A 30-day risk assessment of mastectomy alone compared to immediate breast reconstruction (IBR)

Predictors of surgical site infection following reconstructive flap surgery: A multi-institutional analysis of 37,177 patients

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.

The Impact of Diabetes Mellitus on Breast Reconstruction Outcomes and Complications: A Systematic Literature Review and Meta-analysis

INTRODUCTION

As the incidence of breast cancer and diabetes rises, so does the number of patients with diabetes undergoing breast reconstruction (BR). Patients with diabetes are at a higher risk for post-operative complications. The current study examined the effects of diabetes on BR wound outcomes and overall complications post-operatively.

METHODS

This study followed the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. We conducted a systematic search and meta-analysis for published articles on the effects of DM on BR in January 2022 using the PubMed, MEDLINE, and Cochrane databases. Diabetes, breast reconstruction, and complications were used as keywords.

RESULTS

Forty-three studies were included in the qualitative synthesis, and five provided data to be included in the meta-analysis published between 2006 and 2020. A total of 19,731 patients (9.07%) had diabetes, whereas 197,812 patients had no diabetes. The results of the pooled outcomes revealed no differences in the risk of total flap loss (p = 0.892) and wound infection (p = 0.579,). Nevertheless, the risk of wound dehiscence was significantly higher among patients with diabetes than their non-diabetic counterparts (p < 0.0001).

CONCLUSION

Diabetic patients undergoing BR have a significantly higher risk of wound dehiscence. As a result of the adverse effects of diabetes status on BR outcomes, patients need to be counseled about optimizing their diabetes management before surgery. Because of the heterogeneity in our results, prospective randomized studies are needed to shed light on the consequences of diabetes mellitus in BR surgeries.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Predictors of Complications after Breast Reconstruction Surgery: A Systematic Review and Meta-analysis

Breast reconstruction (BR) is a unique surgical procedure that provides patients undergoing mastectomy with significant psychosocial and aesthetic benefits and has also become a crucial part of the treatment pathway for women with breast cancer. Due to methodological inadequacies and the absence of substantial risk factor analysis, no conclusion can be drawn about the correlation between risk variables and post-surgical complications in BR surgery. We aim to identify the potential risk factors associated with postoperative complications.

Methods

We queried MEDLINE and Cochrane CENTRAL from their inception to March 2022, for published randomized controlled trials and observational studies that assessed complications post-reconstruction procedure in breast cancer patients following mastectomy or evaluated at least one of the following outcomes of major or reoperative complications. The results from the studies were presented as odds ratios with 95% confidence intervals and were pooled using a random-effects model.

Results

Our pooled analysis demonstrated a significant correlation with BR postoperative complications and risk factors such as diabetes, hypertension, and obesity. Diabetes and the development of seroma were found to have a significant relationship. Risk variables such as age, radiotherapy, COPD, and smoking had no significant connection with 0-to-30-day readmission and 30-to-90-day readmission.

Conclusion

This meta-analysis shows that risk factors like age, smoking history, high blood pressure, and body mass index (BMI) have a big effect on complications after BR, and patients with risk factors have a high rate of developing infection.

Impact of diabetes on outcomes in breast reconstruction: A systematic review and meta-analysis

BACKGROUND

As rates of breast cancer and type II diabetes increase, so does the number of women with diabetes undergoing breast reconstruction (BR). Patients with diabetes are at increased risk of postoperative complications. This meta-analysis seeks to evaluate the post-operative outcomes of women with diabetes who underwent BR following mastectomy.

METHOD

This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The EMBASE, PUBMED, and MEDLINE electronic databases were searched from inception to November 1, 2020 for studies published in English. Outcomes evaluated were overall complications, surgical complications, and longer hospital stay. Subgroup analysis investigated outcomes, such as implant/flap failure, infection, and necrosis.

RESULTS

Sixty-five studies met our inclusion criteria and 38 provided data to be included in the meta-analysis. A total of 151,585 patients were included, of which 9299 had diabetes. Women with diabetes were more likely to experience overall complications (11.6% vs 5.6%; p<0.0001) and surgical complications (7.7% vs 3.3%; p<0.0001), and were more likely to have a prolonged hospital stay (p = 0.04) than women without diabetes. Subgroup analysis showed that implant loss (2.5% vs 1.6%; p = 0.0003), infection (6.8% vs 2.5%; p<0.0001) and necrosis (23.8% vs 6.5; p = 0.001) were significantly higher in women with diabetes.

CONCLUSIONS

This study provides evidence that diabetes mellitus increases the risk of complications in patients with breast cancer undergoing BR after mastectomy. Prospective studies are required to establish whether diabetes that is well-controlled prior to reconstruction, including diabetes that is paired with adjuvant radiation therapy, reduces the perioperative risks.

