Combined (endo-)vascular intervention and microsurgical lower extremity free flap reconstruction-A propensity score matching analysis in 5386 ACS-NSQIP patients

Pedicled Flaps for High-Risk Open Vascular Procedures of the Lower Extremity: An Analysis of The National Surgical Quality Improvement Project Database

BACKGROUND

 Use of pedicled flaps in vascular procedures is associated with decreased infection and wound breakdown. We evaluated the risk profile and postoperative complications associated with lower extremity open vascular procedures with and without pedicled flaps.

METHODS

 The American College of Surgeons National Surgical Quality Improvement Program database (2010-2020) was queried for Current Procedural Terminology codes representing lower extremity open vascular procedures, including trunk and lower extremity pedicled flaps. Flap patients were compared with a randomized control group without flaps (1:3 cases to controls). Univariate and multivariate analyses were performed.

RESULTS

 We identified 132,934 adults who underwent lower extremity open vascular procedures. Concurrent pedicled flaps were rare (0.7%), and patients undergoing bypass procedures were more likely to receive a flap than nonbypass patients (69 vs. 64%, p < 0.0001). Flap patients had greater comorbidities. On univariate analysis, flap patients were more likely to experience wound (p = 0.0026), mild systemic (p < 0.0001), severe systemic (p = 0.0452), and all-cause complications (p < 0.0001). After adjusting for factors clinically suspected to be associated with increased risk (gender, body mass index, procedure type, American Society of Anesthesiologists classification, functional status, diabetes, smoking, and albumin < 3.5 mg/dL), wound (p = 0.096) and severe systemic complications (p = 0.0719) were no longer significantly associated with flap patients.

CONCLUSION

 Lower extremity vascular procedures are associated with a high risk of complications. Use of pedicled flaps remains uncommon and more often performed in patients with greater comorbid disease. However, after risk adjustment, use of a pedicled flap in high-risk patients may be associated with lower than expected wound and severe systemic complications.

[Revascularization Prior to Defect Reconstruction of the Lower Limb - Essential Cooperation between Plastic and Vascular Surgery]

Treatment of complex ischemic lower leg defects with exposure of deep anatomic structures represents a considerable challenge to involved specialties. In selected patients, limb salvage can be achieved as an alternative to major amputation by means of a combined approach including arterial reconstruction and subsequent free flap transfer. Arterial reconstruction can be performed either by endovascular or open surgical treatment (bypass reconstruction or implantation of an arteriovenous loop) preliminary to defect reconstruction using microsurgical free flap transplantation. Whereas the aim of the arterial reconstruction comprises the establishment of sufficient perfusion and creation of adequate target vessels for the free flap transfer, the selection of the appropriate flap entity depends on the extent of the wound as wells as on the presence of osteomyelitis. Arterial reconstruction and defect reconstruction can be performed as one-stage or two-stage procedure and has become an established and feasible treatment approach in centers. Evaluation of microperfusion by means of indocyanine green can further increase safety and feasibility of this method. Against this background, combined arterial reconstruction and subsequent free flap transfer provides excellent results in terms of amputation free survival and postoperative mobility. Essential is however an individualized decision making in consideration of patient selection and possible contraindications. This approach may be evaluated in mobile patients with complex wounds prior to major amputation.

Combined Revascularization and Free Flap Reconstruction for Chronic Limb-Threatening Ischemia: A Systematic Review and Meta-Analysis

BACKGROUND

 Combined revascularization and free flap reconstruction is one treatment method for chronic limb-threatening ischemia (CLTI) with complex wounds. The purpose of this systematic review and meta-analysis was to investigate the characteristics of this combined procedure and to assess postoperative outcomes.

METHODS

 A systematic search was performed across PubMed, Scopus, and the Web of Science for studies between January 2000 and February 2022. A random-effects meta-analysis for postoperative outcome was conducted.

