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Hospital Peer Review: A Focus On Advances In Breast Surgery
A Focus On Advances In Breast Surgery: MMUH Breast Team Perspective
Written by Professor Malcolm Kell, and Aoife Sartini-Bhreathnach
Breast surgery is ever advancing in terms of surgical procedures through the introduction of new techniques and the revival and improvement of the old. This article focuses on some of the advances adapted by the Breast team in the Mater Misericordiae Hospital to date. Advances are continually made to improve surgical options for our patients in both breast reconstruction and breast conserving surgeries. This article will discuss the pre-pectoral implant reconstruction technique, a procedure that has made a resurgence in recent years and the introduction of magseed guided surgery to our unit; a new localisation method for impalpable Breast lesions. Alongside surgical advancements the team have also been supportive in advancing new roles within Irish healthcare, such as that of the Physician associate (PA).
Physician Associate Role
The role of the PA in Ireland is a rapidly developing professional group where worldwide there are over 110,000 PAs now employed in the US. PAs are trained in the medical model and work under the consultant’s supervision. Miss Sartini-Bhreathnach graduated with her MSc in Physician associate studies in 2019 as part of the second cohort of Physician Associate’s in Ireland. Eligibility for the MSc programme requires a relevant undergraduate degree and previous experience is desirable. Miss Sartini-Bhreathnach obtained her undergraduate in Biomedical Sciences in 2012 and prior to commencing the PA programme worked with a number of research groups. A career as a Physician Associate has given the opportunity to pioneer a new profession within healthcare and be directly involved in the management of patients under the medical model. Aoife has been working for the Breast team in the Mater hospital for almost two years to date where she works alongside the surgical team. The opportunities she has availed of have included: educational progression and learning. Aoife assists in surgical cases; reviews patients post operatively and at their clinical appointments. She has also had the opportunity to continue with new research endeavours.
Professor Malcolm Kell is Consultant Breast Surgeon in Breastcheck, Mater Misericordiae University Hospital and Mater Private, Dublin. Professor Kell has special interest in oncoplastic, aesthetic and reconstructive breast surgery. He is widely published; current research focuses on optimising outcome after breast surgery. Aoife Sartini-Bhreathnach, Physician Associate PA-IC, Mater Misericordiae University Hospital
Advancements In Implant Based Breast Reconstruction
Globally there is an increase in patients availing of breast reconstruction, following mastectomy, with 80-95% of reconstruction being implant based. Breast reconstruction can be performed with the use of autologous tissue to reconstruct the breast in procedures such as latissimus dorsi (LD) reconstruction. The addition of an implant can be common in these procedures and may be placed to enhance the aesthetic outcome. Reconstruction options can also include the sole use of the implant without autologous tissue. Implant based reconstruction of the breast cavity is a popular surgical procedure of which was traditionally performed as part of a two stage process. Firstly the mastectomy was performed followed by the insertion of a tissue expander. A second procedure was scheduled to remove and replace the expander with a permanent prosthesis. While this 2-stage process may still provide a suitable reconstruction option for a select cohort of patients,the majority of implant reconstructions performed by the breast team in the MMUH are direct-to-implant, one stage procedures. Historically the use of an implant to reconstruct the breast cavity has been in practice since the 1970’s where, at this time, the implant was mostly positioned in front of the pectoralis muscle. Positioning in this pre-pectoral position,following mastectomy, allows for the implant to be placed directly into the cavity in front of the pectoralis muscle where there is no manipulation of the pectoralis muscle. Post-operative complications were high, following pre-pectoral reconstruction, with complications such as flap necrosis, implant extrusion and overall implant loss. Due to this there was a natural progression away from the placement of the implant directly in front of the pectoralis muscle and towards a subpectoral positioning. Subpectoral implant reconstruction differs from the pre-pectoral procedure due to the manipulation of the pectoralis muscle. Following mastectomy, the inferior border of the pectoralis muscle is released and the implant is positioned under the muscle. Elevation of the pectoralis muscle provides tissue coverage to the superior aspect of the implant and an additional layer between the implant and skin, all of which was absent in the prepectoral technique. There is wide acceptance of subpectoral implant reconstruction and to this day it is a popular surgical procedure amongst reconstructive breast surgeons.
