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Regarding: Long-term patient outcomes after surgical stabilization of rib fractures
The American Journal of Surgery (2015) 210, 199-200
Letters to the Editor
Oncoplastic surgery: fashion or necessity? With interest we read the article by Tenofski et al.1 This article compares the immediate and long-term complications and consequences of oncoplastic and nononcoplastic breast-conserving surgeries (BCS). It is a retrospective study of 142 procedures in 140 patients, of which 84 were traditional and 58 oncoplastic BCS. Among the oncoplastic group, the majority had simple level 1 oncoplastic procedures and the rest either reduction therapeutic or donut mammoplasty. The 2 groups had statistically not different size of tumors removed or number of cases needing re-excision. However, oncoplastic surgery caused delayed healing, fat necrosis, and pain 6 to 12 months after surgery more often. Finally, oncoplastic techniques did not seem to improve the cosmetic outcome even many months into the postoperative period. The aim of oncoplastic BCS is to achieve conservation in cases of large tumors. It also ‘‘hides’’ scars, reduces the contralateral breast to achieve symmetry, reconstructs the nipple, and so forth. And it does all thisdwith no compromise of the oncologic resultdwith the aim to improve the final cosmetic result. However, it is not a cheap exercise as it takes up significant time and resources in today’s cost-conscious environment. The latter should not be deterrent if oncoplastic BCS actually delivers on its promises. Being provocative, one can support that this publication does not seem to justify the application of oncoplastic BCS in this case. This type of procedure treated cancers of the same size, did not affect the rates of re-excision, increased the complications and complaints, and had similar cosmetic results as the more traditional method. Therefore, it is reasonable to question its necessity. Surely, one has to acknowledge that attention to cosmesis has become more ‘‘fashionable’’ among breast cancer patients, and this increases patients’ expectations from their procedure.
The younger age of the oncoplastic group may mean that these patients had higher cosmetic expectations and were stricter with the judgment of the esthetic result. Besides, radiotherapy may also affect cosmesis, and it seems that there was a difference between the groups. Finally, one cannot avoid noticing that the oncoplastic group was heterogeneous from the technical point of view, with about two thirds of it being adjacent tissue transfer. As different oncoplastic techniques have different indications and complications (rates and types), it would be methodologically more accurate not to put all the oncoplastic procedures in the same pot. Besides, we feel that the oncoplastic techniques ‘‘not’’ studied here are the ones that actually deliver on the promise and are able to remove large cancers with breast conservation. Being strong supporters of oncoplastic surgery but having become devil’s advocates for the purposes of this article, we are looking forward to the authors’ comments. Demetrios Moris, M.D. Michael Kontos, M.D., Ph.D. First Department of Surgery, ‘‘Laikon’’ General Hospital, University of Athens, Athens 11474, Greece http://dx.doi.org/10.1016/j.amjsurg.2014.09.042
Reference 1. Tenofsky P, Dowell P, Topalovski T, et al. Surgical, oncologic, and cosmetic differences between oncoplastic and nononcoplastic breast conserving surgery in breast cancer patients. Am J Surg 2014;207:398–402.
Regarding: Long-term patient outcomes after surgical stabilization of rib fractures To the Editor: This letter is in regards to our recently published manuscript, ‘‘Long-term patient outcomes after surgical
0002-9610/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved.