RESULTS

 Fifteen articles encompassing 1,176 patients with 1,194 free flaps were ultimately included in the qualitative and quantitative assessment. Our meta-analysis showed the following complication rates for short-term postoperative outcomes: 37% (95% confidence interval [CI], 18-53%; I 2 = 74%) for reoperation, 13% (95% CI, 2-24%; I 2 = 0%) for vascular thrombosis, 9% (95% CI, 0-17%; I 2 = 0%) for total flap failure, 8% (95% CI, 0-17%; I 2 = 0%) for partial flap failure, 4% (95% CI, 0-10%; I 2 = 0%) for amputation, and 3% (95% CI, 0-9%; I 2 = 0%) for 30-day mortality. The 1-, 3-, and 5-year limb salvage rates were 86% (95% CI, 78-92%), 81% (95% CI, 68-88%), and 71% (95% CI, 53-83%), respectively. The 1-, 3-, and 5-year patient survival rates were 93% (95% CI, 90-96%), 92% (95% CI, 77-97%), and 75% (95% CI, 50-88%), respectively.

CONCLUSION

 Combined revascularization and free flap reconstruction for CLTI with complex wounds was clearly effective for the long-term outcomes. However, this combined procedure should be considered on the assumption that the reoperation rate is high and that flap-related complications rate may be higher than lower extremity reconstruction of other etiologies.

Incidence and Risk Factors of Postoperative Complications After Rhinoplasty: A Multi-Institutional ACS-NSQIP Analysis

OBJECTIVE

Despite the popularity of rhinoplasty, outcome research has been mainly limited to single-surgeon or single-institution reports. Therefore, we performed a multi-institutional analysis to present a broader portrait of the postoperative outcomes and risk factors for adverse events after rhinoplasty surgery.

METHODS

We reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2009-2019) to identify patients who underwent rhinoplasty. The postoperative outcomes of interest included 30-day mortality, reoperation, readmission, and surgical and medical complications. We also analyzed risk factors for complication occurrence, including patient comorbidities and preoperative laboratory values.

RESULTS

We identified 835 patients, 72% (n=602) of whom underwent a primary, 21% (n=175) a secondary, and 6.7% (n=58) a cleft nasal deformity procedure. The average patient age was 41±17 years, with most patients being female (n=472; 57%) and white (n=643; 77%). Complications rates were generally low, with reoperation (n=19; 2.3%) and superficial incisional infection (n=9; 1.1%) account for the most common general and surgical adverse event, respectively. Multivariable analysis revealed male sex ( P =0.04) and higher ASA scores ( P <0.0001) as risk factors for complications. Low serum albumin ( P =0.04) and hematocrit ( P =0.003) levels were associated with the occurrence of any complication, whereas low serum albumin ( P =0.02) also correlated with the incidence of surgical adverse events.

CONCLUSION

Complication rates after rhinoplasty were overall low and seemed to correlate with male sex and ASA scores. We identified preoperative albumin and hematocrit as predictive biomarkers of adverse events. Preoperative nutritional optimization and management of low hematocrit may improve postoperative outcomes.

Characteristics and Outcomes of Patients Undergoing Surgical Management of Hidradenitis Suppurativa: An ACS-NSQIP Data Analysis

Objective: Hidradenitis suppurativa (HS) is a painful inflammatory skin disease. Management is largely medical, with surgery reserved for severe refractory cases. In this study, we sought to conduct a retrospective analysis of a multi-institutional surgical database to investigate the surgical management of patients with HS and identify trends in the postoperative outcomes. Approach: The 2011-2019 American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was reviewed to identify patients who underwent surgery for management of HS. Postoperative outcomes were assessed, including surgical and medical complications, length of hospital stay, reoperation, readmission, and nonhome discharge. This article was reported according to the STROBE criteria. Results: We identified 1,030 patients, of which 62% were female and 50% were black. The most common comorbidity was obesity (61%). Surgery was mainly performed by general surgeons (62%) and plastic surgeons (31%). Complications were overall low, with readmission being the most common (7.1%, unplanned 6.0%), followed by reoperation (5.8%). The most common surgical complication was superficial incisional infection (5.1%) and most common medical complication was sepsis (3.8%). Obesity is seen to affect surgical complication rates, with patients with obesity having higher rates of dehiscence (obese: 3.1% and nonobese: 1.0%; p = 0.03) but lower rates of organ space infection (obese: 0.5% and nonobese: 2.0%; p = 0.03) and transfusion (obese: 2.5% and nonobese: 5.2%; p = 0.04). A focus on complications in patients undergoing flap reconstruction (n = 293; 23%), identified higher rates of surgical complications, with superficial incisional infection being the most common (flap reconstruction: 7.5% and incision and drainage, debridement, skin graft: 4.1%; p = 0.04). Innovation: The surgical management of HS is analyzed at the national level, with postoperative complications seen to depend on race and obesity-status. Conclusions: Surgical management for HS is associated with low postoperative complications, making surgery a viable treatment option for this debilitating disease.

