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Bitoiu B, Schlagintweit S, Zhang Z, Bovill E, Isaac K, Macadam S. Conversion from Alloplastic to Autologous Breast Reconstruction: What Are the Inciting Factors? Plast Surg (Oakv) 2024; 32:213-219. [PMID: 38681249 PMCID: PMC11046274 DOI: 10.1177/22925503221107214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2024] Open
Abstract
Introduction: Failure of alloplastic breast reconstruction is an uncommon occurrence that may result in abandonment of reconstructive efforts or salvage with conversion to autologous reconstruction. The purpose of this study was to identify factors that predict failure of alloplastic breast reconstruction and conversion to autologous reconstruction. Methods: A retrospective chart review was conducted of patients who underwent mastectomy and immediate alloplastic breast reconstruction between 2008 and 2019. Inclusion criteria included patients 18 years or older who underwent initial alloplastic reconstruction with a minimum of 3-year follow-up. Data collected included age, body mass index, cancer type, surgical characteristics, neo/adjuvant treatment details, and complications. Results were analyzed using Fischer's exact test, t-test, and multivariate logistic regression. Results: A total of 234 patients met inclusion criteria. Of those, 23 (9.8%) required conversion from alloplastic to autologous reconstruction. Converted patients had a mean age of 50.1 ± 8.5. The time from initial alloplastic reconstruction to conversion was 30.7 months. The most common reasons for conversion included soft tissue deficiency (48%), infection (30%), and capsular contracture (22%). Patients were converted to deep inferior epigastric perforator flap (DIEP; 52%), latissimus dorsi flap with implant (26%), and DIEP with implant (22%). Multivariate logistic regression modeling identified radiation (OR 8.4 [CI = 1.7-40.1]) and periprosthetic infection (OR 14.6 [CI = 3.4-63.8]) as predictors for conversion. Conclusions: Among patients undergoing mastectomy with immediate alloplastic breast reconstruction, those treated with radiation have 8.4 greater odds of conversion and those with a periprosthetic infection have 14.6 greater odds for conversion to an autologous reconstruction.
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Affiliation(s)
| | | | - Zach Zhang
- University of British Columbia, Vancouver, BC, Canada
| | - Esta Bovill
- University of British Columbia, Vancouver, BC, Canada
| | - Kathryn Isaac
- University of British Columbia, Vancouver, BC, Canada
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2
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Use of Antibiotic-impregnated Polymethylmethacrylate (PMMA) Plates for Prevention of Periprosthetic Infection in Breast Reconstruction. Plast Reconstr Surg Glob Open 2023; 11:e4764. [PMID: 36776590 PMCID: PMC9911200 DOI: 10.1097/gox.0000000000004764] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 11/18/2022] [Indexed: 01/19/2023]
Abstract
Periprosthetic infections remain a major challenge for breast reconstruction. Local antibiotic delivery systems, such as antibiotic beads and spacers, have been widely used within other surgical fields, but their use within plastic surgery remains scarce. In this study, we demonstrate the use of antibiotic-impregnated polymethylmethacrylate (PMMA) plates for infection prophylaxis in tissue expander (TE)-based breast reconstruction. Methods A retrospective review of patients who underwent immediate breast reconstruction with prepectoral TEs over the span of 5 years performed by two surgeons was completed, revealing a total of 447 patients. Data pertaining to patient demographics, operative details, and postoperative outcomes were recorded. Fifty patients underwent TE reconstruction with the addition of a PMMA plate (Stryker, Kalamazoo, Michigan) impregnated with tobramycin and vancomycin. Antibiotic plates were removed at the time of TE-to-implant exchange. Patient-matching analysis was performed using the 397 patients without PMMA plates to generate a 50-patient nonintervention cohort for statistical analysis. Results The intervention cohort (n = 50) and 1:1 patient-matched nonintervention cohort (n = 50) demonstrated no statistically significant differences in patient demographics or operative characteristics other than PMMA plate placement. The rate of operative periprosthetic infection was 4% in the intervention group and 14% in the nonintervention group (P = 0.047). The rate of TE explantation was also reduced in the intervention group (6% versus 18%; P = 0.036). Follow-up averaged 9.1 and 8.9 months for the intervention and nonintervention groups, respectively (P = 0.255). Conclusion Local antibiotic delivery using antibiotic-impregnated PMMA plates can be safely and effectively used for infection prevention with TE-based breast reconstruction.
