Protocol Hasnath Presentation Finallpptx

Protocol Hasnath Presentation

1. Welcome to thesis protocol presentation

2. Proposed title Quilting Stitch Versus Simple Suture Closure in Prevention of Seroma after Mastectomy in Breast Cancer Patient

3. Investigator Dr. Md. Hasnath Kabir MS Phase-B (Resident) Department of Surgery Sylhet MAG Osmani Medical college, Sylhet

4. Guide Dr. Kazi Zana Alam Associate Professor Department of Surgery Sylhet MAG Osmani Medical College, Sylhet

5. Co-guide: Dr. Arun Kumar Baishnab Assistant Professor Department of Surgery Sylhet MAG Osmani Medical College, Sylhet .

6. Introduction Breast cancer is the most frequent cancer among women, which cause significant morbidity and mortality. It is the second most common cancer and the fourth most common causes of death globally which leads to a tremendous burden on the healthcare system worldwide (GLOBOCAN 2022).

7. Cont… There was 2.3 million women diagnosed with breast cancer and 670000 deaths globally (Cancer: WHO 2022).In Bangladesh the incidence of breast cancer was about 22.5 per 100000 females. Breast cancer has been reported as the highest prevalence 19.3 per 100,000among Bangladeshi women between 15 and 44 years of age (Begum et al., 2019).

8. Cont… Surgery plays a central role in the management of breast cancer. Mastectomy is the most commonly perform surgery. Although the paradigms of breast cancer surgery are now shifted towards breast conservative surgery, mastectomy still has some specific indications, and mastectomy are routinely performed worldwide.

9. Cont… After mastectomy, wound closure is an important issue for proper healing and minimizing complications. Seroma formation is a common complication after mastectomy for breast cancer. Seroma can be defined as a collection of serous fluid in dead space (Turner, Benson and Winters 2014). The pathophysiology of seroma formation is still an enigma. Several factors have been held accountable for seroma formation ,such as the use of electrocautery and extensive dissection during surgery (Kuroi et. al;2005).The sequelae of seroma are delayed wound healing, increase chance of infection, prolonged hospital stays, skin flap necrosis, patient discomfort, delays in commencing adjuvant therapies and increased surgical expenditures ( Bastelaar et al., 2018)

10. The incidence of seroma formation following mastectomy varies in different studies. The study conducted by Lotte j. Van, et al. (2021) found the rate of seroma formation in the simple suture closure at 81.5% compared to the quilting s titch group at 31.0%. A study conducted by Wu et al. (2020) found 26.1%in the simple suture closure and 27.6% quilting stitch. Chand et al. (2013) report 25% in quilting stitch and 60% in simple suture closure. M yint et al (2020) found 2.8%in the simple suture closure and 1.9% quilting stitch,A study conducted by Wu et al. (2020) found 26.1%in the simple suture closure and 27.6% quilting stitch. Chand et al. (2013) report 25% in quilting stitch and 60% in simple suture closure. myint et al (2020) found 2.8%in the simple suture closure and 1.9% quilting stitch.

11. Cont… For prevention of seroma following mastectomy several wound closure techniques are used, such as simple suture closure and quilting s titch . In simple suture closure, the skin flap is not fixed with the underlying muscle but sutured at the edges, drain is inserted beneath the flaps near the medial and inferior border of the dead space at the pectoral area.

12. Cont… Simple suture closure is easy to perform, has a shorter surgical time and has no effect on shoulder mobility. Despite these advantages, a potential disadvantage of simple suture closure is higher rates of clinically detectable seroma . A suction drain is commonly used with simple suture closure to prevent seroma formation.

13. Cont… Seroma frequently occurs after the removal of the drain (Barton et al;2006). The drain is associated with patient discomfort, chance of wound infection, and longer hospital stay and increase hospital cost. In quilting s titch , the skin flaps were sutured to the underlying pectoralis major to reduce dead space.