stabilization of rib fractures.’’1 In this descriptive study, we identified 101 patients who had surgical stabilization of severe rib fractures over a 31-month period between 2010 and 2012, and invited them to participate in a
200
The American Journal of Surgery, Vol 210, No 1, July 2015
telephone survey after hospital discharge. The survey asked patients to recall their level of pain, narcotic use, feeling of chest wall stability, and overall satisfaction with their surgery. Fifty (50%) patients completed the survey. Eight (16%) still had pain in their ribs at the time of survey. Only 2 (4%) still required narcotics, however. Of the 48 who were not on long-term narcotics, the average time to discontinue pain medications was 4.7 weeks. Thirty-three of 36 (92%) patients who were employed before their injury were able to return to work at the same job. Forty-six patients (92%) reported no significant limitations in their lives as a result of their chest injuries. In the Comment section of our manuscript, we make the statement that ‘‘there are two studies examining long-term outcomes and quality of life in patients who have undergone surgical stabilization of rib fractures.’’ We go on to describe the results of these studies which largely corroborate our findings.2,3 It has recently been brought to our attention that there are two other such studies that we did not mention. Long-term outcomes are obviously a relevant piece of the overall rib fixation puzzle; perhaps, more relevant than the short-term outcomes that many authors have reported (Mayberry JC, personal communication). For this reason, we feel compelled to draw our readers’ attention to the studies that we had previously overlooked. In 1997, Mouton et al4 published a prospective assessment of 23 patients who had surgical rib fixation over a 6-year period in Switzerland. This group used a plate and screw method for rib repair that appears similar to the hardware that we used in our study. They followed their patients clinically and radiographically for a mean of 28 months postoperatively. Over the follow-up period, they found that 5 (24%) patients had pain at the operative site for more than 3 months after operation. Two patients had their plates removed at 6 months after surgery which ameliorated the pain. Overall, 95% of their cohort was able to return to full-time work, and 86% to their preoperative level of sports activity. In 2009, Mayberry et al5 published the results of a retrospective review of 46 patients who had their ribs surgically stabilized over a 10-year period in Oregon. There were 3 different techniques of rib fixation used over the course of the study. This group contacted their patients by mail, and asked them to respond to an extensive, multipart postdischarge outcome survey, which included the McGill Pain Questionnaire and the RAND-36 measure of health related quality of life general health survey. They then compared the rib plating patients’ responses on the RAND-36 with a cohort of adults with one or more medical comorbidities,
adults with a history of orthopedic injuries, and adults with a mean age of 42 who were likely healthy and active. Fifteen patients completed the survey at a mean of 48 months postinjury. Mayberry found that the patients who had rib fixation had low long-term McGill Pain Questionnaire scores and scored basically the same on the RAND-36 as the adults with one or more comorbidities. As compared with healthy adults, the rib fixation group scored the same on the RAND-36, except for role limitations because of physical issues, where the rib fixation group scored worse. As compared with patients who had suffered orthopedic trauma, the rib fixation group was better, except for general health, where they were the same. Seventy percent of patients said that they were capable of ‘‘physical or nonphysical’’ labor. Five (11%) were disabled. Both the above studies add a level of robustness to the existing literature on the long-term outcomes/benefits to rib fixation surgery that was not acknowledged in our original article. We must point out that indications for surgery varied a bit between all of the groups’ studies. Despite this, the results from both other groups are quite similar to ours, which further strengthen our conclusion that there are longterm clinical, and likely, socioeconomic benefits to surgically fixing rib fractures in patients with severe chest wall injury.
Sarah Majercik, M.D., M.B.A., F.A.C.S Quinn Cannon, B.A. Steven R. Granger, M.D., F.A.C.S Don H. Van Boerum, M.D., F.A.C.S Thomas W. White, M.D., F.A.C.S Department of Trauma Services and Surgical Critical Care, Intermountain Medical Center, Murray, UT, USA http://dx.doi.org/10.1016/j.amjsurg.2015.03.020
References 1. Majercik S, Cannon Q, Granger SR, et al. Long-term patient outcomes after surgical stabilization of rib fractures. Am J Surg 2014;208:88–92. 2. Bille A, Okiror L, Campbell A, et al. Evaluation of long-term results and quality of life in patients who underwent rib fixation with titanium devices after trauma. Gen Thorac Cardiovasc Surg 2013;61:345–9. 3. Campbell N, Conaglen P, Martin K, et al. Surgical stabilization of rib fractures using Inion OTPS wrapsdtechniques and quality of life follow-up. J Trauma 2009;67:596–601. 4. Mouton W, Lardinois D, Furrer M, et al. Long-term follow-up of patients with operative stabilization of a flail chest. Thorac Cardiovasc Surg 1997;45:242–4. 5. Mayberry JC, Kroeker AD, Ham LB, et al. Long-term morbidity, pain and disability after repair of severe chest wall injuries. Am Surg 2009;75:389–94.