Association of Diabetes Mellitus With Postoperative Complications and Mortality After Non-Cardiac Surgery: A Meta-Analysis and Systematic Review

BACKGROUND

Although a variety of data showing that diabetes mellitus (DM) (Type 1 or Type 2) is associated with postoperative complication, there is still a lack of detailed studies that go through the specific diabetic subgroups. The goal of this meta-analysis is to assess the relationship between DM and various complications after non-cardiac surgery.

METHODS

We searched articles published in three mainstream electronic databases (PubMed, EMBASE, Web of science) before November, 2020. A random effects model was conducted since heterogeneity always exist when comparing results between different types of surgery.

RESULTS

This paper included 125 studies with a total sample size of 3,208,776 participants. DM was a risk factor for any postoperative complication (Odds ratio (OR)=1.653 [1.487, 1.839]). The risk of insulin-dependent DM (OR=1.895 [1.331, 2.698]) was higher than that of non-insulin-dependent DM (OR=1.554 [1.061, 2.277]) for any postoperative complication. DM had a higher risk of infections (OR=1.537 [1.322, 1.787]), wound healing disorders (OR=2.010 [1.326, 3.046]), hematoma (OR=1.369 [1.120, 1.673]), renal insufficiency (OR=1.987 [1.311, 3.013]), myocardial infarction (OR=1.372 [0.574, 3.278]). Meanwhile, DM was a risk factor for postoperative reoperation (OR=1.568 [1.124, 2.188]), readmission (OR=1.404 [1.274, 1.548]) and death (OR=1.606 [1.178, 2.191]).

CONCLUSIONS

DM is a risk factor for any postoperative complications, hospitalization and death after non-cardiac surgery. These findings underscore the importance of preoperative risk factor assessment of DM for the safe outcome of surgical patients.

Outcomes analysis of microsurgical physiologic lymphatic procedures for the upper extremity from the United States National Surgical Quality Improvement Program

INTRODUCTION

Physiologic microsurgical procedures to treat lymphedema include vascularized lymph node transfer (VLNT) and lymphovenous bypass (LVB). The purpose of this study was to assess 30-day outcomes of VLNT and LVB using the National Surgical Quality Improvement Program (NSQIP) database.

METHODS

NSQIP was queried (2012-2018) for lymphatic procedures for upper extremity lymphedema after mastectomy. Prophylactic lymphatic procedures and those for lower extremity lymphedema were excluded. Outcomes were assessed for three groups: LVB, VLNT, and patients who had procedures simultaneously (VLNA+LVB). Primary outcomes measured were operative time, 30-day morbidities, and hospital length of stay.

RESULTS

The study included 199 patients who had LVB (n = 43), VLNT (n = 145), or VLNT+LVB (n = 11). There was no difference in co-morbidities between the groups (p = 0.26). 30-day complication rates including unplanned reoperation (6.9% VLNT vs. 2.3% LVB) and readmission (0.69% VLNT vs. none in LVB) were not statistically significant (p = 0.54). Surgical site infection, wound complications, deep vein thromboembolism, and cardiac arrest was also similar among the three groups. Postoperative length of stay for VLNT (2.5 days± 2.3), LVB (1.9 days± 1.9), and VLNT+LVB (2.8 days± 0.3) did not differ significantly (p = 0.20). Operative time for LVB (305.4 min ± 186.7), VLNT (254 min ± 164.4), and VLNT+LVB (295.3 min ± 43.2) was not significantly different (p = 0.21).

CONCLUSIONS

Our analysis of the NSQIP data revealed that VLNT and LVB are procedures with no significant difference in perioperative morbidity. Our results support that choice of VLNT versus LVB can be justifiably made per the surgeon's preference and experience as the operations have similar complication rates.

Use of a 5-Item Modified Frailty Index for Risk Stratification in Patients Undergoing Breast Reconstruction

INTRODUCTION

Frailty can be quantified using an index score to effectively predict surgical outcomes and complications. The modified frailty index (mFI) score includes 5 patient-specific medical history comorbidities including diabetes mellitus, congestive heart failure, hypertension, chronic obstructive pulmonary disease/pneumonia, and nonindependent functional status. The purpose of our study was to apply the 5-item mFI score to predict and minimize complications in patients undergoing breast reconstruction.

METHODS

The National Surgical Quality Improvement Program was queried for all patients undergoing primary breast reconstruction from 2016 to 2018. Patients were divided based on timing of reconstruction and type of reconstruction: immediate or delayed, and implant based or autologous based. A validated modified fragility score was applied to all patients. Patients were stratified by mFI scores of 0 (no comorbidities), 1 (1 comorbidity), and 2+ (2 or more comorbidities). Patient demographics and 30-day complications rates were recorded.