14. Some recent evidence suggests that quilting s titch reduces the incidence of seroma ,SSI and significantly shorter length of hospital stay ( Bemmel et al;2011) . It also has some disadvantages, including increased surgery time, impaired shoulder function, pain and scar retraction. Cont…

15. Cont… Post-operative complications hamper the optimal surgical outcome of any procedure. Seroma , hematoma, Surgical site infection, and Flap necrosis are the common early post-operative complications in breast cancer surgery. Various studies show variable results regarding these complications irrespective of procedures.

16. Cont… Seroma formation or the execution of closure techniques significantly influence the incidence of hematoma formation following surgery. Studies show that the rate of hematoma formation in simple suture closure is 26.7% and in Quilting stitch 30% ( Khater et al., 2015). A study conducted by Huang et al. 2021 found 5% in simple suture closure and 5% in quilting stitch .

17. Cont… Surgical site infection is one of the sequelae of seroma formation, which increase post operative morbidity. Lotte j. van, et al. 2021 found the rate of SSI formation in the simple suture closure was 18.5% compared to quilting stitch group1%. A study conducted by Wu et al. 2020 found 3.4%in the simple suture closure and 4.3% quilting stitch . Wolde et al. 2017 reports 31% in quilting stitch and 11.2% in the simple suture closure.

18. Cont… One of the contributing factors for flap necrosis is the presence of prolonged or tension seromas . Flap necrosis refers to the death of tissue in a surgical flap. A study conducted by Khater et al. 2015 found that flap necrosis in simple suture closure 10% compared to Quilting stitch 8.3%, whereas study conducted by Myint . et al. 2020 found 1% in the simple suture closure and 0% in Quilting stitch .

19. Operative time is an independent factor with no direct relationship to seroma formation. However, the use of quilting stitches usually extends the duration of the procedure. Study conducted by Khater . et al. 2015 found that the operative time in simple suture closure is 105 min and in quilting stitch 127 min, whereas a study conducted by Vettuparambil and Subramanya . 2020 found 98 min in simple suture closure and 102 min in quilting stitch. Cont…

20. It seems that there is a significant difference in operative time between conventional closure and quilting stitch. From the above background knowledge, it has been seen that there are variations in results, and controversy still persists between simple suture closure and quilting stitch regarding which one is better for mastectomy wound closure. Cont…

21. Rationale Mastectomy is a commonly performed procedure for breast cancer patients, and closure of the mastectomy wound can be achieved through simple suture closure and quilting stitch . Due to less seroma formation, SSI and significantly shorter lengths of hospital stay, quilting stitch are becoming more popular nowadays. However, there are still a number of un-clarified issues regarding the advantage over the simple suture what should be the ideal approach for the closure of a mastectomy wound.

22. Cont… Many studies show different results in terms of early and late post-operative outcome between quilting stitch and simple suture closure. In SOMCH, there is no study comparing the outcomes of the two approaches. This triggered me to do a study on quilting stitch versus simple suture closure in the prevention of seroma after total mastectomy in breast cancer patients.

23. Research Question Does Quilting Stitch has better outcome than Simple Suture closure in prevention of Seroma after Mastectomy in Breast cancer Patient?

24. Hypothesis Quilting Stitch has better outcome than Simple Suture closure in prevention of Seroma after Mastectomy in Breast cancer patient.

25. General objective To compare the outcome of Quilting Stitch versus Simple Suture closure in the prevention of Seroma after Mastectomy in Breast cancer patients.

26. Specific objective To record and compare the following outcomes of Quilting Stitch versus Simple Suture closure. 1. To identify the wound related complications a. Seroma b. Hematoma c. Surgical site infection d. Flap necrosis 2. Operative time

27. Methodology Study design: It will be a Quasi- experimental study. Place of study: This study will be carried out at the department of surgery at Sylhet MAG Osmani Medical College Hospital, Sylhet . Period of study: October 2023 to September 2025.