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Cui W, Xie Y. Oncological results in women with wound complications following mastectomy and immediate breast reconstruction: A meta‐analysis. Int Wound J 2022; 20:1361-1368. [PMID: 36336978 PMCID: PMC10088858 DOI: 10.1111/iwj.13982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 10/05/2022] [Accepted: 10/07/2022] [Indexed: 11/09/2022] Open
Abstract
We performed a meta-analysis to evaluate the oncological results in women with wound complications following mastectomy and immediate breast reconstruction. A systematic literature search up to August 2022 was performed and 1618 subjects with mastectomy and immediate breast reconstruction at the baseline of the studies; 443 of them were with wound complications, and 1175 were with no wound complications as a control. Odds ratio (OR) and mean difference (MD) with 95% confidence intervals (CIs) were calculated to assess the oncological results in women with wound complications following mastectomy and immediate breast reconstruction using dichotomous or contentious methods with a random or fixed-effect model. The wound complications had a significantly longer length of time to adjuvant therapy (MD, 9.44; 95% CI, 4.07-14.82, P < .001) compared with no wound complications in subjects with mastectomy and immediate breast reconstruction. However, no significant difference was found between wound complications and no wound complications in subjects with mastectomy and immediate breast reconstruction in breast cancer recurrence (OR, 1.96; 95% CI, 0.95-4.06, P = .07), death rates (OR, 1.95; 95% CI, 0.89-4.27, P = .09), and kind of immediate breast reconstruction (OR, 1.01; 95% CI, 0.53-1.92, P = .98). The wound complications had a significantly longer length of time to adjuvant, however, no significant difference was found in breast cancer recurrence, death rates, and kind of immediate breast reconstruction. The analysis of outcomes should be done with caution even though no low sample size was found in the meta-analysis but a low number of studies was found in certain comparisons.
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Affiliation(s)
- Wenting Cui
- Department of Breast Surgery, Huangpu Branch, Ninth People's Hospital Shanghai Jiaotong University School of Medicine Shanghai People's Republic of China
| | - Yiqun Xie
- Department of Breast Surgery, Huangpu Branch, Ninth People's Hospital Shanghai Jiaotong University School of Medicine Shanghai People's Republic of China
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4
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Exploring breast surgeons’ reasons for women not undergoing immediate breast reconstruction. Breast 2022; 63:37-45. [PMID: 35299033 PMCID: PMC8927853 DOI: 10.1016/j.breast.2022.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 02/12/2022] [Accepted: 02/20/2022] [Indexed: 11/22/2022] Open
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5
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Sarver MM, Rames JD, Ren Y, Greenup RA, Shammas RL, Hwang ES, Hollenbeck ST, Hyslop T, Butler PD, Fayanju OM. Racial and Ethnic Disparities in Surgical Outcomes after Postmastectomy Breast Reconstruction. J Am Coll Surg 2022; 234:760-771. [PMID: 35426388 PMCID: PMC9347225 DOI: 10.1097/xcs.0000000000000143] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Women of color with breast cancer are less likely to undergo post-mastectomy reconstruction compared with White women, but it is unclear whether their perioperative outcomes are worse. The goal of this study was to investigate differences in preoperative comorbidities and postoperative complications by race/ethnicity among women with breast cancer undergoing postmastectomy reconstruction. STUDY DESIGN Data were collected from the National Inpatient Sample database of the Healthcare Cost and Utilization Project from 2012 to 2016. Patient demographics, types of reconstruction, comorbid conditions, Charlson-Deyo Combined Comorbidity (CDCC) scores, length of stay (LOS), and perioperative complications were abstracted. Multivariate linear and logistic regression were performed to model LOS and likelihood of postoperative complications, respectively. RESULTS Compared with White women (n = 19,730), Black women (n = 3,201) underwent autologous reconstruction more frequently (40.7% vs 28.3%), had more perioperative comorbidities (eg diabetes: 12.9% vs 5.8%), higher CDCC scores (% CDCC ≥ 4: 5.5% vs 2.7%), and longer LOS (median 3 vs 2 days, all p < 0.001). Being Black (vs White: +0.13 adjusted days, 95% CI 0.06 to 0.19) was also associated with longer LOS and an increased likelihood of surgical complications (vs White: odds ratio 1.24, 95% CI 1.09 to 1.42, both p < 0.01), but this association did not persist when outcomes were limited to microsurgical complications. CONCLUSION Disparities in postmastectomy breast reconstruction between Black and White women extend beyond access to care and include perioperative factors and outcomes. These findings suggest an important opportunity to mitigate inequities in reconstruction through perioperative health optimization and improved access to and co-management with primary care.