©2015 Elsevier
Letters to the Editor
Oncoplastic surgery: fashion or necessity? With interest we read the article by Tenofski et al.1 This article compares the immediate and long-term complications and consequences of oncoplastic and nononcoplastic breast-conserving surgeries (BCS). It is a retrospective study of 142 procedures in 140 patients, of which 84 were traditional and 58 oncoplastic BCS. Among the oncoplastic group, the majority had simple level 1 oncoplastic procedures and the rest either reduction therapeutic or donut mammoplasty. The 2 groups had statistically not different size of tumors removed or number of cases needing re-excision. However, oncoplastic surgery caused delayed healing, fat necrosis, and pain 6 to 12 months after surgery more often. Finally, oncoplastic techniques did not seem to improve the cosmetic outcome even many months into the postoperative period. The aim of oncoplastic BCS is to achieve conservation in cases of large tumors. It also ‘‘hides’’ scars, reduces the contralateral breast to achieve symmetry, reconstructs the nipple, and so forth. And it does all thisdwith no compromise of the oncologic resultdwith the aim to improve the final cosmetic result. However, it is not a cheap exercise as it takes up significant time and resources in today’s cost-conscious environment. The latter should not be deterrent if oncoplastic BCS actually delivers on its promises. Being provocative, one can support that this publication does not seem to justify the application of oncoplastic BCS in this case. This type of procedure treated cancers of the same size, did not affect the rates of re-excision, increased the complications and complaints, and had similar cosmetic results as the more traditional method. Therefore, it is reasonable to question its necessity. Surely, one has to acknowledge that attention to cosmesis has become more ‘‘fashionable’’ among breast cancer patients, and this increases patients’ expectations from their procedure.
The younger age of the oncoplastic group may mean that these patients had higher cosmetic expectations and were stricter with the judgment of the esthetic result. Besides, radiotherapy may also affect cosmesis, and it seems that there was a difference between the groups. Finally, one cannot avoid noticing that the oncoplastic group was heterogeneous from the technical point of view, with about two thirds of it being adjacent tissue transfer. As different oncoplastic techniques have different indications and complications (rates and types), it would be methodologically more accurate not to put all the oncoplastic procedures in the same pot. Besides, we feel that the oncoplastic techniques ‘‘not’’ studied here are the ones that actually deliver on the promise and are able to remove large cancers with breast conservation. Being strong supporters of oncoplastic surgery but having become devil’s advocates for the purposes of this article, we are looking forward to the authors’ comments. Demetrios Moris, M.D. Michael Kontos, M.D., Ph.D. First Department of Surgery, ‘‘Laikon’’ General Hospital, University of Athens, Athens 11474, Greece http://dx.doi.org/10.1016/j.amjsurg.2014.09.042
Reference 1. Tenofsky P, Dowell P, Topalovski T, et al. Surgical, oncologic, and cosmetic differences between oncoplastic and nononcoplastic breast conserving surgery in breast cancer patients. Am J Surg 2014;207:398–402.
Regarding: Long-term patient outcomes after surgical stabilization of rib fractures To the Editor: This letter is in regards to our recently published manuscript, ‘‘Long-term patient outcomes after surgical
0002-9610/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved.
