Improving the assessment and outcome of free tissue transfer breast reconstruction

Introduction: Free tissue transfer using an abdominal tissue flap is a commonly used method of breast reconstruction. However, there are well recognised complications including venous congestion, fat necrosis and flap loss associated with the perfusion of these flaps. Post-operative aesthetic outcome assessment of such breast reconstructions have also proven to be difficult with current methods displaying poor inter-rater reliability and patient correlation. The aim of this research was to investigate potential improvements to the post-operative outcome of free abdominal tissue transfer breast reconstruction by assessing the effects of vascular augmentation interventions on flap perfusion and to assess the use of real-time digital video as a post-operative assessment tool. Methods: An in-vivo pilot study carried out on 12 patients undergoing DIEP flap breast reconstruction assessed the effect on Zone IV perfusion, using LDI and ICG angiography, of vascular augmentation of the flap using the contralateral SIEA and SIEV. A further animal experimental study was carried out on 12 Sprague Dawley rats to assess the effects on main pedicle arterial blood flow and on Zone I and Zone IV perfusion of vascular augmentation of the abdominal flap using the contralateral vascular system. A separate post-operative assessment study was undertaken on 35 breast reconstruction patients who evaluated their own reconstructions via patient questionnaire and underwent photograph and real-time digital video capture of their reconstructions with subsequent panel assessment. Results: Our results showed that combined vascular augmentation of DIEP flaps, using both the SIEA and SIEV together, led to an increase in Zone IV perfusion. Vascular augmentation of the rat abdominal flaps also led to a significant increase in Zone I/IV perfusion, but the augmentation procedure resulted in a decreased main pedicle arterial blood flow. Our post-operative assessment study revealed that real-time digital video footage led to greater inter-rater agreement with regards to cosmesis and shape than photography and also correlated more with patient self-assessment. Conclusion: Vascular augmentation of abdominal free tissue flaps using the contralateral vascular system results in an increase to Zone IV perfusion, however this may lead to decreased main pedicle arterial blood flow. Real-time digital video is a valid post-operative aesthetic assessment method of breast reconstruction outcome and is superior to static photography when coupled with panel assessment.

An examination of verbal descriptors of cancer-induced bone pain and neuropathic cancer pain

Aims: The aim of the thesis was to identify verbal descriptors of cancer induced bone pain (CIBP) and neuropathic cancer pain (NCP). An examination of the verbal descriptors associated with these two pain syndromes further considered the relationship between common verbal descriptors, cancer type, performance status and analgesia. Methods: The project was conducted in two phases; Phase one was a systematic review of the literature to examine current evidence of verbal descriptors in CIBP and NCP. Phase two utilised secondary data analysis methodology. Data from 120 patients with confirmed CIBP and 61 patients with confirmed NCP were deemed eligible for entry into a de novo database for secondary analysis. Key descriptive data were considered such as gender, ECOG and pain scores to characterise the patient population. Verbal descriptors of CIBP and NCP were considered in detail across the secondary de novo database. Results: Gender was not identified as a diagnostic characteristic of CIBP and NCP with similar distribution across prevalence of pain reporting and also pain severity. Patients with breast (n=52,43.3%), prostate (n=35,29.2%) and lung (n=14,11.7%) cancer were found to be at an increased risk of CIBP. Those with NCP more was found more commonly among patients with breast cancer (n=21,34.4%). Patients with CIBP were found to have an ECOG performance of 1 (n=49, 40.8%) or 2 (n=43, 35.8%) which was lower than those with NCP with an ECOG of 0 (n=32, 52.5%) or 2 (n=18, 29.5%). Comparisons were made across analgesia and treatment options for CIBP and NCP. Patients with CIBP received a greater variety of treatment options including bisphosphonates and radiotherapy while patients with NCP were more commonly treated with analgesia alone. Patients with CIBP and NCP were taking strong opioids, however those with NCP (n=45, 73.8%) were more likely to utilise strong opioids than those with CIBP (n=61, 50.8%). It was noted that those with NCP required a daily morphine equivalence of almost 50% higher than those with CIBP. Average consumption of opioids was 155.6mg, for patients with NCP, compared to 76mg in patients with CIBP. Common verbal descriptors of CIBP and NCP were identified. The most common verbal descriptors for CIBP were aching, gnawing and throbbing and the most common verbal descriptors of NCP were aching, tender and sharp. Of the most common 6 descriptors for CIBP and NCP only one descriptor was unique to each pain type, gnawing for CIBP and stabbing for NCP. Conclusions: Patients with CIBP and NCP use similar verbal descriptors to characterise their pain with gnawing being unique to CIBP and stabbing being unique to NCP in the data considered within project. Further research is required to explore verbal descriptors which are both common and unique to CIBP and NCP. Further exploration of verbal descriptors would assist development of a comprehensive pain assessment tool which would enhance pain assessment for nurses, clinicians and patients.