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Affiliation(s)
- Melissa M Sarver
- From the Duke University School of Medicine, Durham, NC (Sarver, Rames)
- Divisions of Surgical Oncology (Sarver, Greenup, Hwang, Fayanju), Duke University School of Medicine, NC
| | - Jess D Rames
- From the Duke University School of Medicine, Durham, NC (Sarver, Rames)
- Plastic and Reconstructive Surgery (Rames, Shammas, Hollenbeck), Duke University School of Medicine, NC
| | - Yi Ren
- Duke Cancer Institute, Durham, NC (Ren, Greenup, Hwang, Hyslop, Fayanju)
| | - Rachel A Greenup
- Duke Cancer Institute, Durham, NC (Ren, Greenup, Hwang, Hyslop, Fayanju)
- Divisions of Surgical Oncology (Sarver, Greenup, Hwang, Fayanju), Duke University School of Medicine, NC
- Department of Surgery, and Departments of Population Health Sciences (Greenup, Fayanju), Duke University School of Medicine, NC
| | - Ronnie L Shammas
- Plastic and Reconstructive Surgery (Rames, Shammas, Hollenbeck), Duke University School of Medicine, NC
| | - E Shelley Hwang
- Duke Cancer Institute, Durham, NC (Ren, Greenup, Hwang, Hyslop, Fayanju)
- Divisions of Surgical Oncology (Sarver, Greenup, Hwang, Fayanju), Duke University School of Medicine, NC
| | - Scott T Hollenbeck
- Plastic and Reconstructive Surgery (Rames, Shammas, Hollenbeck), Duke University School of Medicine, NC
| | - Terry Hyslop
- Duke Cancer Institute, Durham, NC (Ren, Greenup, Hwang, Hyslop, Fayanju)
- Biostatistics and Bioinformatics (Hyslop), Duke University School of Medicine, NC
| | - Paris D Butler
- Division of Plastic Surgery, Department of Surgery, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, PA (Butler)
| | - Oluwadamilola M Fayanju
- Duke Cancer Institute, Durham, NC (Ren, Greenup, Hwang, Hyslop, Fayanju)
- Divisions of Surgical Oncology (Sarver, Greenup, Hwang, Fayanju), Duke University School of Medicine, NC
- Department of Surgery, and Departments of Population Health Sciences (Greenup, Fayanju), Duke University School of Medicine, NC
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6
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Lisa A, Belgiovine C, Maione L, Rimondo A, Battistini A, Agnelli B, Murolo M, Galtelli L, Monari M, Klinger M, Vinci V. Study of Inflammatory and Infection Markers in Periprosthetic Fluid: Correlation with Blood Analysis in Retrospective and Prospective Studies. BIOMED RESEARCH INTERNATIONAL 2021; 2021:6650846. [PMID: 33791369 PMCID: PMC7997767 DOI: 10.1155/2021/6650846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 02/25/2021] [Accepted: 03/08/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Surgical site infection represents the most severe complication in prosthetic breast reconstruction. Risk profiling represents a useful tool for both clinicians and patients. MATERIALS AND METHODS In our hospital, 534 breast reconstructions with tissue expander implants, in 500 patients, were performed. Several clinical variables were collected. In our study, we evaluated the different inflammatory markers present in the periprosthetic fluid and we compared them with the ones present in plasma. RESULTS The surgical site infection rate resulted to be 10.5%, and reconstruction failed in 4.5% of the cases. The hazard ratio for complications was 2.3 in women over 60 (CI: 1.3-4.07; p = 0.004), 2.57 in patients with expander volume ≥ 500 cc (CI: 1.51-4.38; p < 0.001), 2.14 in patients submitted to previous radiotherapy (CI: 1.05-4.36; p < 0.037), and 1.05 in prolonged drain use (CI: 1.03-1.07; p < 0.001). 25-OH, PCT, and total protein were less concentrated, and ferritin and LDH were more concentrated in the periprosthetic fluid than in plasma (p < 0.001). CRP (p = 0.190) and β-2 microglobulin (p = 0.344) did not change in the two fluids analyzed. PCT initial value is higher in patients who underwent radiotherapy, and it could be related to the higher rate of their postoperative complications. Patients with a tissue expander with a volume ≥ 500 cc show an increasing trend for CRP in time (p = 0.009). CONCLUSIONS Several risk factors (prolonged time of drains, age older than 60 years, and radiotherapy) have been confirmed by our study. The study of markers in the periprosthetic fluid with respect to their study in plasma could point toward earlier infection detection and support early management.
