1
|
Cauley RP, Rahmani B, Adebagbo OD, Park J, Garvey SR, Chen A, Nickman S, Tobin M, Valentine L, Weidman AA, Singhal D, Dowlatshahi A, Lin SJ, Lee BT. Optimizing Surgical Outcomes and the Role of Preventive Surgery: A Scoping Review. J Reconstr Microsurg 2024. [PMID: 38782025 DOI: 10.1055/a-2331-7885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
BACKGROUND Plastic and reconstructive surgeons are often presented with reconstructive challenges as a sequela of complications in high-risk surgical patients, ranging from exposure of hardware, lymphedema, and chronic pain after amputation. These complications can result in significant morbidity, recovery time, resource utilization, and cost. Given the prevalence of surgical complications managed by plastic and reconstructive surgeons, developing novel preventative techniques to mitigate surgical risk is paramount. METHODS Herein, we aim to understand efforts supporting the nascent field of Preventive Surgery, including (1) enhanced risk stratification, (2) advancements in postoperative care. Through an emphasis on four surgical cohorts who may benefit from preventive surgery, two of which are at high risk of morbidity from wound-related complications (patients undergoing sternotomy and spine procedures) and two at high risk of other morbidities, including lymphedema and neuropathic pain, we aim to provide a comprehensive and improved understanding of preventive surgery. Additionally, the role of risk analysis for these procedures and the relationship between microsurgery and prophylaxis is emphasized. RESULTS (1) medical optimization and prehabilitation, (2) surgical mitigation techniques. CONCLUSION Reconstructive surgeons are ideally placed to lead efforts in the creation and validation of accurate risk assessment tools and to support algorithmic approaches to surgical risk mitigation. Through a paradigm shift, including universal promotion of the concept of "Preventive Surgery," major improvements in surgical outcomes may be achieved.
Collapse
Affiliation(s)
- Ryan P Cauley
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Benjamin Rahmani
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Oluwaseun D Adebagbo
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
- Department of Surgery, Tufts University School of Medicine, Boston, Massachusetts
| | - John Park
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Shannon R Garvey
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Amy Chen
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Sasha Nickman
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Micaela Tobin
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Lauren Valentine
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Allan A Weidman
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Dhruv Singhal
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Arriyan Dowlatshahi
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Samuel J Lin
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Bernard T Lee
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
2
|
Garvey SR, Valentine L, Weidman AA, Chen A, Nanda AD, Lee D, Lin SJ, Lee BT, Liang P, Cauley RP. Pedicled Flaps for High-Risk Open Vascular Procedures of the Lower Extremity: An Analysis of The National Surgical Quality Improvement Project Database. J Reconstr Microsurg 2024; 40:276-283. [PMID: 37579780 DOI: 10.1055/a-2153-4439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/16/2023]
Abstract
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.
Collapse
Affiliation(s)
- Shannon R Garvey
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Lauren Valentine
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Allan A Weidman
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Amy Chen
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Asha D Nanda
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Daniela Lee
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Samuel J Lin
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Bernard T Lee
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Patric Liang
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Ryan P Cauley
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
3
|
Guo CR, Rivera Perla KM, Leary OP, Sastry RA, Borrelli MR, Liu DD, Khunte M, Gokaslan ZL, Liu PY, Kwan D, Fridley JS, Woo AS. Systematic Review of Prophylactic Plastic Surgery Closure to Prevent Postoperative Wound Complications Following Spine Surgery. World Neurosurg 2024; 184:103-111. [PMID: 38185457 DOI: 10.1016/j.wneu.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 01/01/2024] [Accepted: 01/02/2024] [Indexed: 01/09/2024]
Abstract
Spinal surgeries are increasingly performed in the United States, but complication rates can be unacceptably high at up to 26%. Consequently, plastic surgeons (PS) are sometimes recruited by spine surgeons (SS) for intraoperative assistance with soft tissue closures. An electronic multidatabase literature search was systematically conducted to determine whether spinal wound closure performed by PS minimizes postoperative wound healing complications when compared to closure by SS (neurosurgical or orthopedic), with the hypothesis that closures by PS minimizes incidence of complications. All published studies involving patients who underwent posterior spinal surgery with closure by PS or SS at index spine surgery were identified. Filtering by exclusion criteria identified 10 studies, 4 of which were comparative in nature and included both closures by PS and SS. Of these 4, none reported significant differences in postoperative outcomes between the groups. Across all studies, PS were involved in cases with higher baseline risk for wound complications and greater comorbidity burden. Closures by PS were significantly more likely to have had prior chemotherapy in 2 of the 4 (50%) studies (P = 0.014, P < 0.001) and radiation in 3 of the 4 (75%) studies (P < 0.001, P < 0.01, P < 0.001). In conclusion, closures by PS are frequently performed in higher risk cases, and use of PS in these closures may normalize the risk of wound complications to that of the normal risk cohort, though the overall level of evidence of the published literature is low.