RESULTS

A total of 22,700 patients were identified. There were 10,673 patients who underwent immediate breast reconstruction, and 12,027 patients who underwent delayed breast reconstruction. A total of 14,159 patients underwent implant-based, and 8541 underwent autologous-based reconstruction. A total of 16,627 patients had an mFI score of 0, 4923 had a mFI score of 1, and 1150 had a mFI score of 2+. Compared with patients with an mFI score of 0, patients with an mFI score of 2 or greater were more likely to develop a postoperative complication (7.2 vs 12.3; P < 0.0001). Patients undergoing immediate reconstruction were more likely to develop a postoperative complications for every mFI category. The most common complications were wound and hematologic related.

CONCLUSION

Patients with higher mFI scores are likely to have an increase in postoperative complications after breast reconstruction. Increasing body mass index increases postoperative complications independent of frailty index scores. Patients with increasing frailty index scores undergoing immediate breast reconstruction have a significantly higher risk of postoperative complications compared with delayed reconstruction.Patients with increasing frailty index scores undergoing autologous breast reconstruction have a significantly higher risk of postoperative complications compared with implant-based reconstruction. High frailty index scores are associated with a higher risk of postoperative complications, reoperation rates, and readmission rates. Patients with higher mFI scores may benefit from a delayed implant-based reconstruction.

Early Postoperative Complications From National Surgical Quality Improvement Program: A Closer Examination of Timing and Technique of Breast Reconstruction

BACKGROUND

Despite the recent surge in rates of immediate breast reconstruction, there is a paucity of large multicenter studies to compare differences in morbidity after immediate versus delayed breast reconstruction. This study used the National Surgical Quality Improvement Program (NSQIP) to study the association between timing of breast reconstruction and complication rates, stratified by reconstructive modality.

STUDY DESIGN

The NSQIP database was used to identify breast reconstructions from 2005 to 2012. Rates of major complications were compared by timing within each reconstructive modality (implant vs autologous). Cohort differences in baseline characteristics and variables associated with increased complication rates were identified in bivariate analyses. A multivariable model was created to compare the association between the timing of reconstruction and major complications.

RESULTS

Of 24,506 postmastectomy reconstructions, 85.8% were immediate, 14.2% were delayed, 84% were implant, and 16% were autologous reconstructions. Overall, 10.0% of patients suffered a major complication. After stratification, only implant reconstructions showed a statistically higher complication rate with immediate (8.8%) reconstruction compared with delayed (5.3%) (odds ratio, 1.7, P < 0.01). There was no significant difference in complication rates between autologous immediate (18.4%) or delayed (19.0%) reconstructions. After controlling for baseline cohort differences and other risk factors, immediate reconstruction remained as an independent significant predictor of major complications in implant reconstructions (odds ratio, 1.8, P < 0.01).

CONCLUSIONS

Immediate rather than delayed breast reconstruction is associated with a significantly higher rate of major complications in implant reconstruction but not in autologous reconstruction. It is important to include these findings in the routine preoperative surgeon-patient discussion of reconstructive options.

Obesity and Energy Balance Considerations in Triple-Negative Breast Cancer

ABSTRACT

Obesity is an increasingly prevalent state of energy imbalance that contributes to breast cancer risk and outcomes. The effects of obesity differ by breast cancer subtype and menopause. While most studies have focused on postmenopausal hormone receptor-positive disease, less is known about the relationship between obesity and triple-negative breast cancer (TNBC). Here we will review the observations linking obesity to TNBC, the socioeconomic disparities that contribute to obesity-related TNBC, and putative biologic mechanisms. Finally, we will consider the impact of obesity on surgical and medical treatment of TNBC and novel strategies to improve energy balance after cancer diagnosis.

Immediate versus secondary DIEP flap breast reconstruction: a multicenter outcome study

PURPOSE

Immediate breast reconstruction (IBR) at the time of mastectomy is gaining popularity, as studies show no negative impact on recurrence or patient survival, but better aesthetic outcome, less psychological distress and lower treatment costs. Using the largest database available in Europe, the presented study compared outcomes and complications of IBR vs. delayed breast reconstruction (DBR).

METHODS

3926 female patients underwent 4577 free DIEP-flap breast reconstructions after malignancies in 22 different German breast cancer centers. The cases were divided into two groups according to the time of reconstruction: an IBR and a DBR group. Surgical complications were accounted for and the groups were then compared.

RESULTS

Overall, the rate of partial-(1.0 versus 1.2 percent of cases; p = 0.706) and total flap loss (2.3 versus 1.9 percent of cases; p = 0.516) showed no significant difference between the groups. The rate of revision surgery was slightly, but significantly lower in the IBR group (7.7 versus 9.8 percent; p = 0.039). Postoperative mobilization was commenced significantly earlier in the IBR group (mobilization on postoperative day 1: 82.1 versus 68.7 percent; p < 0.001), and concordantly the mean length of hospital stay was significantly shorter (7.3 (SD3.7) versus 8.9 (SD13.0) days; p < 0.001).

CONCLUSION

IBR is feasible and cannot be considered a risk factor for complications or flap outcome. Our results support the current trend towards an increasing number of IBR. Especially in times of economic pressure in health care, the importance of a decrease of hospitalization cannot be overemphasized.