Perioperative Outcomes and Risk Profile of 4730 Cosmetic Breast Surgery Cases in Academic Institutions: An ACS-NSQIP Analysis

BACKGROUND

Cosmetic breast surgery (CBS) can be subdivided into augmentation, mastopexy, reduction, and reconstruction.

OBJECTIVES

The aim of this study was to retrospectively analyze a multi-institutional national database to investigate the outcomes of CBS and identify clinical patterns to optimize care.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database (2008-2020) was reviewed to identify female patients who underwent CBS. Postoperative outcomes (30-day surgical and medical complications, reoperation, readmission, and mortality) and risk factors for complications were assessed.

RESULTS

In total, 4733 patients were identified (mean age, 40 [13] years; mean BMI, 24 [4.5] kg/m2) with augmentation accounting for 54% of cases. There were complications in 2.0% of cases. Age >65 years (P = .002), obesity (P < .0001), setting (P < .0001), and diabetes (P = .04) were risk factors for any complication. Age >65 years (P = .02), obesity (P = .03), diabetes (P = .01), history of chronic obstructive pulmonary disease (COPD) (P = .002) and congestive heart failure (P < .0001), smoking in the past year (P = .003), setting (P = .007), and increased American Society of Anesthesiology score (P < .0001) were predictors of surgical complications such as dehiscence and infection. Multivariable analysis confirmed that chronic obstructive pulmonary disease, obesity Class 1 and 3, and inpatient status were independent risk factors for occurrence of any complication (P = .0005, .0003, < .0001 and <.0001, respectively). Additionally, multiple procedures (P = .02) and smoking (P = .005) were found to be risk factors for surgical complications.

CONCLUSIONS

This study confirms the positive safety profile of CBS. Healthy BMI is a protective factor, while complications were more likely among inpatient procedures. A correlation between multiple procedures and increased surgical complications was identified. Awareness of these risk factors can assist surgeons to further refine their perioperative protocols.

Early Outcomes and Risk Factors in Orthognathic Surgery for Mandibular and Maxillary Hypo- and Hyperplasia: A 13-Year Analysis of a Multi-Institutional Database

BACKGROUND

Orthognathic surgery (OS) is a frequently performed procedure for the correction of dentofacial deformities and malocclusion. Research on OS is mostly limited to single-surgeon experience or single-institutional reports. We, therefore, retrospectively analyzed a multi-institutional database to investigate outcomes of OS and identify risk factors for peri- and postoperative complications.

METHODS

We reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2008-2020) to identify patients who underwent OS for mandibular and maxillary hypo- and hyperplasia. The postoperative outcomes of interest included 30-day surgical and medical complications, reoperation, readmission, and mortality. We also evaluated risk factors for complications.

RESULTS

The study population included 674 patients, 48% of whom underwent single jaw surgery, 40% double jaw surgery, and 5.5% triple jaw surgery. The average age was 29 ± 11 years, with an equal gender distribution (females: n = 336; 50%, males: n = 338; 50%). Adverse events were relatively rare, with a total of 29 (4.3%) complications reported. The most common surgical complication was superficial incisional infection (n = 14; 2.1%). While the multivariable analysis revealed isolated single lower jaw surgery (p = 0.03) to be independently associated with surgical complication occurrence, it also identified an association between the outpatient setting and the frequency of surgical complications (p = 0.03) and readmissions (p = 0.02). In addition, Asian ethnicity was identified as a risk factor for bleeding (p = 0.003) and readmission (p = 0.0009).

CONCLUSION

Based on the information recorded by the ACS-NSQIP database, our analysis underscored the positive (short-term) safety profile of OS. We found OS of the mandible to be associated with higher complication rates. The calculated risk role of OS in the outpatient setting warrants further investigation. A significant correlation between Asian OS patients and postoperative adverse events was found. Implementation of these novel risk factors into the surgical workflow may help facial surgeons refine their patient selection and improve patient outcomes. Future studies are needed to investigate the causal relationships of the observed statistical correlations.