Revival of Pre-Pectoral Implant Reconstruction
In more recent years however, there has been a surge in the use of pre-pectoral implant reconstruction, with many surgeons favouring this technique once more. Recent studies have reported positive outcomes when comparing the pre-pectoral technique to the subpectoral equivalent. The literature has reported an overall reduction in post-operative complications when compared to the subpectoral implant reconstruction technique. Aesthetic outcomes have also been favourable for the prepectoral technique, where an independent evaluation of pre versus subpectoral aesthetic outcomes reported that bilateral pre-pectoral implant procedures scored highest on a visual analog scale of aesthetic outcomes. Research continues to report a positive trend of reduced post-operative complications and a move towards this surgical procedure. The breast team in the MMUH have also progressed towards the pre-pectoral reconstruction procedure acknowledging the potential advancements it can provide to improved patient outcomes and breast reconstruction.
By avoiding the manipulation of the pectoralis muscle there have been positive patient and surgical outcomes such as:
• Decrease animation deformity • Reduced pain post op • Less widening of cleavage
Advancing surgical techniques: Synthetic Mesh
A contributing factor to the revival of the pre-pectoral procedure was the development and use of mesh material in implant reconstruction. Both biological and synthetic forms of mesh are approved for use in reconstruction procedures. Acellular dermal matrix (ADM), is a form of biological mesh that derives from biotechnologically engineered bovine or porcine tissue . ADMs are internationally the predominate form of mesh used in implant reconstruction of the breasts.
The use of synthetic mesh in implant reconstruction is a newer advancement in breast surgery. Our Breast team solely use synthetic mesh, in the form of TIGR mesh, for all implant based reconstructions.
TIGR mesh is a bioresorbable synthetic material with a decreased cost in comparison to biological mesh material. To date the use of TIGR mesh has provided substantial support to the implant reconstruction procedure with minimal specific concerns post operatively.
Pre-pectoral Surgical Technique using TIGR mesh
Following mastectomy the implant and TIGR mesh are prepared ex-vivo prior to placement in the mastectomy cavity. The TIGR mesh is enveloped around the implant and both are immersed in antibiotic solution.
The implant and mesh are then positioned in the mastectomy cavity in front of the pectoralis Fig 2: Placement of the mesh around the implant
muscle and sutured to secure in place. A pain catheter and drain are placed with the latter remaining in situ until less than 30mls are drained within a 24hr period.
Advancements in Breast Conservation Surgery: Magseed guided localization:
Wire guided localization has been widely utilised as the standard method of pre-operative localization of breast lesions. Whilst it is a safe procedure there are some disadvantages associated with the use of wire guided procedures. Wires are placed pre-operatively which can cause delays to theatre
Fig 3: Implant placement in the prepectoral position
Fig 4: Magseed
The paper details the results of a retrospective review of a prospective database of which was performed on the first 100 patients who underwent a Magseed guided breast surgery between November 2018 and November 2019.
The aim was to measure the retrieval of the magseed and excision of the lesion. Data was also gathered on post-operative complications, time to theatre and re-excision rates.
and the additional possibility of dislodgment of the wire whilst transferring the patient. Patients have also reported discomfort following the procedure. Magnetic seeds (magseed) were developed to potentially eliminate some of the disadvantages associated with wires.
The breast team in the Mater almost solely use the magnetic seeds for the localisation of impalpable breast lesions and have most recently published a paper on our experience to date.
Fig 1: TIGR mesh following direct placement Results have shown that over 50% of magseed guided cases are suitable as first theatre case procedures in comparison to wire guided procedures that are not ready morning of surgery. This can reduce delays to theatre. In regards to re-excision rates for margin clearance, in therapeutic Magseed guided cases, the rate was 9.4%.
Overall the introduction of magseed guided surgery has had positive feedback from our unit . It has shown many benefits including efficient theatre planning, low re-excision rates and ease of localisation and excision.
The Impact of Covid 19 on the Mental Health of Healthcare Workers: What is the Evidence?