28. Study population: All patients with breast cancer require mastectomy Study Sample : Patients who will undergo Mastectomy surgery during the study period fulfilling the selection criteria in department of surgery, SOMCH. Sampling method: Convenient sampling.

29. Sample size Here, n= Desired sample size P1= Anticipated probability of Seroma formation in group A (Quilting) = 26.7 % ( Vettuparambil and Subramanya , 2020) P2= Anticipated probability of Seroma formation in group B (Simple Suture) = 54.8% ( Vettuparambil and Subramanya , 2020) Zα =Z-value at a definite level of significance, e.g. 1.96 at a 5% level of significance. (95% confidence interval) Zβ =Z-value at a definite power, e.g. 0.84 at 80% power.

30. For calculating the sample size for my study, the formula is: = 44.02 According to this formula the calculated sample size is 44 in each group

31. Selection criteria Inclusion criteria: Female patients who require mastectomy . Patients older than 18 years.

32. Exclusion criteria: Patients with recurrent breast cancer. Patients undergoing immediate breast reconstruction. patients with bilateral breast cancer.

33. Variables A. Outcome variable- Primary Outcome variable- a. Seroma Secondary Outcome variable- Hematoma Surgical site infection Flap necrosis Operative time B. Demographic variable : 1. Age. 2. Sex.

34. Data collection Data will be collected by using structured questionnaire designed for the study by researcher himself. The questionnaire will be prepared by reviewing literature and by consulting with guide and experts.

35. Data collection tools A preformed structured questionnaire Informed written consent form in Bangla Informed written consent form in English

36. Study procedure All the patients admitted in surgery department at Sylhet MAG Osmani Medical College Hospital during the study period, who will fulfill the selection criteria, will be enrolled in this study. Patients will be informed in details regarding the procedures of the study and informed written consent will be obtained.

37. Study population will be allocated into two groups, Group A and Group B. Group A ( Quilting Group). Group B ( Simple Suture Group). Sample will be collected by conveniently. A total of 88 patients will be allocated in two groups (44 patients in each group).

38. All patient will be operated after thorough history taking, clinical examination and necessary investigations (complete blood count, liver function tests, renal function tests, coagulation profile, ECG, Chest x-ray, abdominal ultrasound). All patients will receive prophylactic antibiotic (intravenous ceftriaxone 75mg/kg) before 60 minutes of surgical incision. The selected patients will undergo mastectomy for carcinoma breast by surgeons at level of Assistant Professor and above.

39. Operative procedure: Mastectomies will be performed by using a standardized technique. The skin incision will include the tumor biopsy site, any invaded or oedematous skin, plus the nipple-areola complex. Diathermy will be used to dissect the upper and lower skin flaps and find the bloodless plane between the smaller lobules of the subcutaneous fat and the larger lobules of the fat in the breast. Finally, the whole of the posterior aspect of the breast from the pectoralis major will be freed.

40. In group A (Quilting) - In the quilting stitch technique, skin flaps will be fixed to the pectoralis major muscle before subcutaneous and skin closure. Skin flaps will be sutured to the pectoral muscle using absorbable 2-0 Vicryl interrupted sutures. The cranial skin flap will be quilted from cranial to caudal in several rows. The suture will be started medially, with five to seven stitches laterally and back. The caudal flap will be quilted from caudal to cranial in several rows. The skin flaps at the edges will be closed by 2-0 vicryl , and the skin will be closed by 2-0 prolene . Then a closed suction drain will be inserted in the axillary area subcutaneously and connected to a sealed suction bottle.

41. In group B (Simple Suture)- In a simple suture technique, the skin flaps are not fixed subcutaneously but sutured at the edges by 2-0 vicryl , and the skin is closed by 2-0 prolene . A closed suction drain is inserted beneath the flaps near the medial and inferior border of the dead space at the pectoral area, and another drain is placed subcutaneously in the axillary area. Both these drains are connected to a sealed suction bottle.