The relationship between post-surgery infection and breast cancer recurrence

Breast cancer is the second most prevalent form of cancer in women worldwide, with surgery remaining the standard treatment. The adverse impact of the surgery remains controversial. It has been suggested that systemic factors during the postoperative period may increase the risk of recurrence, specifically surgical site infection (SSI). The aim of this review was to critically appraise current published literature regarding the influence of SSIs, after primary breast cancer surgery, on breast cancer recurrence, and to delve into potential links between these. This systematic review adopted two approaches: to identify the incidence rates and risk factors related to SSI after primary breast cancer surgery; and, secondly, to examine breast cancer recurrence following SSI occurrence. Ninety-nine studies with 484,605 patients were eligible in the SSI-focused searches, and 53 studies with 17,569 patients for recurrence-focused. There was a 13.07% mean incidence of SSI. Six-hundred and thirty-eight Gram-positive and 442 Gram-negative isolates were identified, with methicillin-susceptible Staphylococcus aureus and Escherichia coli most commonly identified. There were 2077 cases of recurrence (11.8%), with 563 cases of local recurrence, 1186 cases of distant and 25 cases which recurred both locally and distantly. Five studies investigated the association between SSI and breast cancer recurrence with three concluding that an association did exist. In conclusion, there is association between SSI and adverse cancer outcomes, but the cellular link between them remains elusive. Confounding factors of retrospective study design, surgery type and SSI definition make results challenging to compare and interpret. A standardized prospective study with appropriate statistical power is justified.

Thirty-day postoperative morbidity in patients with breast cancer following neoadjuvant chemotherapy

BACKGROUND

Early post-operative complications for patients having partial and total mastectomies after neoadjuvant chemotherapy have not been well defined. The objective was to compare post-operative complication rates among patients treated with partial mastectomy (PM), unilateral mastectomy (UM), and bilateral mastectomy (BM) after NAC.

STUDY DESIGN

398 patients with breast cancer who had NAC from 2008 to 2016 were identified from a prospectively maintained database. The primary outcome measure was 30-day post-operative morbidity.

RESULTS

125 patients (31.4%) underwent PM, 107 patients (26.9%) UM, and 166 (41.7%) BM. There was no significant difference among the 3 groups with respect to histology (ductal: 96.0% PM, 88.8% UM, 92.6% BM, p = 0.161). Groups were similar with respect to estrogen receptor positivity (overall 58.8%, p = 0.331) and triple negative biomarker status (overall 23.9%, p = 0.559). The PM group had a higher rate of HER2 positive disease (n = 58, 47.5%, p = 0.012). Patients who underwent PM had a lower clinical T Stage at presentation (p=<0.001), fewer axillary lymph node dissections (n = 32, 25.6%, p=<0.001), and a higher rate of pathologic complete response (n = 48, 38.4%, p = 0.037) compared with patients who underwent mastectomies. Overall, 52 patients (13.1%) had a complication within the 30 day post-operative period. 30-day complication rates were significantly higher in the BM group compared to the PM group: 6.4% (n = 8) for PM, 12.2% (n = 13) for UM, and 18.7% (n = 31) for BM, (p = 0.008). 30-day readmission rates were significantly higher in the BM group compared to the PM group (overall 4.5%; 0.8% PM, 2.8% UM, 8.4% BM, p = 0.004).

CONCLUSION

Bilateral mastectomy is associated with higher rates of 30-day morbidity and re-admissions compared to partial mastectomy, but not unilateral mastectomy in patients who received neoadjuvant chemotherapy.

Implant-sparing Mastectomy: An Alternative for Women Undergoing Mastectomy With Retropectoral Implants

INTRODUCTION

Implant-sparing mastectomy (ISM) is a skin-sparing mastectomy that preserves a retropectoral implant and potentially eliminates the need for tissue expansion or complex reconstruction. This study aimed to determine oncologic and surgical outcomes and reconstructive patterns in patients undergoing ISM.

PATIENTS AND METHODS

A single-institution, retrospective review of patients undergoing ISM from 2006 to 2018 was performed. Patient/tumor characteristics, stage, adjuvant therapy use, 90-day complication rates, reconstruction type, and disease recurrence were collected.

RESULTS

A total of 121 ISMs in 73 women were performed. Seventy (57.9%) ISMs were for breast cancer (BC) treatment and 51 (42.1%) for prophylaxis. Among BC cases, 72.3% were cT1/cT2 and 73.8% were cN0; 72.3% received systemic therapy and 33.8% received radiation therapy. There were 3 deaths owing to BC at the median follow-up of 35 months. Among 5 recurrences, only 1 was local. There was no BC identified after prophylactic ISM. Total 90-day complication rate per ISM was 15.7%. Rates were 0.8% for both seroma and wound infection, 2.5% for wound dehiscence, 3.3% for hematoma, and 8.2% for skin necrosis. The majority (72.6%) of patients required only implant exchange for reconstruction. Overall use of autologous reconstruction was low (12.3%); 77.8% of flaps were performed in patients receiving radiation therapy.