Written by Professor Brendan Kelly, Professor of Psychiatry, Trinity College Dublin
The Covid-19 pandemic has had a significant impact on mental health, especially among healthcare workers. Research evidence over the course of 2020 indicated that the combined effect of the Covid-19 pandemic and associated restrictions was that approximately one person in every five in the general population experienced significantly increased psychological distress (e.g. anxiety or depression).1 Rates of significant psychological distress are higher among healthcare workers, at approximately 40%. Clearly, this is an area in need of careful consideration, continued study and urgent intervention. A series of systematic reviews and meta-analyses in early 2021 have assisted greatly in quantifying this issue, elucidating the nature of the problems, and suggesting potential solutions for healthcare workers and their employers, as the pandemic continues. In March, a systematic review and meta-analysis of the prevalence of depression, anxiety and post-traumatic stress disorder (PTSD) in healthcare workers during the pandemic examined 65 studies involving 97,333 health care workers.2 These studies were conducted between December 2019 and August 2020 across 21 countries This meta-analysis found a pooled prevalence of 21.7% for depression, 22.1% for anxiety and 21.5% for PTSD. Studies conducted in the Middle-East provided the highest prevalence estimates for depression (34.6%) and anxiety (28.9%). These prevalences are notably high and the authors conclude that appropriate support is needed as a matter of urgency. Another systematic review and meta-analysis published the same month in Neuroscience and Biobehavioral Reviews looked at anxiety, depression, traumarelated and sleep disorders among healthcare workers during the pandemic.3 This analysis included 70 studies with 101,017 participants. The authors reported a pooled prevalence of 31.1% for depression, 30.0% for anxiety, 20.2% for PTSD, 56.5% for acute stress and 44.0% for sleep disorders. Again, these authors recommended the development of targeted prevention and support strategies, both now and in the future, for those affected. The high prevalence of problems with sleep is deeply concerning, as disturbances to sleep are strongly linked with poor physical health and diminished psychological wellbeing. To gain a deeper qualitative perspective on these problems, Kristina Newman and colleagues examined experiences and emotional strain among frontline workers in the National Health
Brendan Kelly is Professor of Psychiatry at Trinity College Dublin and author of ‘The Science of Happiness: The Six Principles of a Happy Life and the Seven Strategies for Achieving It’ (Gill Books, 2021). Service (NHS) during the peak of the pandemic.4 In this study, survey data from 395 NHS staff were developed into three key themes: (a) despair and uncertainty, with feelings of being overwhelmed; (b) behavioural and psychological impact, which affect wellbeing and functioning; and (c) coping and employer support, involving getting the help that is needed. These authors conclude that NHS staff felt enormous burdens during the peak of the pandemic. It is likely that these stresses will be sustained and even increase for as long as the pandemic persists. So, what can be done to support healthcare workers in these extraordinary circumstances? In addition to identifying the prevalence and nature of stresses and mental health problems during the pandemic, the literature has now started to identify factors relating to coping and support, in order to guide the interventions that are so clearly needed. One systematic review of quantitative studies of psychological resilience, coping behaviours and social support among healthcare workers during the pandemic identified 31 r elevant articles.5 This analysis found that healthcare workers used both problem-centred and emotion-centred coping to manage the stresses associated with the pandemic. Notwithstanding the unique nature of current circumstances, substantial evidence supports the effectiveness of certain coping behaviours, resilience and social support in this situation. This paper concludes that, in order to protect the mental health of healthcare workers, administrators should implement proactive measures to sustain resilience, develop coping skills and introduce creative ways to grow social support, using theory-based interventions, supportive leadership and building resilient work environments.
Practical measures can make an enormous difference in these tasks: careful rostering and timetabling of work, ensuring staff can take the leave to which they are entitled, and employers providing organisational support where and when it is needed.1,6 In many circumstances, ‘psychological first aid’ is also useful, along with appropriate follow-on care for those who require further treatment and support.7 Finally, it is important to remember that, in addition to the effects of the pandemic on stresses at work, infection with Covid-19 also carries significant psychological and psychiatric risk. In April, Maxime Taquet and colleagues published data on 6-month neurological and psychiatric outcomes in 236,379 survivors of Covid-19 in Lancet Psychiatry, using electronic health records.8 This group found that the estimated incidence of a neurological or psychiatric diagnosis during the six months following Covid-19 infection was 33·6%, with 12·8% of people receiving their first such diagnosis during this period. For patients admitted to intensive care with Covid-19, the estimated incidence was 46·4%, with 25.8% receiving their first such diagnosis. The specific conditions seen in this study included anxiety disorder (17.4%), ischaemic stroke (2.1%), psychotic disorder (1.4%), dementia (0.7%), intracranial haemorrhage (0.6%) and parkinsonism (0.1%). Among those admitted to intensive care, incidences were generally higher: anxiety disorder (19.1%), ischaemic stroke (6.9%), psychotic disorder (2.8%), intracranial haemorrhage (2.7%), dementia (1.7%) and parkinsonism (0.3%). Most diagnostic categories were more common in patients who had Covid-19 compared to those who had influenza or other respiratory tract infections. Covid-19, it seems, has an especially high rate of psychological and psychiatric sequelae, especially after severe illness.
Overall, the impact of Covid-19 on the mental health of healthcare workers has been substantial and will continue to be significant for some time to come. Ensuring practical support in the workplace, as well as appropriate follow-up care, will help manage the lingering psychological consequences of the pandemic as it subsides.