42. The patient will be followed up according to SOAP guidelines. Drains will be emptied everyday and drain volume will be monitored daily. The drains will be removed at 5th post-operative day or kept further until the drain volume is less than 50 ml in 24 hours. All the patients will be planned to be discharged at the 5th POD, depending on recovery. During discharge, a phone number will be provided to contact in case complications ( seroma , hematoma, infection or flap necrosis etc.) arise. Further follow-up will be advised at 1 week and 1 month. Patients will be assessed to see the outcome variables during each follow-up visit.

43. Data Processing & Statistical analysis Data will be processed and analyzed with the help of SPSS (Statistical package for social sciences) software, version 25. Quantitative data will be analyzed by mean and standard deviation. Qualitative data will be analyzed by rate, ratio, percentage. Appropriate test will be applied. A probability value of <0.05 will be considered statistically significant.

44. Ethical Consideration 1. Ethical approval must be taken from Institutional Ethical Review Board (IERB) of Sylhet MAG Osmani Medical College. 2. The nature, purpose and clinical implication of the study as well as benefits and risks will be explained to participating patients in clearly understandable local language and informed written consent will be obtained from them before data collection and/or intervention. 3. All information will be collected confidentially with complete respect to the patient wish and without any force or pressure. Patient’s interest would not be compromised anyway to protect their rights to health.

45. 4. No standard treatment protocol will be omitted or obscured for the purpose of the study. 5. Patients will be assured of adequate treatment and if any complication arises in relation to the study procedure, it will be managed by the hospital authority. 6. Patients will have the full right to withdraw themselves from the study at any time for any reasons what-so-ever.

46. Observation and Result Observation and results will be presented by different tables, graphs, charts, diagrams etc.

47. Discussion Discussion will be made after obtaining the results of the study according to the objectives with references and cross references.

48. Conclusion Will be made on the basis of findings.

49. Recommendation Will be done on the basis of finding.

50. Operational definition Mastectomy: Removal of the entire breast tissue, including the skin over the tumour , nipple areolacomplex and axillary tail. Seroma : Seroma is the abnormal accu Hematoma: Hematoma is a collection of blood within a body tissue in response to injury of a blood vesselmulation of serous fluid in a dead space containing plasma and lymphatic fluid. Surgical site infection: Infection presenting up to 30 days after a surgical procedure if no prosthetic is placed and up to 1 year if a prosthetic is implanted in the patients. Operative time: Operative time will be calculated in minutes from surgical incision to wound closer.

51. Flow chart Population Selection criteria Study population (n=88) Group A (44) Group B (44) Quilting Simple Suture Outcome Outcome Data collection Data collection Data analysis Result

52. Time schedule Activity Oct 23 to Dec 23 Jan 24 to May 24 June 24 to June 25 July 25 Aug 25 to  Sep 25 Problem definition Literature review Research design Data collection Data analysis  Report writing & binding Submission

53. Budget Internet  2000/- Books and literature 3000/- Data analysis and compose 5000/- Pinting and binding 5000/- Investigations 80000/- Suture materials 15000/- Total 1,10000/-