CONCLUSION

ISM is a unique approach for patients pursuing mastectomy for BC treatment or prevention with equivalent oncologic outcomes and complication rates to mastectomy with reconstruction. Reconstruction for the majority was markedly simplified by elimination of tissue expansion while maintaining a low rate of flap reconstruction.

Does timing of alloplastic breast reconstruction in older women impact immediate postoperative complications? An analysis of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database

BACKGROUND

Alloplastic breast reconstruction is safe in well-selected older women. The impact of timing of surgery on complication rates is unknown. This study aimed to determine the immediate (30-day) postoperative complication rates of older women who underwent immediate (IBR) and delayed breast reconstruction (DBR) with alloplastic techniques.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was used to identify women ≥70 years old with in situ or invasive breast cancer who underwent either IBR or DBR (2005-2016). Outcomes included 30-day postoperative morbidity and mortality.

RESULTS

A total of 2,085 older women underwent alloplastic breast reconstruction of which 90% and 10% were IBR and DBR, respectively. Both groups had similar median age, body mass index, and frequency of smoking, diabetes mellitus, and steroid use. Tumors were mainly invasive in the IBR group (83.5%) and in situ in the DBR group (83.3%). IBR had significantly longer operative times (median 154 min vs 98 min, p < 0.0001), but equal length of stay (median 3 days vs 3 days, p = 0.1). The 30-day overall morbidity (medical or surgical complication) rate was significantly higher in the IBR group (7.5% vs 1.0%, p < 0.0004). Women with IBR were significantly more likely to develop infectious complications (6% vs 1%, p = 0.002). Cardiac/transfusion, pulmonary, thromboembolic, renal, and neurological morbidity rates were equal between groups. Thirty-day mortality rates were similar across both groups (IBR: 0.05% vs DBR: 0%, p = 0.74).

CONCLUSIONS

While overall thirty-day postoperative complication rates in older women who undergo breast reconstruction were low, there were higher rates of infectious complications in the IBR cohort. The risks and benefits of alloplastic breast reconstruction should be discussed with older women undergoing mastectomy for breast cancer treatment.

Returns to the operating room after breast surgery at a tertiary care medical center

BACKGROUND

Evaluation of returns to the operating room (RORs) may spur practice modifications to improve patient outcomes and hospital practices. We determined the frequency and indications for RORs after breast operations.

METHODS

We identified patients ≥18 years who underwent a breast operation at our institution 1/1/14-1/13/17 and assessed ROR within 45-days. RORs were categorized as unplanned/planned, staged/unstaged, or unrelated procedures. Univariate and multivariable analyses compared variables between patients who did and did not have an ROR.

RESULTS

2,914 patients underwent a breast operation of whom 117 (4.0%) had 121 RORs. Planned staged procedures accounted for 48 RORs (39.7%), while unplanned complications accounted for 65 (53.7%). On multivariable analysis, ROR was more common among patients undergoing total, skin-sparing, or nipple-sparing mastectomy (versus lumpectomy) all p < 0.03, while immediate breast reconstruction did not increase RORs.

CONCLUSIONS

RORs following breast operations occurred in 4% of patients, with approximately one-third for a staged oncologic procedure. Implementation of ROR documentation tools should be encouraged, as these data provide benchmarks for clinical practice improvement initiatives to improve the quality of patient care.

Scoping Review of the National Surgical Quality Improvement Program in Plastic Surgery Research

BACKGROUND

The National Surgical Quality Improvement Program (NSQIP) is a robust, high-quality surgical outcomes database that measures risk-adjusted 30-day outcomes of surgical interventions. The purpose of this scoping review is to describe how the NSQIP is being used in plastic surgery research.

METHODS

A comprehensive electronic literature search was completed in PubMed, Embase, MEDLINE, and CINAHL. Two reviewers independently reviewed articles to determine their relevance using predefined inclusion criteria. Articles were included if they utilized NSQIP data to conduct research in a domain of plastic surgery or analyzed surgical procedures completed by plastic surgeons. Extracted information included the domain of plastic surgery, country of origin, journal, and year of publication.

RESULTS

A total of 106 articles met the inclusion criteria. The most common domain of plastic surgery was breast reconstruction representing 35% of the articles. Of the 106 articles, 95% were published within the last 5 years. The Plastic and Reconstructive Surgery journal published most of the (59%) NSQIP-related articles. All of the studies were retrospective. Of note, there were no articles on burns and only one study on trauma as the domain of plastic surgery.

CONCLUSION

This scoping review describes how NSQIP data are being used to analyze plastic surgery interventions and outcomes in order to guide quality improvement in 106 articles. It demonstrates the utility of NSQIP in the literature, however also identifies some limitations of the program as it applies to plastic surgery.

