Restitution of the NHS breast reconstruction service during the recovery phase of the Covid 19 pandemic.

During the recovery restitution phase of the coronavirus pandemic, breast reconstruction teams have faced particular challenges to restarting this essential service. This is due to the length and complexity of the surgery, along with the demands on healthcare staff. The Royal College of Surgeons have classified immediate breast reconstruction as priority 2 and the National Institute for Health and Care Excellence have provided a pre-operative pathway for resumption of elective procedures. We therefore describe our experience in restarting our service for providing a breast reconstruction service from the 29th June 2020.

Dear Sir,

We read with interest the article by Masud et al. in August 2020. The authors layout the problems faced due to the cessation of elective breast reconstruction surgery as a result of the initial phase of the COVID-19 response, and their algorithm for recommencing their service. Our service noted as the recovery restitution phase from the coronavirus pandemic continues, a particular challenge is faced by breast reconstruction teams. Multiple institutions around the UK continue to struggle with approval to restart this essential service, worsening the acknowledged postcode lottery that exists in the management of breast cancer and reconstruction.

A standard approach to autologous free flap breast reconstruction will require at least 1.5–2 sessions in most institutions and ideally should be supported by a team of expert scrub and anaesthetic staff. Patients should then be monitored by experienced plastic surgery nurses and most will follow an Enhanced Recovery After Surgery (ERAS) protocol.

Although immediate reconstructions have been re-categorised as priority 2 by the Royal College of Surgeons, many teams are struggling with access to appropriately staffed lists. This is a dual problem related to staffing with many members of our teams continuing to shield, and theatre capacity, where hospitals are creating green ‘COVID-lite’ pathways. In fact, challenges related to theatre capacity from the hand trauma perspective have been described.

Our experience

In Bristol we have a large catchment area and before the pandemic halted elective operating, there was a waiting list of approximately 70 patients including immediate, delayed, and risk reducing cases. Fortunately we were able to complete the outstanding immediate reconstructions prior to cessation of elective operating, but during the peak of the pandemic all non-urgent (i.e. P3/4) surgery ceased, along with the screening programme for breast cancer. As we emerge from the crisis and limited capacity elective lists have been reinstated, we identified an early opportunity to restart with immediate unilateral reconstruction and describe below our experience thus far.

We have prospectively collected information on patients operated on as we restore our breast reconstruction services. We have modified our approach to these cases, and now operate a 2-consultant system for each procedure to reduce surgical time. Post-operatively our patients go to a ‘COVID-lite’ green ward which is not our usual plastic surgery ward. Although the nurses on this ward are gathering experience, we arranged for a plastics-trained nurse to cover for the first night. All patients have a COVID swab 72 h pre-operatively after shielding for 2 weeks (these recommendations are changing in line with NICE guidance).

Results

Our first case was performed on 29th June and in the 8 weeks since then we have undertaken 19 free flaps (17 patients). Two patients had bilateral reconstruction and four had bipedicled flaps. Seven were immediate reconstructions. In the same time period in 2019 we performed 26 reconstructions (1 TDAP, 2 TUG, 23 DIEPs) with three bilateral cases, three bipedicled flaps and eight immediate reconstructions. The average length of stay (LOS) in 2019 was 3.27 and in 2020 is 3.12 days. There have been no significant complications since restarting, no patients have displayed symptoms of coronavirus peri- or post-operatively and there have been no deaths.

We are working on the principle of minimising patient contact by reviewing patients once post-discharge. We also recommend that they shield for at least 2 weeks post-operatively. This is reinforced by the ERAS protocol and patients are supported remotely wherever possible. Although the learning curve for free flap monitoring and ward care has been steep we are seeing increasing confidence among the nursing staff who are caring for these patients. We continue to support them with educational sessions and overnight support from the medical team. Graph 1

Graph 1

Graph showing the number of breast reconstruction operations conducted in the years 2019 and 2020, between 29th June and 28th August.

Looking to the future

This data supports the principle that autologous breast reconstruction is safe to be conducted during this phase of the coronavirus pandemic, providing appropriate safeguards are put in place. The tenet that the NHS provides standardised care opportunities to patients is essential to prevent some centres becoming overwhelmed and we therefore strongly support our colleagues in restarting their services. As more data emerges from the UK National Flap Registry we expect there will be growing pressure to provide this service at all units. Logistical challenges continue to affect our service and we are functioning at approximately 65% of the capacity compared with last year. This is likely related to the restrictions that have been put in place to ensure patient (and staff) safety, such as shielding pre-operatively, but has resulted in difficulties populating available theatre lists.

Going forwards we anticipate significant challenges with the usual winter pressures exacerbated by coronavirus. We are optimistic that the Nightingale Hospitals will take some of the pressure off the bed base to avoid another full stop to elective surgery, in addition to the green ‘COVID-lite’ pathways. However, we expect the rate limiting step to be related to availability of theatre staff and anaesthetic team members, both of which are beyond our control.

Declaration of Competing Interest

None.

Funding

None.

Ethical approval

N/A