54. Abbreviations

55. Bibliography Barton, A., Blitz, M., Callahan, D., Yakimets, W., Adams, D. and Dabbs, K., 2006. Early removal of postmastectomy drains is not beneficial: results from a halted randomized controlled trial. The American journal of surgery, 191(5), pp.652-656. Begum, S.A., Mahmud, T., Rahman , T., Zannat , J., Khatun , F., Nahar , K., Towhida , M., Joarder , M., Harun , A. and Sharmin , F., 2019. Knowledge, attitude and practice of Bangladeshi women towards breast cancer: a cross sectional study. Mymensingh Med J, 28(1), pp.96-104. Chand , N., Aertssen , A.M. and Royle , G.T., 2013. Axillary “exclusion”—A successful technique for reducing seroma formation after mastectomy and axillary dissection. Advances in Breast Cancer Research , 2 (01), pp.1-6. Christiansen, P., Mele, M., Bodilsen, A., Rocco, N., & Zachariae, R. (2022). Breast-Conserving Surgery or Mastectomy?: Impact on Survival. Annals of surgery open : perspectives of surgical history, education, and clinical approaches, 3(4), e205. De Rooij , L., van Kuijk , S.M., van Haaren , E.R., Janssen, A., Vissers , Y.L., Beets, G.L. and van Bastelaar , J., 2020. A single-center, randomized, non-inferiority study evaluating seroma formation after mastectomy combined with flap fixation with or without suction drainage: protocol for the S eroma reduction and dr A in f R ee m A stectomy (SARA) trial. BMC cancer, 20, pp.1-8. Foulon , A., Mancaux , A., Theret , P., Naepels , P., Mychaluk , J., Merviel , P., Abboud , P. and Fauvet , R., 2023. Efficacy and aesthetic outcomes for quilting sutures in the prevention of seroma after mastectomy. Scientific Reports, 13(1), p.1898. H Turner, E.J., Benson, J.R. and Winters, Z.E., 2014. Techniques in the prevention and management of seromas after breast surgery. Future oncology, 10(6), pp.1049-1063.

56. Cont… Huang, J., Wang, S., Wu, Y., Hai , J., Mao, J., Dong, X. and Xiao, Z., 2021. Conventional suture with prolonged timing of drainage is as good as quilting suture in preventing seroma formation at pectoral area after mastectomy. World Journal of Surgical Oncology, 19(1), p.148. Khater , A., Elnahas , W., Roshdy , S., Farouk, O., Senbel , A., Fathi , A., Hamed , E., Abdelkhalek , M. and Ghazy , H., 2015. Evaluation of the quilting technique for reduction of postmastectomy seroma : a randomized controlled study. International journal of breast cancer, 2015. Kuroi, K., Shimozuma, K., Taguchi, T., Imai, H., Yamashiro, H., Ohsumi, S. and Saito, S., 2005. Pathophysiology of seroma in breast cancer. Breast cancer, 12, pp.288-293. Luo , C., Li, N., Lu, B., Cai , J., Lu, M., Zhang, Y., Chen, H. and Dai, M., 2022. Global and regional trends in incidence and mortality of female breast cancer and associated factors at national level in 2000 to 2019. Chinese medical journal, 135(01), pp.42-51. Madhu , B.S., Kalabairav , S., Reddy, A.V. and Mallikarjunappa , S.S., 2017. A randomized controlled trial evaluating the efficacy of mastectomy flap quilting sutures in reducing post modified radical mastectomy seroma formation. International Surgery Journal, 4(2), pp.714-718. Myint , S.T., Khaing , K.S., Yee, W., Mon, S.M. and Lwin , T., 2020. Quilting suture versus conventional closure in prevention of seroma after total mastectomy and axillary dissection in breast cancer patients. ANZ journal of surgery, 90(7-8), pp.1408-1413.

