American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

New Crucial Literature: The Science You Need to Know

Literature selections curated by Lewis Flint, MD, FACS, and reviewed by the Bulletin Brief editorial board.

Pair of JACSJournal of the American College of Surgeons

Delayed Breast Reconstruction in T4 Breast Cancer Advantageous Versus Immediate Reconstruction

Pawloski KR, Barrio AV, Gemignani ML, et al. Reconstruction in Women with T4 Breast Cancer after Neoadjuvant Chemotherapy: When Is It Safe? J Am Coll Surg. April 24, 2021 [Epub ahead of print].

T4 breast cancers are locally extensive and associated with specific tumor characteristics including extension to the skin and/or chest wall, peau d'orange appearance of the skin, diffuse erythema and edema. Current treatment approaches for T4 tumors include preoperative neoadjuvant therapy, mastectomy and postoperative radiotherapy. Immediate reconstruction of the breast has increased, especially in younger women, probably because the significant reduction of tumor size associated with neoadjuvant therapy creates anatomy that is amenable to reconstruction. Although early reconstruction may be appealing to patients, there are inherent risks, such as interruption of the therapy sequence due to complications.

This report examined rates of reoperation, postoperative complications, time to beginning of radiation therapy, and recurrence rates in patients treated with immediate reconstruction compared with patients treated with delayed reconstruction or no reconstruction. The data analysis showed that immediate reconstruction was associated with significantly increased postoperative complications and delays in beginning radiation therapy. Median time to first recurrence was 18 months; time to first recurrence was longer in the delayed reconstruction group, but this was not a statistically significant difference. The authors concluded that delayed reconstruction was advantageous, particularly for patients with the most extensive tumors (T4d) because of fewer complications, earlier beginning of postoperative radiation therapy and detection of tumor recurrence before reconstruction.

ACS NSQIP Data Used for QI Effort to Decrease Postoperative Pneumonia

Alligood DM, Albo D, Meiler SE, et al. Using NSQIP Data to Reduce Institutional Postoperative Pneumonia Rates in Non-ICU Patients: A Plan-Do-Study-Act Approach. J Am Coll Surg. May 17, 2021 [Epub ahead of print].

This report describes a quality improvement project undertaken to reduce the risk of postoperative pneumonia. Based on ACS NSQIP® data reports, the authors learned that the postoperative pneumonia rate in their institution was 4.2 percent. They began a multidisciplinary program based on the plan-do-study-act model of change management. They organized a group of diverse health care professionals and created a program that focused on preoperative patient education to reduce tobacco use, improve oral hygiene, inform patients regarding early mobility, and teach deep breathing exercises. Changes in intraoperative management included reduced procedure duration and early, complete reversal of paralysis. Postoperatively patients underwent aggressive respiratory therapy.

The effort resulted in reduction of the postoperative pneumonia rate to 1.14 percent. The study data suggested that maintaining improvement was a significant challenge, as pneumonia rates were reduced to less than 1 percent after the first two years of the program but then increased in the third year. Effective quality improvement efforts require creation of dedicated systems to sustain success over the medium and long term.

Other Article

Examining the Development of Scar Fibroblasts

Mascharak S, desJardins-Park HE, Davitt MF, et al. Preventing Engrailed-1 Activation In Fibroblasts Yields Wound Regeneration Without Scarring. Science. 2021;372(6540):eaba2374.

Scars differ from normal unwounded skin in several ways, including lack of hair follicles, sebaceous glands and other dermal appendages. In addition, scars are composed of dense parallel extracellular matrix fibers instead of the "basket weave" pattern of the extracellular matrix seen in normal skin. The authors studied skin wounds to determine whether scar fibroblasts were derived from normal En1 fibroblasts or from de novo En1-negative fibroblasts.

Using fibroblast transplantation and lineage-tracing techniques, the researchers learned that more than 50 percent of scar fibroblasts were of En1-negative lineage; these fibroblasts developed because of inhibition of mechanical signaling proteins and produced the inflexible fibrous extracellular matrix found in scar tissue. Experimental reversal of this inhibition promoted regeneration of skin with normal appendages and flexibility. The authors concluded that modulation of En1 expressing fibroblasts can result in healed wounds that have normal skin structure and mechanical characteristics.