Objective Assess the evidence for Enhanced Recovery After Surgery (ERAS) protocols in the cleft palate population. Design A systematic review of MEDLINE, Embase, Cochrane, and CINAHL databases for articles detailing the use of ERAS protocols in patients undergoing primary palatoplasty. Setting New York-Presbyterian Hospital. Patients/Participants Patients with cleft palate undergoing primary palatoplasty. Interventions Meta-analysis of reported patient outcomes in ERAS and control cohorts. Main Outcome Measure(s) Methodological quality of included studies, opioid use, postoperative length of stay (LOS), rate of return to emergency department (ED)/readmission, and postoperative complications. Results Following screening, 6 original articles were included; all were of Modified Downs & Black (MD&B) good or fair quality. A total of 354 and 366 were in ERAS and control cohorts, respectively. Meta-analysis of comparable ERAS studies showed a difference in LOS of 0.78 days for ERAS cohorts when compared to controls ( P < .05). Additionally, ERAS patients utilized significantly less postoperative opioids than control patients ( P < .05). Meta-analysis of the rate of readmission/return to ED shows no difference between ERAS and control groups ( P = .59). However, the lack of standardized reporting across studies limited the power of meta-analyses. Conclusions ERAS protocols for cleft palate repair offer many advantages for patients, including a significant decrease in the LOS and postoperative opioid use without elevating readmission and return to ED rates. However, this analysis was limited by the paucity of literature on the topic. Better standardization of data reporting in ERAS protocols is needed to facilitate pooled meta-analysis to analyze their effectiveness.

Background: The additional donor site incisions in autologous breast reconstruction can predispose to abdominal complications. The purpose of this study is to delineate predictors of donor site morbidity following DIEP flap harvest and use those predictors to develop a machine learning model that can identify high risk patients. Methods: This is a retrospective study of women who underwent DIEP flap reconstruction from 2011 to 2020. Donor site complications included abdominal wound dehiscence, necrosis, infection, seroma, hematoma, and hernia within 90 days postoperatively. Multivariate regression analysis was used to identify predictors for donor site complications. Variables found significant were used to construct machine learning models to predict donor site complications. Results: Of 258 patients, 39 patients (15 percent) developed abdominal donor site complications, which included 19 cases of dehiscence, 12 cases of partial necrosis, 27 cases of infection, and 6 cases of seroma. On univariate regression analysis, age (p = 0.026), body mass index (p = 0.003), mean flap weight (p = 0.006), and surgery time (p = 0.035) were predictors of donor site complications. On multivariate regression analysis, age (p = 0.025), body mass index (p = 0.010), and surgery duration (p = 0.048) remained significant. Radiographic features of obesity, such as abdominal wall thickness and total fascial diastasis were not significant predictors of complications (p > 0.05). In our machine learning algorithm, the logistic regression model was the most accurate at predicting donor site complications with accuracy of 82 percent, specificity of 0.93, and negative predictive value of 0.87. Conclusion: This study demonstrates that body mass index is superior to radiographic features of obesity in predicting donor site complications following DIEP flap harvest. Other predictors include older age and longer surgery duration. Our logistic regression machine learning model has the potential to quantify risk of donor site complications.

PURPOSE:Despite equivalent oncologic survivorship, U.S. lumpectomy rates previously declined in favor of more aggressive surgical options such as mastectomy, often performed in conjunction with a contralateral prophylactic mastectomy (CPM) with or without reconstruction. Using three national datasets, this study evaluates longitudinal trends in lumpectomy/mastectomy, CPM, and breast reconstruction rates, determining characteristics most associated with current surgical practice. METHODS:Trends in lumpectomy, mastectomy, and reconstruction rates were evaluated using the NSQIP, SEER, and NCDB databases from 2005-2017, further examining mastectomy with a focus on CPM. Longitudinal trends were analyzed with Cochran-Armitage Trend tests and Poisson regression. Multivariate logistic regression using NCDB identified predictors of the described surgeries. RESULTS:We analyzed 3,467,645 female surgical breast cancer patients. Lumpectomy rates reached a nadir between 2010-2013, with a significant increase thereafter (NSQIP: +1%/year; SEER +1.6%/year; NCDB: +1.6%/year, all p<0.001). Concurrently there was corresponding decrease in mastectomy rates. Both CPM and reconstruction rates increased significantly from 2005-2013 (p<0.001), but have since stabilized. CONCLUSION:Longitudinal data demonstrate a reversal of prior trends which favored more aggressive surgical management of breast cancer. This is also the first evidence of level breast reconstruction rates since passage of the WHCRA. Further research is required to understand factors driving these recent practice changes and associated impact on patient reported outcomes.

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