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Affiliation(s)
- Andrea Lisa
- Humanitas Clinical and Research Center-IRCCS, Via Manzoni 56, 20089 Rozzano Milan, Italy
| | - Cristina Belgiovine
- Humanitas Clinical and Research Center-IRCCS, Via Manzoni 56, 20089 Rozzano Milan, Italy
- Scuola di Specializzazione in Microbiologia e Virologia, Università degli Studi di Pavia, 27100 Pavia, Italy
| | - Luca Maione
- Humanitas Clinical and Research Center-IRCCS, Via Manzoni 56, 20089 Rozzano Milan, Italy
- University of Milan, Reconstructive and Aesthetic Plastic Surgery School-Clinica San Carlo-Plastic Surgery Unit-Paderno Dugnano (Milan), Italy
| | - Andrea Rimondo
- Humanitas Clinical and Research Center-IRCCS, Via Manzoni 56, 20089 Rozzano Milan, Italy
| | - Andrea Battistini
- Humanitas Clinical and Research Center-IRCCS, Via Manzoni 56, 20089 Rozzano Milan, Italy
| | - Benedetta Agnelli
- Humanitas University Department of Biomedical Sciences, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele, Milan, Italy
| | - Matteo Murolo
- Humanitas Clinical and Research Center-IRCCS, Via Manzoni 56, 20089 Rozzano Milan, Italy
| | - Leonardo Galtelli
- Humanitas Clinical and Research Center-IRCCS, Via Manzoni 56, 20089 Rozzano Milan, Italy
| | - Marta Monari
- Clinical Investigation Laboratory, Humanitas Clinical and Research Center, Via Alessandro Manzoni 56 20089 Rozzano Milano, Italy
| | - Marco Klinger
- Plastic Surgery Unit, Department of Medical Biotechnology and Translational Medicine BIOMETRA, Humanitas Clinical and Research Hospital, Reconstructive and Aesthetic Plastic Surgery School, University of Milan, Via Manzoni 56, Rozzano, Milan 20090, Italy
| | - Valeriano Vinci
- Humanitas Clinical and Research Center-IRCCS, Via Manzoni 56, 20089 Rozzano Milan, Italy
- Humanitas University Department of Biomedical Sciences, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele, Milan, Italy
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Balasubramanian I, Harding T, Boland MR, Ryan EJ, Geraghty J, Evoy D, McCartan D, McDermott EW, Prichard RS. The Impact of Postoperative Wound Complications on Oncological Outcomes Following Immediate Breast Reconstruction for Breast Cancer: A Meta-analysis. Clin Breast Cancer 2020; 21:e377-e387. [PMID: 33451964 DOI: 10.1016/j.clbc.2020.12.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 12/08/2020] [Accepted: 12/13/2020] [Indexed: 12/21/2022]
Abstract
The association between immediate breast reconstruction (IBR)-related wound complications and breast cancer recurrence (BCR) remains uncertain. This study aimed to investigate the oncological outcomes in patients with wound complications following mastectomy and IBR. A comprehensive search was undertaken for all studies describing complications in patients with breast cancer following IBR. Studies were included if they reported on complications and investigated their relationship with BCR. A meta-analysis was performed using a random-effects model, with data presented as odds ratios and 95% confidence intervals. A total of 1418 patients from five studies were included in the final analysis. The mean age of patients included was 47.2 years. A total of 382 (26.9%) patients had postoperative complications following a majority of implant-based IBR (929/1418). A total of 158 (11.1%) recurrences, which included 63 locoregional and 106 distant recurrences, was noted at a mean follow-up of 66 months. Although there was an increase in recurrence rates in the complication group (n = 66/382; 17.3% vs. n = 92/1036; 8.9%), there was no significant association between complications and BCR (17.3% vs. 8.9%; P = .18) or mortality (3.6% vs. 2.3%; P = .15). Time to adjuvant therapy was significantly increased in patients with complications (mean difference, 8.69 days; range, 1.18-16.21 days; P = .02; I2 = 0.02). This meta-analysis demonstrated a higher incidence of wound complications following IBR and a statistically significant increased time to adjuvant therapy. However, this did not translate into adverse oncological outcomes in patients with breast cancer undergoing IBR.
