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Objective: Infective complications following breast implant surgery may result in implant removal. This causes patient distress and is costly to treat. A range of precautions is undertaken at the time of surgery to reduce infection, with varying levels of supporting evidence. This study aimed to determine how frequently and consistently infection prevention precautions are used during breast implant surgery. Methods: Multicenter observational study of surgical practice with real-time data collection during breast implant surgery. Results: From 7 NHS breast units, 121 implant procedures were assessed in 94 patients under the care of 22 consultant surgeons. The commonest procedure was immediate reconstruction (58%; 70/121). All patients were methicillin-resistant Staphylococcus aureus (but not methicillin-sensitive Staphylococcus aureus ) screened. Antibiotics were given at surgery in all cases; 92% (85/94) received postoperative antibiotics. Other precautions included closed glove technique (67%; 63/94), door signs to reduce theater traffic (72%; 68/94), glove changing prior to implant handling (98%; 119/121), laminar air flow theaters (55%; 52/94), disposable drapes (94%; 88/94) and gowns (74%; 70/94), and cavity washing (89%; 108/121). Among the 14 consultants evaluated on more than 1 procedure (range, 2-22; median = 5), only 1 consistently used exactly the same precautions when siting an implant. Conclusion: Despite national guidance, infection prevention measures are not applied consistently during breast implant surgery, with variability between surgeons and within individual surgeon's practice. The introduction of an infection prevention checklist for all breast implant procedures could improve the reliability with which these precautions are undertaken.

Introduction: As a result of increasing use of implant-based breast reconstruction, complications such as infection are being encountered more frequently. Surgical Site Infections (SSIs) cause morbidity for the patient, can lead to capsular contracture or implant loss and are costly to healthcare systems. National Guidelines suggesting methods to reduce SSI related complications have been produced, but are limited in the scope of interventions covered and underlying evidence presented., Methods: We performed a literature review encompassing a wide variety of possible SSI prevention strategies. We aimed to present summaries of the available evidence and give pragmatic recommendations as to their validity to use as guidelines for infection prevention strategies for implant-based breast reconstruction., Results: A lack of high quality data relating to the benefit of SSI prevention strategies in implant-based breast reconstruction exists. Many papers relate to orthopaedic implant surgery, or clean surgery in general. Following review of the evidence, sufficient data exists to support use of perioperative antibiotics at implant-based breast reconstruction, with continuation for an extended period in "high risk" patients. Alcohol containing skin preparations should be used over aqueous solutions. Laminar air flow use is suggested. Theatre traffic should be kept to a minimum, as should duration of operative procedure. The implant pocket should be washed prior to implantation. Double gloving and conductive warming are also endorsed., Conclusions: We have produced a perioperative "Theatre Implant Checklist" for SSI prevention in implant-based breast surgery, with a set of pragmatic up to date guidelines, which allows the reader to evaluate the evidence upon which our recommendations are based., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Background: Symptomatic calculus biliary disease is common with associated morbidity and occasional mortality, further confounded when there is concomitant common bile duct (CBD) stones. Choledocholithiasis and clearance of the duct reduces recurrent cholangitis, but the question is whether after clearance of the CBD if there is a need to perform a cholecystectomy. This meta-analysis evaluated outcomes in patients undergoing ERCP with or without sphincterotomy to determine if cholecystectomy post-ERCP clearance offers optimal outcomes over a wait-and-see approach. Methods: A Prospero registered meta-analysis of the literature using PRISMA guidelines incorporating articles related to ERCP, choledocholithiasis, cholangitis and cholecystectomy was undertaken for papers published between 1st January 1991 and 31st May 2021. Existing research that demonstrates outcomes of ERCP with no cholecystectomy versus ERCP and cholecystectomy was reviewed to determine the related key events, complications and mortality of leaving the gallbladder in situ and removing it. Odds ratios (OR) were calculated using Review Manager Version 5.4 and meta-analyses performed using OR using fixed-effect (or random-effect) models, depending on the heterogeneity of studies. Results: 13 studies (n = 2598), published between 2002 and 2019, were included in this meta-analysis, 6 retrospective, 2 propensity score-matched retrospective studies, 3 prospective studies and 2 randomised control trials from a total of 11 countries. There were 1433 in the no cholecystectomy cohort (55.2%) and 1165 in the prophylactic cholecystectomy (44.8%) cohort. Cholecystectomy resulted in a decreased risk of cholecystitis (OR = 0.15; CI 0.07–0.36; p < 0.0001), cholangitis (OR = 0.51; CI 0.26–1.00; p = 0.05) and mortality (OR = 0.38; CI 0.16–0.9; p = 0.03). In addition, prophylactic cholecystectomy resulted in a significant reduction in biliary events, biliary pain and pancreatitis. Conclusions: In patients undergoing CBD clearance, consideration should be given to performing prophylactic cholecystectomy to optimise outcomes. [ABSTRACT FROM AUTHOR]