Oncoplastic breast surgery techniques - a new look at surgical treatment of breast cancer

Breast cancer is the most common cancer among Polish women [1], thus, the problem of surgical treatment of breasts, especially with regard to conserving and/or reconstruction surgery, is extensively discussed. Currently, in Poland, efforts are made to increase the number of oncologic and reconstructive breast centers which offer specialized treatment of this cancer, the so-called ‘Breast Units’ [1]. This paper analyzes methods of reconstructions, discusses the techniques used in particular types of surgeries and additionally informs the reader of the oncological aspects of the procedures. Based on literature, statistical data of breast reconstructions from Poland and the world are presented. Moreover, complications and psychological aspects of mammary gland surgery are dealt with, and the aesthetic effects of breast reconstructions are discussed. To support of our findings, we also present selected clinical cases from the oncological and reconstructive point of view.

Impact of Diabetes on 30-Day Complications in Mastectomy and Implant-Based Breast Reconstruction

BACKGROUND

Diabetic patients are known to be at increased risk of postoperative complications after multiple types of surgery. However, conflicting evidence exists regarding the association between diabetes and wound complications in mastectomy and breast reconstruction. This study evaluates the impact of diabetes on surgical outcomes after mastectomy procedures and implant-based breast reconstruction.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database review from 2010 to 2015 identified patients undergoing total, partial, or subcutaneous mastectomy, as well as immediate or delayed implant reconstruction. Primary outcomes included postoperative wound complications and implant failure. Preoperative variables and outcomes were compared between diabetic and nondiabetic patients. Multivariate regression was used to control for confounders.

RESULTS

The following groups were identified: partial (n = 52,583), total (n = 41,540), and subcutaneous mastectomy (n = 3145), as well as immediate (n = 4663) and delayed (n = 4279) implant reconstruction. Diabetes was associated with higher rates of superficial incisional surgical site infection (SSI) in partial mastectomy (odds ratio [OR] = 8.66; P = 0.03). Diabetes was also associated with higher rates of deep incisional SSI (OR = 1.61; P = 0.01) in subcutaneous mastectomy and both superficial (OR = 1.56; P = 0.04) and deep incisional SSI (OR = 2.07; P = 0.04) in total mastectomy. Diabetes was not associated with any wound complications in immediate reconstruction but was associated with higher rates of superficial incisional SSI (OR = 17.46; P < 0.001) in the delayed reconstruction group. There was no association with implant failure in either group.

CONCLUSIONS

Evaluation of the largest national cohort of mastectomy and implant reconstructive procedures suggests that diabetic patients are at significantly increased risk of 30-d postoperative infectious wound complications but present no difference in rates of early implant failure.

Patient-reported factors influencing the treatment decision-making process of older women with non-metastatic breast cancer: a systematic review of qualitative evidence

PURPOSE

Older women (≥ 70 years old) with breast cancer undergo different treatments than young women. Studies have examined factors that influence this disparity, but synthesized patient-reported data are lacking in the literature. This study aims to identify, appraise, and synthesize the existing qualitative evidence on patient-reported factors influencing older women's decision to accept or decline breast cancer treatment.

METHODS

A systematic review was performed in accordance with Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA) principles. Medline, Embase, CINAHL, and PsycINFO were searched for qualitative studies describing patient-reported factors influencing the decision-making process of older women (≥ 70 years old) with non-metastatic invasive breast cancer. Quality was assessed using the Standards for Reporting Qualitative Research (SRQR) criteria. Common ideas were coded, thematically organized, and synthesized within a theoretical framework.

RESULTS

Of 5998 studies identified, 10 met eligibility criteria. The median SRQR total score was 13.04 (IQR 12.84-13.81). The studies represented a range of cancer treatments; most of the studies focused on surgery and primary endocrine therapy. Our data show that the most common patient-reported factors in the decision-making process included treatment characteristics, personal goals/beliefs, patient characteristics, physician's recommendation, and personal/family experience. These factors led the patient to either accept or decline treatment, and were not consistent across all studies included. Studies used different interview guides, which may have affected these results.

CONCLUSIONS

This systematic review highlights the complexity of factors that influence an older woman's treatment decision-making process. Acknowledging and addressing these factors may improve discussions about treatment choices between older women and their health care providers, and encourage maximization of a patient-centered approach.

Thirty-day postoperative morbidity and mortality in elderly women with breast cancer: an analysis of the NSQIP database

PURPOSE

Postoperative complication rates for elderly women undergoing breast cancer surgery have not been well studied. We describe the postoperative complication rates of elderly (≥ 70 years) women with breast cancer and compare them with young (40-69 years) women.

METHODS

Data were extracted from the National Surgical Quality Improvement Program database (2004-2014). We included women with invasive breast cancer who underwent surgery. Outcomes were 30-day postoperative morbidity and mortality (complications), which were compared between young and elderly women. Morbidity was categorized using the Surgical Risk Preoperative Assessment System (SURPAS) clusters.