Collapse
Affiliation(s)
- Cynthia R Guo
- Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA; Department of Plastic and Reconstructive Surgery, Rhode Island Hospital, Providence, Rhode Island, USA.
| | - Krissia M Rivera Perla
- Department of Plastic and Reconstructive Surgery, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Owen P Leary
- Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Rahul A Sastry
- Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Mimi R Borrelli
- Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA; Department of Plastic and Reconstructive Surgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - David D Liu
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Mihir Khunte
- Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Ziya L Gokaslan
- Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Paul Y Liu
- Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA; Department of Plastic and Reconstructive Surgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Daniel Kwan
- Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA; Department of Plastic and Reconstructive Surgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Jared S Fridley
- Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Albert S Woo
- Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA; Department of Plastic and Reconstructive Surgery, Rhode Island Hospital, Providence, Rhode Island, USA
| |
Collapse
|
4
|
Dalton T, Darner G, McCray E, Price M, Baëta C, Erickson M, Karikari IO, Abd-El-Barr MM, Goodwin CR, Brown DA. Prophylactic Muscle Flaps Decrease Wound Complication Rates in Patients with Oncologic Spine Disease. Plast Reconstr Surg 2024; 153:221-231. [PMID: 37075264 DOI: 10.1097/prs.0000000000010568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2023]
Abstract
BACKGROUND Patients with oncologic spine disease face a high systemic illness burden and often require surgical intervention to alleviate pain and maintain spine stability. Wound healing complications are the most common reason for reoperation in this population and are known to impact quality of life and initiation of adjuvant therapy. Prophylactic muscle flap (MF) closure is known to reduce wound healing complications in high-risk patients; however, the efficacy in oncologic spine patients is not well established. METHODS A collaboration at our institution presented an opportunity to study the outcomes of prophylactic MF closure. The authors performed a retrospective cohort study of patients who underwent MF closure versus a cohort who underwent non-MF closure in the preceding time. Demographic and baseline health data were collected, as were postoperative wound complication data. RESULTS A total of 166 patients were enrolled, including 83 patients in the MF cohort and 83 control patients. Patients in the MF group were more likely to smoke ( P = 0.005) and had a higher incidence of prior spine irradiation ( P = 0.002). Postoperatively, five patients (6%) in the MF group developed wound complications, compared with 14 patients (17%) in the control group ( P = 0.028). The most common overall complication was wound dehiscence requiring conservative therapy, which occurred in six control patients (7%) and one MF patient (1%) ( P = 0.053). CONCLUSIONS Prophylactic MF closure during oncologic spine surgery significantly reduces the wound complication rate. Future studies should examine the precise patient population that stands to benefit most from this intervention. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
Collapse
Affiliation(s)
| | - Grant Darner
- Department of Surgery, Division of Plastic, Maxillofacial, and Oral Surgery
| | | | | | | | - Melissa Erickson
- Department of Orthopedic Surgery, Duke University Medical Center
| | | | | | | | - David A Brown
- Department of Surgery, Division of Plastic, Maxillofacial, and Oral Surgery
| |
Collapse
|
5
|
Gong JH, Sastry R, Koh DJ, Soliman L, Sobti N, Oyelese AA, Gokaslan ZL, Fridley J, Woo AS. Early Outcomes of Muscle Flap Closures in Posterior Thoracolumbar Fusions: A Propensity-Matched Cohort Analysis. World Neurosurg 2023; 180:e392-e407. [PMID: 37769839 DOI: 10.1016/j.wneu.2023.09.078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 09/18/2023] [Accepted: 09/20/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND Plastic surgery closure with muscle flaps after complex spinal reconstruction has become increasingly common. Existing evidence for this practice consists of small, uncontrolled, single-center cohort studies. We aimed to compare 30-day postoperative wound-related complication rates between flap closure and traditional closure after posterior thoracolumbar fusions (PTLFs) for non-infectious, non-oncologic pathologies using a national database. METHODS We performed a propensity-matched analysis using the 2012-2020 National Surgical Quality Improvement Program dataset to compare 30-day outcomes between PTLFs with flap closure versus traditional closure. RESULTS A total of 100,799 PTLFs met our inclusion criteria. The use of flap closure with PTLF remained low but more than doubled from 2012 to 2020 (0.38% vs. 0.97%; P = 0.002). A higher proportion of flap closures had higher American Society of Anesthesiologists classifications and higher number of operated spine levels (all P < 0.001). We included 1907 PTLFs (630 for flap closure; 1257 for traditional closure) in the propensity-matched cohort. Unadjusted 30-day wound complication rates were 1.7% for flap and 2.1% for traditional closure (P = 0.76). After adjusting for operative time, wound complication, readmission, reoperation, mortality, and non-wound complication were not associated flap use (all P > 0.05). CONCLUSIONS Plastic surgery closure was performed in patients with a higher comorbidity burden, suggesting consultation in sicker patients. Although higher rates of wound and non-wound complications were expected for the flap cohort, our propensity-matched cohort analysis of flap closure in PTLFs resulted in non-inferior odds of wound complications compared to traditional closure. Further study is needed to assess long-term complications in prophylactic flap closure in complex spine surgeries.