57. Cont… Ouldamer , L., Bonastre , J., Brunet- Houdard , S., Body, G., Giraudeau , B. and Caille , A., 2016. Dead space closure with quilting suture versus conventional closure with drainage for the prevention of seroma after mastectomy for breast cancer (QUISERMAS): protocol for a multicentre randomised controlled trial. BMJ open, 6(4), p.e009903. Ten Wolde , B., van den Wildenberg , F.J., Keemers -Gels, M.E., Polat , F. and Strobbe , L.J., 2014. Quilting prevents seroma formation following breast cancer surgery: closing the dead space by quilting prevents seroma following axillary lymph node dissection and mastectomy. Annals of surgical oncology, 21, pp.802-807. Van Bastelaar , J., Granzier , R., Van Roozendaal , L.M., Beets, G., Dirksen, C.D. and Vissers , Y., 2018. A multi-center, double blind randomized controlled trial evaluating flap fixation after mastectomy using sutures or tissue glue versus conventional closure: protocol for the Seroma reduction After Mastectomy (SAM) trial. BMC cancer, 18, pp.1-8. Van Bemmel, A.J.M., Van De Velde, C.J.H., Schmitz, R.F. and Liefers, G.J., 2011. Prevention of seroma formation after axillary dissection in breast cancer: a systematic review. European Journal of Surgical Oncology (EJSO), 37(10), pp.829-835. Van Zeelst , L.J., Ten Wolde , B., van Eekeren , R.R., Volders , J.H., de Wilt, J.H. and Strobbe , L.J., 2022. Quilting following mastectomy reduces seroma , associated complications and health care consumption without impairing patient comfort. Journal of Surgical Oncology, 125(3), pp.369-376. Velotti , N., Limite , G., Vitiello , A., Berardi , G. and Musella , M., 2021. Flap fixation in preventing seroma formation after mastectomy: an updated meta-analysis. Updates in Surgery, 73, pp.1307-1314.

58. Vettuparambil , A. and Subramanya , C., 2021. Flap fixation as a technique for reducing seroma formation in patients undergoing modified radical mastectomy: An institutional experience. Indian journal of surgical oncology, 12(1), pp.48-53. Wu, Y., Wang, S., Hai , J., Mao, J., Dong, X. and Xiao, Z., 2020. Quilting suture is better than conventional suture with drain in preventing seroma formation at pectoral area after mastectomy. BMC surgery, 20, pp.1-7. Zeelst , L.V., Ten Wolde , B., Plate, J.D.J., Volders , J.H., van Eekeren , R.R.J.P., Doeksen , A., Hoven-Gondrie , M.L., Olieman , A.F.T., van Riet , Y.E.A., van der Velden , A.S. and Vijfhuize , S., 2023. The QUILT study: quilting sutures in patients undergoing breast cancer surgery: a stepped wedge cluster randomized trial study. BMC cancer, 23(1), p.667.

59. List of Appendices Appendix-I : Data collection sheet Appendix-II : Informed written consent Appendix- III : Visual Analogue Score Appendix-IV : Asepsis Wound Score Appendix V : ASA score Appendix-VI : SOAP Note for post operative follow-up

60. Appendix-I Data Collection Sheet Title: Quilting Stich Versus Simple Suture Closure in Prevention of Seroma After Mastectomy in Breast Cancer Patient. Case. No: Date: Particulars of the patient Name: Age: Sex: Occupation: Address: Reg. No: Ward No & Bed No: Date of admission: Contact number: Presenting symptoms:

61. Present / Past medical history: Personal History: Family History: General Examination: Anaemia : Yes/No Jaundice: Yes/No Dehydration: Yes/No Cyanosis: Yes/No Oedema : Yes/No Clubbing : Yes/No Lymph nodes: Thyroid gland: Pulse (beats/minute) (including peripheral pulses):

62. Breast Examination : On Inspection: Symmetry: Skin overlying the breast: Nipple and areola : Visible lump: Any Engorged vein: Any scar mark: On Palpation: Temperature: Tenderness: Position : Site: Size: Shape: Surface: Consistency: Fixity:

63. Regional Lymph node: Abdominal examination: Other systemic examination: Investigations: Full Blood Count Random Blood Sugar Serum Creatinine ECG Ultrasonography Whole abdomen Chest X-ray Operation note: Indication of surgery Type of surgery: Date of operation: Prophylactic Antibiotics- Yes/No At Per operative finding: Total operating time: Per operative complications:( if any) Yes/No

64. Post-operative follow up findings: 1st post-operative day Appearance: Pulse: Blood pressure: Temperature: Respiratory rate: Post-operative pain (VAS): At 1 week: Seroma Hematoma Infection Flap necrosis At 1 month: Seroma Hematoma Infection Flap necrosi