stabilization of rib fractures.’’1 In this descriptive study, we identified 101 patients who had surgical stabilization of severe rib fractures over a 31-month period between 2010 and 2012, and invited them to participate in a
200
The American Journal of Surgery, Vol 210, No 1, July 2015
telephone survey after hospital discharge. The survey asked patients to recall their level of pain, narcotic use, feeling of chest wall stability, and overall satisfaction with their surgery. Fifty (50%) patients completed the survey. Eight (16%) still had pain in their ribs at the time of survey. Only 2 (4%) still required narcotics, however. Of the 48 who were not on long-term narcotics, the average time to discontinue pain medications was 4.7 weeks. Thirty-three of 36 (92%) patients who were employed before their injury were able to return to work at the same job. Forty-six patients (92%) reported no significant limitations in their lives as a result of their chest injuries. In the Comment section of our manuscript, we make the statement that ‘‘there are two studies examining long-term outcomes and quality of life in patients who have undergone surgical stabilization of rib fractures.’’ We go on to describe the results of these studies which largely corroborate our findings.2,3 It has recently been brought to our attention that there are two other such studies that we did not mention. Long-term outcomes are obviously a relevant piece of the overall rib fixation puzzle; perhaps, more relevant than the short-term outcomes that many authors have reported (Mayberry JC, personal communication). For this reason, we feel compelled to draw our readers’ attention to the studies that we had previously overlooked. In 1997, Mouton et al4 published a prospective assessment of 23 patients who had surgical rib fixation over a 6-year period in Switzerland. This group used a plate and screw method for rib repair that appears similar to the hardware that we used in our study. They followed their patients clinically and radiographically for a mean of 28 months postoperatively. Over the follow-up period, they found that 5 (24%) patients had pain at the operative site for more than 3 months after operation. Two patients had their plates removed at 6 months after surgery which ameliorated the pain. Overall, 95% of their cohort was able to return to full-time work, and 86% to their preoperative level of sports activity. In 2009, Mayberry et al5 published the results of a retrospective review of 46 patients who had their ribs surgically stabilized over a 10-year period in Oregon. There were 3 different techniques of rib fixation used over the course of the study. This group contacted their patients by mail, and asked them to respond to an extensive, multipart postdischarge outcome survey, which included the McGill Pain Questionnaire and the RAND-36 measure of health related quality of life general health survey. They then compared the rib plating patients’ responses on the RAND-36 with a cohort of adults with one or more medical comorbidities,
adults with a history of orthopedic injuries, and adults with a mean age of 42 who were likely healthy and active. Fifteen patients completed the survey at a mean of 48 months postinjury. Mayberry found that the patients who had rib fixation had low long-term McGill Pain Questionnaire scores and scored basically the same on the RAND-36 as the adults with one or more comorbidities. As compared with healthy adults, the rib fixation group scored the same on the RAND-36, except for role limitations because of physical issues, where the rib fixation group scored worse. As compared with patients who had suffered orthopedic trauma, the rib fixation group was better, except for general health, where they were the same. Seventy percent of patients said that they were capable of ‘‘physical or nonphysical’’ labor. Five (11%) were disabled. Both the above studies add a level of robustness to the existing literature on the long-term outcomes/benefits to rib fixation surgery that was not acknowledged in our original article. We must point out that indications for surgery varied a bit between all of the groups’ studies. Despite this, the results from both other groups are quite similar to ours, which further strengthen our conclusion that there are longterm clinical, and likely, socioeconomic benefits to surgically fixing rib fractures in patients with severe chest wall injury.
Sarah Majercik, M.D., M.B.A., F.A.C.S Quinn Cannon, B.A. Steven R. Granger, M.D., F.A.C.S Don H. Van Boerum, M.D., F.A.C.S Thomas W. White, M.D., F.A.C.S Department of Trauma Services and Surgical Critical Care, Intermountain Medical Center, Murray, UT, USA http://dx.doi.org/10.1016/j.amjsurg.2015.03.020
References 1. Majercik S, Cannon Q, Granger SR, et al. Long-term patient outcomes after surgical stabilization of rib fractures. Am J Surg 2014;208:88–92. 2. Bille A, Okiror L, Campbell A, et al. Evaluation of long-term results and quality of life in patients who underwent rib fixation with titanium devices after trauma. Gen Thorac Cardiovasc Surg 2013;61:345–9. 3. Campbell N, Conaglen P, Martin K, et al. Surgical stabilization of rib fractures using Inion OTPS wrapsdtechniques and quality of life follow-up. J Trauma 2009;67:596–601. 4. Mouton W, Lardinois D, Furrer M, et al. Long-term follow-up of patients with operative stabilization of a flail chest. Thorac Cardiovasc Surg 1997;45:242–4. 5. Mayberry JC, Kroeker AD, Ham LB, et al. Long-term morbidity, pain and disability after repair of severe chest wall injuries. Am Surg 2009;75:389–94.
©2015 Elsevier