Collapse
Affiliation(s)
- Jung Ho Gong
- Division of Plastic and Reconstructive Surgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.
| | - Rahul Sastry
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Daniel J Koh
- Boston University School of Medicine, Boston, Massachusetts, USA
| | - Luke Soliman
- Division of Plastic and Reconstructive Surgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Nikhil Sobti
- Division of Plastic and Reconstructive Surgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Adetokunbo A Oyelese
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Ziya L Gokaslan
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Jared Fridley
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Albert S Woo
- Division of Plastic and Reconstructive Surgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| |
Collapse
|
6
|
Hassan B, Abou Koura A, Makarem A, Abi Mosleh K, Dimassi H, Tamim H, Ibrahim A. Predictors of surgical site infection following reconstructive flap surgery: A multi-institutional analysis of 37,177 patients. Front Surg 2023; 10:1080143. [PMID: 36793316 PMCID: PMC9923723 DOI: 10.3389/fsurg.2023.1080143] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 01/02/2023] [Indexed: 01/31/2023] Open
Abstract
Purpose Rates of surgical site infection (SSI) following reconstructive flap surgeries (RFS) vary according to flap recipient site, potentially leading to flap failure. This is the largest study to determine predictors of SSI following RFS across recipient sites. Methods The National Surgical Quality Improvement Program database was queried for patients undergoing any flap procedure from years 2005 to 2020. RFS involving grafts, skin flaps, or flaps with unknown recipient site were excluded. Patients were stratified according to recipient site: breast, trunk, head and neck (H&N), upper and lower extremities (UE&LE). The primary outcome was the incidence of SSI within 30 days following surgery. Descriptive statistics were calculated. Bivariate analysis and multivariate logistic regression were performed to determine predictors of SSI following RFS. Results 37,177 patients underwent RFS, of whom 7.5% (n = 2,776) developed SSI. A significantly greater proportion of patients who underwent LE (n = 318, 10.7%) and trunk (n = 1,091, 10.4%) reconstruction developed SSI compared to those who underwent breast (n = 1,201, 6.3%), UE (n = 32, 4.4%), and H&N (n = 100, 4.2%) reconstruction (p < .001). Longer operating times were significant predictors of SSI following RFS across all sites. The strongest predictors of SSI were presence of open wound following trunk and H&N reconstruction [adjusted odds ratio (aOR) 95% confidence interval (CI) 1.82 (1.57-2.11) and 1.75 (1.57-1.95)], disseminated cancer following LE reconstruction [aOR (CI) 3.58 (2.324-5.53)], and history of cardiovascular accident or stroke following breast reconstruction [aOR (CI) 16.97 (2.72-105.82)]. Conclusion Longer operating time was a significant predictor of SSI regardless of reconstruction site. Reducing operating times through proper surgical planning might help mitigate the risk of SSI following RFS. Our findings should be used to guide patient selection, counseling, and surgical planning prior to RFS.
Collapse
Affiliation(s)
- Bashar Hassan
- Scholars in HeAlth Research Program (SHARP), American University of Beirut Medical Center, Beirut, Lebanon
| | - Abdulghani Abou Koura
- Scholars in HeAlth Research Program (SHARP), American University of Beirut Medical Center, Beirut, Lebanon
| | - Adham Makarem
- Scholars in HeAlth Research Program (SHARP), American University of Beirut Medical Center, Beirut, Lebanon
| | - Kamal Abi Mosleh
- Scholars in HeAlth Research Program (SHARP), American University of Beirut Medical Center, Beirut, Lebanon
| | - Hani Dimassi
- School of Pharmacy, Lebanese American University, Byblos, Lebanon
| | - Hani Tamim
- Clinical Research Institute, Faculty of Medicine, American University of Beirut, Beirut, Lebanon,College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Amir Ibrahim
- Division of Plastic and Reconstructive Surgery, American University of Beirut Medical Center, Beirut, Lebanon,Correspondence: Amir Ibrahim
| |
Collapse
|