RESULTS

We identified 100,037 women of which 26.7% were elderly. Compared to young women, elderly women were more likely to have more comorbidities and undergo breast-conserving surgery, but less likely to undergo lymph node surgery, breast reconstruction, and neoadjuvant chemotherapy. While the 30-day overall morbidity rate was not significantly different between young and elderly women (3.9 vs. 3.8%, p = 0.2), elderly women did have significantly higher rates of pulmonary, cardiac (arrest and myocardial infarction), venous thromboembolic, and neurological morbidity. Specific morbidities that showed significantly lower rates among elderly women included wound disruption and deep and organ space surgical site infection. Any cause death was significantly higher in elderly compared to young women (0.2 vs. 0.05%, p < 0.001).

CONCLUSIONS

While some specific 30-day postoperative morbidities were more often seen in elderly women, the overall 30-day postoperative complication rate was very low. These data support the safety of breast cancer surgery in well-selected elderly patients.

The impact of obesity on outcomes for patients undergoing mastectomy using the ACS-NSQIP data set

PURPOSE

According to the World Health Organization (WHO), 34.7% of females in the United States are obese (BMI ≥ 30) in 2014, compared to 32.5% in 2010. The previous research has demonstrated high BMI as an independent risk factor for surgical complications after breast surgery. As more patients become obese, we sought to examine whether increasing obesity had an effect on outcomes of women who underwent a unilateral mastectomy without breast reconstruction.

METHODS

The study reviewed the 2007-2012 ACS-NSQIP database and identified all patients who underwent a unilateral mastectomy without reconstruction. Patients were then categorized and compared according to the World Health Organization obesity classification. Data were analyzed for minor complications (e.g., UTI and SSI) and major complications (e.g., renal failure, sepsis, deep vein thrombosis, return to operating room [RTOR], and cardiac arrest).

RESULTS

A total of 7207 women were identified. Median BMI was 27.3 kg/m². From the cohort, 453 patients (6.29%) had a major complication and 173 patients (2.40%) had a minor complication. 53 (0.74%) had bleeding complications, 148 (2.05%) had a surgical site infection (SSI), 352 (4.88%) RTOR, and 7 (0.01%) died within 30 days. Major complications (p = 0.005) and minor complications (p < 0.001) significantly increased as BMI increased. SSI and RTOR had increasing trends, but were not statistically significant.

CONCLUSIONS

This study characterizes the risk of complications in women undergoing unilateral mastectomies and shows that increasing obesity is associated with major and minor postoperative complications. Our finding highlights the need for personalized preoperative risk assessment and counseling of obese patients.

Outcomes of immediate versus delayed breast reconstruction: Results of a multicenter prospective study

BACKGROUND

Previous studies suggest that immediate reconstruction following mastectomy produces superior results over delayed procedures. However, for medical or oncological reasons, some patients may be poor candidates for immediate reconstruction. We compared complications and patient-reported outcomes between immediate and delayed breast reconstructions in a prospective, multicenter study.

METHODS

1957 patients (1806 immediate, 151 delayed) met eligibility criteria. Demographic data, major complications, infections, and reconstructive failure rates were evaluated. Patient-reported outcomes were assessed with BREAST-Q, PROMIS, and EORTC QLQ-BR23 surveys, pre- and two years post-operatively. Subscale scores were compared across cohorts using mixed-effects regression models, controlling for patient characteristics and hospitals.

FINDINGS

Complete data were available in 1639 immediate and 147 delayed reconstruction patients. There were significant baseline differences between immediate and delayed cohorts in age, BMI, prevalence of diabetes, lymph node management, use of radiation, and chemotherapy. Controlling for clinical covariates, the delayed group had lower odds of any (OR 0.38, p < 0.001) and major (OR 0.52, p = 0.016) complications, compared with immediate patients. Furthermore, delayed reconstruction was associated with a significantly lower failure rates (6% vs. 1.3%, p = 0.032). However, multivariate analyses found no significant differences in patient satisfaction or in psychosocial, sexual, or physical well-being at two years.

CONCLUSIONS

Compared with immediate techniques, delayed reconstruction following mastectomy was associated with lower rates of overall and major complication, while providing equivalent patient satisfaction and quality of life benefits. Although immediate reconstruction is still the preferred choice of most patients and surgeons, delaying reconstruction does not appear to compromise clinical or patient-reported outcomes.

Assessing the effort associated with teaching residents

BACKGROUND

Intraoperative resident education is an integral mission of academic medical centers and serves as the basis for training the next generation of surgeons. The actual effort associated with teaching residents is unknown as it pertains to additional operative time. Using a large validated multi-institutional dataset, this study aims to quantify the effect of having a resident present in common plastic surgery procedures on operative time. Future directions for developing standardized methods to record and report teaching time are proposed, which can help inform prospective studies.