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Affiliation(s)
| | - Tim Harding
- Department of Surgery, St Vincents University Hospital, Dublin, Ireland
| | - Michael R Boland
- Department of Surgery, St Vincents University Hospital, Dublin, Ireland
| | - Eanna J Ryan
- Department of Surgery, St Vincents University Hospital, Dublin, Ireland
| | - James Geraghty
- Department of Surgery, St Vincents University Hospital, Dublin, Ireland
| | - Denis Evoy
- Department of Surgery, St Vincents University Hospital, Dublin, Ireland
| | - Damian McCartan
- Department of Surgery, St Vincents University Hospital, Dublin, Ireland
| | - Enda W McDermott
- Department of Surgery, St Vincents University Hospital, Dublin, Ireland
| | - Ruth S Prichard
- Department of Surgery, St Vincents University Hospital, Dublin, Ireland
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8
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Death by Implants: Critical Analysis of the FDA-MAUDE Database on Breast Implant-related Mortality. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2554. [PMID: 32537301 PMCID: PMC7288886 DOI: 10.1097/gox.0000000000002554] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 10/09/2019] [Indexed: 01/30/2023]
Abstract
Since the 1992 moratorium by the Food and Drug Administration (FDA), the debate on the association of breast implants with systemic illnesses has been ongoing. Breast implant-associated anaplastic large cell lymphoma has also raised significant safety concerns in recent years. Methods A systematic search of the Manufacturer and User Facility Device Experience (MAUDE) database was performed to identify all cases of breast implant-associated deaths reported to the FDA. Results The search identified 50 reported cases of apparent implant-related mortality; breast implant-associated anaplastic large cell lymphoma comprised the majority of fatal outcomes (n = 21, 42%), followed by lymphoma (n = 4, 8%), breast cancer (n = 3, 6%), pancreatic cancer (n = 2, 4%), implant rupture (n = 2, 4%), and postoperative infections (n = 2, 4%). Single cases (n = 1, 2% each) of leukemia, small bowel cancer, lung disease, pneumonia, autoimmune and joint disease, amyotrophic lateral sclerosis, liver failure, and sudden death, and 2 cases (4%) of newborn deaths, to mothers with breast implants, were also identified. A literature review demonstrated that 54% of alleged implant-related deaths were not truly associated with breast implant use: the majority of these reports (82%) originated from the public and third-party sources, rather than evidence-based reports by health-care professionals and journal articles. Conclusions Although there exists a need for more comprehensive reporting in federal databases, the information available should be considered for a more complete understanding of implant-associated adverse outcomes. With only 46% of FDA-reported implant-related deaths demonstrated to be truly associated with breast implant use, there exists a need for public awareness and education on breast implant safety.