Introduction: Patients undergoing elective laparoscopic cholecystectomy (ELLC) represent a heterogeneous group making it challenging to stratify risk. The aim of this paper is to identify pre-operative factors associated with adverse peri- and post-operative outcomes in patients undergoing ELLC. This knowledge will help stratify risk, guide surgical decision making and better inform the consent process.Methods: All patients who underwent ELLC between January 2015 and December 2019 were included in the study. Pre-operative data and both peri- and post-operative outcomes were collected retrospectively from multiple databases using a deterministic records-linkage methodology. Patients were divided into groups based on clinical indication (i.e. biliary colic versus cholecystitis) and adverse outcomes were compared. Multivariate regression models were generated for each adverse outcome using pre-operative independent variables.Results: Two-thousand one hundred and sixty-six ELLC were identified. Rates of peri- and post-operative adverse outcomes were significantly higher in the cholecystitis versus biliary colic group and increased with number of admissions of cholecystitis (p < 0.05). Rates of subtotal (29.5%), intra-operative complication (9.8%), post-operative complications (19.6%), prolonged post-operative stay (45.9%) and re-admission (16.4%) were significant in the group of patients with ≥ 2 admissions with cholecystitis.Conclusion: Our data demonstrate that patients with repeated biliary admission (particularly cholecystitis) ultimately face an increased risk of a difficult ELLC with associated complications, prolonged post-operative stay and readmissions. These data provide robust evidence that individualised risk assessment and consent are necessary before ELLC. Strategies to minimise recurrent biliary admissions prior to LC should be implemented. [ABSTRACT FROM AUTHOR]

Background Following therapeutic mammoplasty (TM), the contralateral breast may require a later balancing procedure to optimize shape and symmetry. The alternative is to offer patients simultaneous TM with immediate contralateral symmetrization via a dual-surgeon approach, with the goal of reducing costs and minimizing the number of subsequent hospital appointments in an era of COVID-19 surges. The aim of this cost–consequence analysis is to characterize the cost–benefit of immediate bilateral symmetrization dual-operator mammoplasty versus staged unilateral single operator for breast cancer surgery. Method A prospective single-centre observational study was conducted at an academic teaching centre for breast cancer surgery in the UK. Pseudonymized data for clinicopathological variables and procedural care information, including the type of initial breast-conserving surgery and subsequent reoperation(s), were extracted from the electronic patient record. Financial data were retrieved using the Patient-Level Information and Costing Systems. Results Between April 2014 and March 2020, 232 women received either immediate bilateral (n  = 44), staged unilateral (n  = 57) for breast cancer, or unilateral mammoplasty alone (n  = 131). The median (interquartile range (i.q.r.)) additional cost of unilateral mammoplasty with staged versus immediate bilateral mammoplasty was €5500 (€4330 to €6570) per patient (P  < 0.001), which represents a total supplementary financial burden of €313 462 to the study institution. There was no significant difference between groups in age, Charlson comorbidity index, operating minutes, time to adjuvant radiotherapy in months, or duration of hospital stay. Conclusion Synchronous dual-surgeon immediate bilateral TM can deliver safe immediate symmetrization and is financially beneficial, without delay to receipt of adjuvant therapy, or additional postoperative morbidity. [ABSTRACT FROM AUTHOR]

Background: Prepectoral breast reconstruction (PPBR) has recently been introduced to reduce postoperative pain and improve cosmetic outcomes in women having implant-based procedures. High-quality evidence to support the practice of PPBR, however, is lacking. Pre-BRA is an IDEAL stage 2a/2b study that aimed to establish the safety, effectiveness, and stability of PPBR before definitive evaluation in an RCT. The short-term safety endpoints at 3 months after surgery are reported here. Methods: Consecutive patients electing to undergo immediate PPBR at participating UK centres between July 2019 and December 2020 were invited to participate. Demographic, operative, oncology, and complication data were collected. The primary outcome was implant loss at 3 months. Other outcomes of interest included readmission, reoperation, and infection. Results: Some 347women underwent 424 immediate implant-based reconstructions at 40 centres. Mostwere single-stage direct-to-implant (357, 84.2 per cent) biologicalmesh-assisted (341, 80.4 per cent) procedures. Conversion to subpectoral reconstruction was necessary in four patients (0.9 per cent) owing to poor skin-flap quality. Of the 343 women who underwent PPBR, 144 (42.0 per cent) experienced at least one postoperative complication. Implant loss occurred in 28 women (8.2 per cent), 67 (19.5 per cent) experienced an infection, 60 (17.5 per cent) were readmitted for a complication, and 55 (16.0 per cent) required reoperation within 3 months of reconstruction. Conclusion: Complication rates following PPBR are high and implant loss is comparable to that associated with subpectoral mesh-assisted implant-based techniques. These findings support the need for a well-designed RCT comparing prepectoral and subpectoral reconstruction to establish best practice for implant-based breast reconstruction. [ABSTRACT FROM AUTHOR]