The modified 5-item frailty index is a predictor of perioperative risk in breast reconstruction: An analysis of 40,415 cases

BACKGROUND

The aging population has presented surgeons with new challenges as they increasingly must operate on greater numbers of frail patients. The modified frailty index 5 (mFI-5) is a concise comorbidity-based scale that has been shown to accurately predict adverse surgical outcomes. In this study, we sought to evaluate the ability of the mFI-5 to predict the risk of postoperative outcomes in breast reconstruction patients.

METHODS

Utilizing the 2015-2019 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, we identified 40,415 patients who underwent breast reconstruction, of which 29,562 were implant-based reconstructions and 10,853 were autologous breast reconstructions. Demographic and preoperative variables as well as 30-day postoperative outcomes, including mortality, operation duration, length of hospital stay, medical and surgical complications, and discharge destination, were extracted.

RESULTS

Increases in the mFI score correlated with higher rates of reoperation (mFI≥3: 13.5% vs. mFI=0: 5.9%), unplanned readmission (mFI≥3: 10.8% vs. mFI=0: 3.6%), surgical (mFI≥3: 12.2% vs. mFI=0: 4.3%) and medical complications (mFI≥3: 6.8% vs. mFI=0: 1.2%), and lower rates of home discharge (mFI≥3: 96% vs. mFI=0: 99.5%). Multivariate analysis to control for confounders verified significantly higher rates of reoperation (OR=0.01, 95%CI 0.005-0.016), unplanned readmission (OR=0.009, 95%CI 0.005-0.014), and occurrence of surgical complications (OR=0.014, 95%CI 0.009-0.019) and medical complications (OR=0.005, 95%CI 0.002-0.008). Stratification by age showed that the mFI-5 was a stronger risk predictor in younger patients who are frail. Stratification by type of reconstruction showed that increased mFI scores significantly correlated with complications in both autologous and implant-based reconstruction, but the correlation was greater in autologous procedures.

CONCLUSION

The mFI-5 is identified as a powerful risk predictor in breast reconstruction. The application of this easily accessible tool in the preoperative risk stratification of patients undergoing breast reconstruction can enhance treatment planning and support, optimizing patient counseling, informed consent, and decision-making.

The modified 5-item frailty index is a predictor of perioperative risk in head and neck microvascular reconstruction: An analysis of 3795 cases

BACKGROUND

The modified frailty index 5 (mFI-5)-a scale based on the five variables diabetes, hypertension, chronic obstructive pulmonary disease, congestive heart failure, and functional dependency-has been shown to be a valid predictor of surgical outcomes. In this study we sought to evaluate the ability of the mFI-5 to predict the postoperative outcomes of head and neck microvascular reconstruction.

METHODS

Review of the 2015-2019 American College of Surgeons, National Surgical Quality Improvement Program (ACS NSQIP) database identified 5323 cases of microvascular reconstruction, of which 3795 were head and neck cases that provided parameters necessary to calculate the mFI-5. The groups were compared in terms of demographics and comorbidities. Post-operative outcomes assessed included mortality, average operative time and length of hospital stay, surgical and medical complications, and non-home discharge.

RESULTS

Increases in the mFI were associated with longer hospitalization periods (10.5 ± 7.5 days in mFI 0 vs 14.9 ± 15.4 in mFI ≥ 3; p < 0.0001) higher rates of mortality (1% in mFI 0 vs 3.1% in mFI ≥ 3; p = 0.02), reoperation (15.4% in mFI 0 vs 17.2% in mFI ≥ 3; p = 0.002) and unplanned readmission (7.6% in mFI 0 vs 18.8% in mFI ≥ 3; p = 0.001). Rates of any complications (p < 0.0001), as well as surgical (p < 0.002) and medical (p < 0.0001) complications specifically were higher with greater mFI scores. Higher mFI scores also predicted decreased home discharge (p < 0.0001). Differences remained significant on multivariate analysis and subgroup analysis by age.

CONCLUSION

The mFI-5 is a significant predictor of risk in microvascular head and neck reconstruction. Subgroup analysis by age highlights that the tool can help identify younger patients who are frail and hence at risk. Through appropriate pre-operative identification of frail patients surgeons can prospectively modify their operative and discharge planning as well as post-operative support.