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9
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Making an informed choice: Which breast reconstruction type has the lowest complication rate? Am J Surg 2019; 218:1040-1045. [DOI: 10.1016/j.amjsurg.2019.09.033] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Revised: 09/12/2019] [Accepted: 09/25/2019] [Indexed: 11/22/2022]
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10
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Xu F, Sun H, Zhang C, Jiang H, Guan S, Wang X, Wen B, Li J, Li X, Geng C, Yin J. Comparison of surgical complication between immediate implant and autologous breast reconstruction after mastectomy: A multicenter study of 426 cases. J Surg Oncol 2018; 118:953-958. [PMID: 30261115 DOI: 10.1002/jso.25238] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 08/19/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Feng Xu
- Department of Breast Surgery; Beijing Chao-Yang Hospital; Beijing China
| | - Haihui Sun
- Department of Breast Surgery; Beijing Chao-Yang Hospital; Beijing China
| | - Chao Zhang
- Department of Breast Surgery; Beijing Chao-Yang Hospital; Beijing China
| | - Hongchuan Jiang
- Department of Breast Surgery; Beijing Chao-Yang Hospital; Beijing China
| | - Shan Guan
- Department of General Surgery; Beijing Tongren Hospital; Beijing China
| | - Xiang Wang
- Department of Breast Surgery; Cancer Hospital, Chinese Academy of Medical Sciences; Beijing China
| | - Bing Wen
- Department of plastic and reconstructive Surgery; The first hospital of Peking University; Beijing China
| | - Jinfeng Li
- Department of Breast center; Peking University Cancer Hospital; Beijing China
| | - Xiru Li
- Department of General Surgery; General Hospital of People's Liberation Army; Beijing China
| | - Cuizhi Geng
- Department of Breast Center; The Fourth Hospital of Hebei Medical University; Shijiazhuang Hebei China
| | - Jian Yin
- Department of Breast Surgery; Tianjin Medical University Cancer Institute and Hospital; Tianjin China
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11
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Keskey RC, LaJoie AS, Sutton BS, Kim IK, Cheadle WG, McMasters KM, Ajkay N. Cost-effectiveness Analysis of Contralateral Prophylactic Mastectomy Compared to Unilateral Mastectomy with Routine Surveillance for Unilateral, Sporadic Breast Cancer. Ann Surg Oncol 2018; 24:3903-3910. [PMID: 29039025 DOI: 10.1245/s10434-017-6094-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Contralateral prophylactic mastectomy (CPM) rates in younger women with unilateral breast cancer have more than doubled. Studies of cost and quality of life of the procedure remain inconclusive. METHODS A cost-effectiveness analysis using a decision-tree model in TreeAge Pro 2015 was used to compare long-term costs and quality of life following unilateral mastectomy (UM) with routine surveillance versus CPM for sporadic breast cancer in women aged 45 years. A 10-year risk period for contralateral breast cancer (CBC), reconstruction, wound complications, cost of routine surveillance, and treatment for CBC were used to estimate accrued costs. In addition, a societal perspective was used to estimate quality-adjusted life years (QALYs) following either treatment for a period of 30 years. Medical costs were obtained from the 2014 Medicare physician fee schedule and event probabilities were taken from recent literature. RESULTS The mean cost of UM with surveillance was $14,141 and CPM was $20,319. Treatment with CPM resulted in $6178 more in costs but equivalent QALYs (17.93) compared with UM over 30 years of follow-up. Even with worst-case scenario and varying assumptions, CPM is dominated by UM in terms of cost and quality. CONCLUSIONS From this refined model, UM with routine surveillance costs less and provides an equivalent quality of life. Patients undergoing CPM may eliminate the anxiety of routine surveillance, but they face the burden of higher lifetime medical costs.