65. Appendix-II Informed Written Consent Getting full information about the purpose, procedure and utility of this study, I give consent to participate in this study. I have not been influenced by anybody or groups or my fundamental human rights have not been violated due to participation in this study. I am assured that confidentiality of all gathered information will be maintained and will be used only for study purpose and my personal information will not be disclosed to others. My participation in this study is entirely voluntary. My decision whether or not to participate will not prejudice my medical care. I have right to withdraw my consent and discontinue participation at any time without prejudice to me or effect on my medical care. I will have got no remuneration or travel expenses due to participation in this study. I am willingly giving signature to this consent form. Signature/ Left thumb impression Signature/ Left thumb impression of Of the participant the attendant   Signature/ Left thumb impression Signature of the investigator Of the witness

66. সম্মতিপত্র আমি জনাব / জনাবা ............................................. এতদ্বারা ভালভাবে অবগত হয়ে ডাঃ মোঃ হাছনাত কবির পরিচালিত “Quilting Stich Versus Simple Suture Closure in Prevention of Seroma After Mastectomy in Breast Cancer Patient” শীর্ষক গবেষনা কর্মে অংশগ্রহণের সম্মতি প্রদান করলাম । আমি সম্পূর্ণভাবে বুঝতে পারলাম যে , এই গবেষণা কর্মে অংশগ্রহণ ভবিষ্যতে আমার এবং আরও অনেকের জন্য সন্তোষজনক উপকারি ফলাফল বয়ে আনবে । আমি আশ্বস্থ যে , এই গবেষণা ফলাফলে আমি কোন ও অপ্রয়োজনীয় শারীরিক , মানসিক , সামাজিক অথবা আইনগত ঝুঁকির সম্মুখীন হবনা । আমি আরও বিশ্বাস রাখি যে , আমার ব্যাক্তিগত গোপনীয়তা সর্বতভাবে সংরক্ষিত থাকবে ।   স্বাক্ষর/বৃদ্ধাঙ্গুলির ছাপ তারিখ : স্বেচ্ছাসেবকের নাম : ঠিকানা :

67. Appendix - III Visual Analogue scale

68. Appendix - IV Asepsis Wound Score

69. Appendix - V ASA Score ASA 1: A normal healthy patient. Fit non obese (BMI under 30), a non-smoking patient with good exercise tolerance. ASA 2: A patient with a mild systemic disease, Example: Patient with no functional limitations and a well-controlled disease (e.g. Treated hypertension, obesity with BMI under 35, frequent social drinker or is a cigarette smoker). ASA3: A patient with severe systemic disease that is not life- threatening. Example: Patient with Some functional limitation as a result of disease (e.g., poorly treated hypertension or diabetes, morbid obesity, chronic renal failure, a bronchospastic disease with intermittent exacerbation, stable angina, and implanted pacemaker). ASA 4 : A patient with severe systemic disease that is a constant threat to life. Patient with functional limitation from severe, life-threatening disease (e.g., unstable angina, poorly treated COPD, symptomatic CHF, recent (less than three months ago) myocardial infarction or stroke. ASA 5: A moribund patient who is not expected to survive without the operation. The patient is not expected to survive beyond the next 24 hours without surgery. Examples: ruptured abdominal aortic aneurysm, massive trauma, and extensive intracranial hemorrhage with mass effect. ASA 6: A brain-dead patient whose organs are being removed with the intension of transplanting them into another patient. The addition of “E” to the ASAPS (e.g., ASA2E) denotes an emergency surgical procedure. The ASA defines an emergency surgical procedure. The ASA defines an emergency as existing “when the delay in treatment of the patient would lead to a significant increase in the threat of life or body part.”

70. Appendix VI SOAP Note for post operative follow-up

71. Thank You