Background: Prepectoral implant-based breast reconstruction with acellular dermal matrix has become an increasingly popular option for selected patients. There are no randomized data to demonstrate short- or long-term outcomes. Cohort studies to date have demonstrated safety, but risk factors for complications are unknown. Methods: A prospective cohort study of all patients undergoing prepectoral implant-based breast reconstruction between 2013 and 2019. Clinical factors and those related to reconstruction were analysed in relation to complications and implant loss using univariable and multivariable logistic regression. Results: A total of 469 reconstructions were undertaken in 289 women; the majority of reconstructions were performed using a onestage direct-to-implant technique with acellular dermal matrix. Median follow-up was 21 (range 2-71) months. Minor complications were seen after 11·2 per cent of reconstructions, major complications after 5·9 per cent, and the rate of implant loss by 3months was 3·1 per cent. In the final multivariable model, sentinel node biopsy (odds ratio (OR) 5·06, 95 per cent c.i. 2·00 to 12·80), axillary clearance (OR 6·67, 1·17 to 37·94) and adjuvant radiotherapy (OR 7·11, 1·60 to 31·61) were independent risk factors for development of a major complication, and sentinel node biopsy (OR 4·32, 1·23 to 15·22) for implant loss. Conclusion: Prepectoral implant-based breast reconstruction has acceptable medium-term results but careful patient selection is advised. [ABSTRACT FROM AUTHOR]

Background: Day-case surgery is associated with significant patient and cost benefits. However, only 43% of cholecystectomy patients are discharged home the same day. One hypothesis is day-case cholecystectomy rates, defined as patients discharged the same day as their operation, may be improved by better assessment of patients using standard preoperative variables. Methods: Data were extracted from a prospectively collected data set of cholecystectomy patients from 166 UK and Irish hospitals (CholeS). Cholecystectomies performed as elective procedures were divided into main (75%) and validation (25%) data sets. Preoperative predictors were identified, and a risk score of failed day case was devised using multivariate logistic regression. Receiver operating curve analysis was used to validate the score in the validation data set. Results: Of the 7426 elective cholecystectomies performed, 49% of these were discharged home the same day. Same-day discharge following cholecystectomy was less likely with older patients (OR 0.18, 95% CI 0.15–0.23), higher ASA scores (OR 0.19, 95% CI 0.15–0.23), complicated cholelithiasis (OR 0.38, 95% CI 0.31 to 0.48), male gender (OR 0.66, 95% CI 0.58–0.74), previous acute gallstone-related admissions (OR 0.54, 95% CI 0.48–0.60) and preoperative endoscopic intervention (OR 0.40, 95% CI 0.34–0.47). The CAAD score was developed using these variables. When applied to the validation subgroup, a CAAD score of ≤5 was associated with 80.8% successful day-case cholecystectomy compared with 19.2% associated with a CAAD score >5 (p < 0.001). Conclusions: The CAAD score which utilises data readily available from clinic letters and electronic sources can predict same-day discharges following cholecystectomy. [ABSTRACT FROM AUTHOR]

Introduction: The reinsertion of an infected implant when peri-prosthetic infection occurs early after breast augmentation or breast reconstruction remains controversial. In this experimental study, the authors tried to remove bacteria, and their biofilm, from the colonized surface of breast prostheses, without damaging their integrity.Materials and Methods: A total of 112 shell samples of silicone breast prostheses, smooth (SPSS) and textured (TPSS), were colonized by S. epidermidis (SE) or S. aureus (SA) strains, all able to produce biofilms. After 15 days, all the samples were removed from the contaminated culture broth and constituted 4 groups of 20 contaminated samples: SPSS/SE (group I), SPSS/SA (group II), TPSS/SE (group III), TPSS/SE (group IV). In another group—group SEM−, 16 colonized samples were used for documentation with scanning electron microscopy (SEM). The remaining 16 samples were used to test the limits of detection of the sterility test. All samples of groups I-IV and 8 samples of group SEM were « washed » with a smooth brush in a povidone-iodine bath and rinsed with saline solution. A subset of the washed samples was sent for SEM and the others were immersed in sterile broth and were incubated at 35 °C for 3 weeks (groups I-IV). Results: Fifteen days after contamination, all the samples in groups I-IV were colonized. In the SEM group, SEM images attested to the presence of bacteria in biofilm attached to the shells. After cleaning, SEM did not reveal any bacteria and there was no visible alteration in the outer structure of the shell. Sterility tests performed after decontamination in groups I-IV remained negative for all the samples.Conclusion: Breast prostheses recently contaminated with Staphylococci, frequently involved in peri-prosthetic breast implant infection and capable of producing biofilms, can be efficiently decontaminated by the procedure used in this study. Our decontamination procedure did not alter the surface structure of the prostheses. This decontamination procedure could allow reinsertion of an infected implant when peri-prosthetic infection occurs early after breast augmentation or breast reconstruction and when a salvage procedure is indicated.No Level Assigned: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266. [ABSTRACT FROM AUTHOR]