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Affiliation(s)
- Robert C Keskey
- The Hiram C. Polk Jr. MD Department of Surgery, University of Louisville School of Medicine, Louisville, KY, USA.,Department of Surgery, University of Chicago, Chicago, IL, USA
| | - A Scott LaJoie
- University of Louisville School of Public Health and Information Sciences, Louisville, KY, USA
| | - Brad S Sutton
- Department of Medicine, Cardiovascular Medicine, University of Louisville School of Medicine, Louisville, KY, USA.,Center for Health Process Innovation, University of Louisville, Louisville, KY, USA
| | - In K Kim
- Center for Health Process Innovation, University of Louisville, Louisville, KY, USA.,Department of Pediatrics, Emergency Medicine, University of Louisville School of Medicine, Louisville, KY, USA
| | - William G Cheadle
- The Hiram C. Polk Jr. MD Department of Surgery, University of Louisville School of Medicine, Louisville, KY, USA
| | - Kelly M McMasters
- The Hiram C. Polk Jr. MD Department of Surgery, University of Louisville School of Medicine, Louisville, KY, USA
| | - Nicolas Ajkay
- The Hiram C. Polk Jr. MD Department of Surgery, University of Louisville School of Medicine, Louisville, KY, USA.
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12
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Jain U, Somerville J, Saha S, Ver Halen JP, Antony AK, Samant S, Kim JY. Predictors of adverse events after neck dissection: An analysis of the 2006-2011 National Surgical Quality Improvement Program (NSQIP) Database. EAR, NOSE & THROAT JOURNAL 2017; 96:E37-E45. [PMID: 28231375 DOI: 10.1177/014556131709600218] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
While neck dissection is an important primary and adjunctive procedure in the treatment of head and neck cancer, there is a paucity of studies evaluating outcomes. A retrospective review of the National Surgical Quality Improvement Program (NSQIP) database was performed to identify factors associated with adverse events (AEs) in patients undergoing neck dissection. A total of 619 patients were identified, using CPT codes specific to neck dissection. Of the 619 patients undergoing neck dissection, 142 (22.9%) experienced an AE within 30 days of the surgical procedure. Risk factors on multivariate regression analysis associated with increased AEs included dyspnea (odds ratio [OR] 2.57; 95% confidence interval [CI] 1.06 to 6.22; p = 0.037), previous cardiac surgery (OR 3.38; 95% CI 1.08 to 10.52; p = 0.036), increasing anesthesia time (OR 1.005; 95% CI 1 to 1.009; p = 0.036), and increasing total work relative value units (OR 1.09; CI 1.04 to 1.13; p < 0.001). The current study is the largest, most robust analysis to identify specific risk factors associated with AEs after neck dissection. This information will assist with preoperative optimization, patient counseling, and appropriate risk stratification, and it can serve as benchmarking for institutions comparing surgical outcomes.
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Affiliation(s)
- Umang Jain
- Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
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13
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Chattha A, Bucknor A, Kamali P, Van Veldhuisen CL, Flecha-Hirsch R, Sharma R, Tobias AM, Lee BT, Lin SJ. Comparison of risk factors and complications in patients by stratified mastectomy weight: An institutional review of 1041 consecutive cases. J Surg Oncol 2017; 116:811-818. [DOI: 10.1002/jso.24753] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2017] [Accepted: 06/12/2017] [Indexed: 01/18/2023]
Affiliation(s)
- Anmol Chattha
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center; Harvard Medical School; Boston Massachusetts
| | - Alexandra Bucknor
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center; Harvard Medical School; Boston Massachusetts
| | - Parisa Kamali
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center; Harvard Medical School; Boston Massachusetts
| | - Charlotte L. Van Veldhuisen
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center; Harvard Medical School; Boston Massachusetts
| | - Renata Flecha-Hirsch
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center; Harvard Medical School; Boston Massachusetts
| | - Ranjna Sharma
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center; Harvard Medical School; Boston Massachusetts
| | - Adam M. Tobias
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center; Harvard Medical School; Boston Massachusetts
| | - Bernard T. Lee
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center; Harvard Medical School; Boston Massachusetts
| | - Samuel J. Lin
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center; Harvard Medical School; Boston Massachusetts
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Abstract
