. Patients noted relief of symptoms including, erythema, breast tenderness and nipple discharge following 30-60 days of MTX treatment. 

Conclusion: Evidence in most literature has shown most patients with GM have a troublesome course of recurrence. There is no consensus on treatment but non-invasive alternatives such as steroids and methotrexate are good options. More cases using methotrexate alone or in combination with corticosteroids are needed to confirm those results. Ultimately, treatment depends on the size of the lesions and symptom severity. Prompt diagnosis and treatment with methotrexate can often treat the disease or provide symptomatic improvement without subjecting patients to multiple trials of medications that could pose risks of adverse effects. 
 

15.09 Prepectoral Breast Reconstruction with BraxonR Acellular Dermal Matrix (ADM): Indications & Pitfalls

Posted on January 31, 2019

E. Theodorakopoulou1, D. T. Ghorra1,2, S. Samaras1, P. Forouhi3, C. M. Malata1,3,4  1Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s Hospital, Cambridge, UK,Department Of Plastic & Reconstructive Surgery,Cambridge, ENGLAND, United Kingdom 2University of Alexandria Medical School,Department Of Plastic & Reconstructive Surgery,Alexandria, ALEXANDRIA, Egypt 3Cambridge Breast Unit,Department Of Surgery,Cambridge, ENGLAND, United Kingdom 4Anglia Ruskin Univerisity School of Medicine,Surgery,Cambridge & Chelmsford, ENGLAND, United Kingdom

Introduction:
Epipectoral implant placement is a new technic designed to simplify and minimize the drawbacks of immediate implant-based breast reconstruction. As with most new procedures the indications have yet to be clearly defined. A single plastic surgeon's initial experience with prosthetic reconstruction using BraxonR total acellular dermal matrix coverage of the implant/expander in the prepectoral plane at the time of mastectomy is presented.

Methods:
Patients undergoing Braxon (porcine ADM) immediate breast reconstruction by a single surgeon (2017-2018) were reviewed with respect to demographics, specific indication, implant type & volume, mastectomy type and early outcomes. They were identified from a prospective Implant Register and data collected from Epic.

Results:
Eleven consecutive patients (mean age 38 years) underwent Braxon-ADM reconstruction of 17 breasts with fixed volume implants i.e., direct-to-implant (7) and permanent expanders (4). The surgical indications (number of breasts) were risk-reduction (9), therapeutic (6) and noncancer (2). The reconstructions were bilateral in six patients. Based on the breast size and shape, mastectomies were performed via a variety of incisions: Wise pattern skin-reducing technics (6 with half of them including dermal slings), inframammary incisions (4), hemi-Y periareolar incisions (4) and traditional elliptical periareolar incisions (3). Twelve breasts had nipple-sparing mastectomies. Uneventful healing was achieved in 9 breasts, implant loss 4 breasts, large seromas (5 breasts – 2 of the implant losses), infection (4 breasts, included in the implant losses), unplanned readmissions (3 patients), severe capsular contracture following unplanned radiotherapy (1 breast), transient localised tenderness at the superior fixation points (3 breasts), exercise-induced "partial dislodging" (1 breast) and visible rippling (4 breasts). Unlike subpectoral breast recosntructions there were no cases of breast animation deformity caused by hyperactive pectoralis major muscle contraction with resulting distortion of the breasts.

The putative prredisposing factors (by patients) to implant loss and significant seromas/ wound dehiscence were smoking (1), skin-reducing mastectomy (2), early (<5 days) removal of drains (1), tight wound closure (1), postoperative radiotherapy (1) and axillary clearance (1).

Conclusion:
Prepectoral implant placement constitutes a practical novel addition to the repertoire of postmastectomy breast reconstruction technics. It is particularly useful in bilateral reconstructions such as for risk-reducing mastectomies. Patient selection is, however, very important to avoid complications and optimise outcomes. It is also more exacting in terms of implant selection for unilateral breast reconstruction. Further large-scale studies are needed to determine the place of prepectoral reconstruction and whether it is an improvement on current implant-based reconstructive methods.
 

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