BACKGROUND Surgical-site infection causes devastating reconstructive failure in implant-based breast reconstructions. Large national database studies offer insights into complication rates, but only capture outcomes within 30 days postoperatively. This study evaluates both early and late surgical-site infection in immediate implant-based reconstruction and identifies predictors. METHODS As part of the Mastectomy Reconstruction Outcomes Consortium Study, 1662 implant-based breast reconstructions in 1024 patients were evaluated for early versus late surgical-site infection. Early surgical-site infection was defined as infection occurring within 30 days postoperatively; late surgical-site infection was defined as infection occurring 31 days to 1 year postoperatively. Minor infection required oral antibiotics only, and major infection required hospitalization and/or surgical treatment. Direct-to-implant patients had 1-year follow-up, and tissue expander patients had 1-year post-exchange follow-up. RESULTS Among 1491 tissue expander and 171 direct-to-implant reconstructions, overall surgical-site infection rate for tissue expander was 5.7 percent (85 of 1491) after first-stage, 2.5 percent (31 of 1266) after second-stage, and 9.9 percent (17 of 171) for direct-to-implant reconstruction. Over 47 to 71 percent of surgical-site infection complications were late surgical-site infection. Multivariate analysis identified radiotherapy and increasing body mass index as significant predictors of late surgical-site infection. No significant difference between the direct-to-implant and tissue expander groups in the occurrence of early, late, or overall surgical-site infection was found. CONCLUSIONS The majority of surgical-site infection complications in immediate implant-based breast reconstructions occur more than 30 days after both first-stage and second-stage procedures. Radiotherapy and obesity are significantly associated with late-onset surgical-site infection. Current studies limited to early complications do not present a complete assessment of infection associated with implant-based breast reconstructions or their long-term clinical outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, II.
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15
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Comparison of immediate breast reconstruction after mastectomy and mastectomy alone for breast cancer: A meta-analysis. Eur J Surg Oncol 2017; 43:285-293. [DOI: 10.1016/j.ejso.2016.07.006] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Revised: 07/03/2016] [Accepted: 07/08/2016] [Indexed: 11/21/2022] Open
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16
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Jain U, Somerville J, Saha S, Hackett NJ, Ver Halen JP, Antony AK, Samant S. Oropharyngeal Contamination Predisposes to Complications after Neck Dissection. Otolaryngol Head Neck Surg 2015; 153:71-8. [DOI: 10.1177/0194599815581808] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Accepted: 03/24/2015] [Indexed: 12/13/2022]
Abstract
Objective While neck dissection is important in the treatment of head and neck cancer, there is a paucity of studies evaluating outcomes. We sought to compare preoperative variables and outcomes between clean and contaminated neck dissections, using the 2006-2011 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data sets. Study Design Retrospective review of prospectively maintained database. Setting Multicenter (university hospitals; tertiary referral centers). Subjects and Methods A retrospective review was performed of the NSQIP database to identify patients undergoing neck dissection in clean vs oropharyngeal contaminated cases. Clinical factors, comorbidities, epidemiologic factors, and procedural characteristics were analyzed to identify factors associated with 30-day postoperative adverse events, including medical and surgical complications, unplanned reoperation, and mortality. Bivariate and multivariable analyses were performed for the outcome of one or more adverse events. Results In total, 8890 patients had clean neck dissections, while 572 patients had neck wound contamination with oropharyngeal flora. On multivariable regression analysis, oropharyngeal contamination was a significant risk factor for surgical complications (odds ratio [OR], 3.42; 95% confidence interval [CI], 1.96-5.96; P < .001). However, medical complications and mortality were not significantly different between the 2 cohorts. This finding persisted after subgroup analysis, with removal of all thyroidectomy patients from analysis (OR, 2.33; 95% CI, 1.25-4.36; P = .008). Conclusion Using the ACS-NSQIP data set, this study found an increased risk of surgical complications in the setting of contaminated neck dissections. These data should be used for patient risk stratification, informed consent, and to guide further research.
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Affiliation(s)
- Umang Jain
- Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jessica Somerville
- Department of Otolaryngology–Head and Neck Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Sujata Saha
- Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | | | - Jon P. Ver Halen
- Department of Plastic, Reconstructive, and Hand Surgery, Baptist Cancer Center–Vanderbilt Ingram Cancer Center, Memphis, Tennessee, USA
| | - Anuja K. Antony
- Division of Plastic and Reconstructive Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Sandeep Samant
- Department of Otolaryngology–Head and Neck Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
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