STUDY DESIGN

The 2006-2012 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried to identify seven isolated plastic surgical procedures that were categorized based on resident involvement and supervision. Linear regression models were used to calculate the difference in operative time with respect to resident participation while controlling for patient and operative factors.

RESULTS

Resident involvement was associated with longer operative times for muscle flap trunk procedures (53 min, 95% CI = [25, 80], p-value = 0.0002) and breast reconstruction procedures with a latissimus dorsi flap (55 min, 95% CI = [22, 88], p-value = 0.001). For six of the seven surgeries evaluated, resident involvement was associated with longer operative times, as compared to no resident involvement.

CONCLUSION

Resident involvement is associated with an increase in operative time for certain plastic surgery procedures. This finding underscores the need for a mechanism to quantify the time and effort that the attending surgeons allocate toward intraoperative resident education. Further study is also necessary to determine the causal impact on patient care.

Defining the Association between Diabetes and Plastic Surgery Outcomes: An Analysis of Nearly 40,000 Patients

Background:

Diabetes is an increasingly prevalent comorbidity in patients presenting for surgery, impacting nearly 14% of adults in the United States. Although it is known that diabetic patients are at an increased risk for postoperative complications, there is a paucity of literature on the specific ramifications of diabetes on different surgical procedures.

Methods:

Using the American College of Surgeons National Surgical Quality Improvement Program dataset, demographics, outcomes, and length of in-patient hospitalization were examined for patients who underwent plastic surgery between 2007 and 2012. Adjusted multivariable logistic regression models were used to assess the relationship between diabetes status and a spectrum of medical and surgical postoperative outcomes.

Results:

Thirty-nine thousand four hundred seventy-five plastic surgery patients were identified, including 1,222 (3.10%) with insulin-dependent diabetes mellitus (IDDM) and 1,915 (4.75%) with non–insulin-dependent diabetes mellitus (NIDDM), who had undergone breast, hand/upper and lower extremity, abdominal, or craniofacial procedures. Logistic regression analyses showed that only insulin-dependent diabetics had a higher likelihood of surgical complications (IDDM: P value < 0.0001; NIDDM: P value < 0.103), whereas patients with both IDDM and NIDDM had increased likelihoods of medical complications (IDDM: P value < 0.001; NIDDM: P value = 0.0093) compared with nondiabetics. Average hospital stay for diabetics was also longer than for nondiabetics.

Conclusions:

Diabetes is associated with an increase in a multitude of postoperative complications and in hospital length of stay, in patients undergoing plastic surgery. Diabetes status should thus be evaluated and addressed when counseling patients preoperatively. Risks may be further stratified based on IDDM versus NIDDM status.

Patient determinants as independent risk factors for postoperative complications of breast reconstruction

BACKGROUND

Breast reconstruction is an essential component in the treatment of breast cancer. Postoperative complications after breast reconstruction are common and affect patient satisfaction. Determining independent risk factors using patient characteristics could be advantageous for patient assessment and counseling.

METHODS

We retrospectively enrolled 623 consecutive patients who underwent reconstruction with a deep inferior epigastric perforator flap (DIEP), latissimus dorsi flap (LD), lateral thoracodorsal flap (LTDF), or tissue expander with a secondary implant (EXP) in this study. Information on demographic and perioperative factors was collected, as well as information on all postoperative complications. Logistic regression was used to analyze associations between possible patient-related risk factors and postoperative complications.

RESULTS

Smoking was associated with the highest number of early overall complications [odds ratio (OR) 2.05, 95% confidence interval (CI) 1.25-3.37, P=0.0005], followed by body mass index (BMI) (OR 1.07, 95% CI 1.01-1.13, P=0.017). High BMI was associated with the highest number of late overall postoperative complications (OR 1.06, 95% CI 1.00-1.11, P=0.042), followed by history of radiotherapy (OR 1.66, 95% CI 1.01-2.74, P=0.046). When the risk factors were combined, the risk for postoperative complications rose exponentially.

CONCLUSIONS

Our results provide evidence that patients should cease smoking and overweight patients should lose weight before undergoing breast reconstruction. Additionally, if the patient has received radiotherapy, the reconstruction method should be carefully chosen. High BMI, history of radiotherapy, and smoking are independent risk factors for many types of both early and late postoperative complications in breast reconstructive surgery. Combining these risk factors multiplies the risk of postoperative complications.

Trends in immediate breast reconstruction and early complication rates among older women: A big data analysis

BACKGROUND

Although approximately 57% of breast cancer (BC) diagnoses are in older patients (>60 years), only 4.1-14% receives breast reconstruction (BR). This has been attributed to physician concerns about operative complications. This paper aims to: 1) analyze the 30-day complication rates in the older patient population undergoing immediate breast reconstruction (IBR); and 2) analyze links between complication type and category of reconstruction.

METHODS

Using the ACS-NSQIP database (2005-2014), all women older than 60 years of age diagnosed with BC and DCIS were identified. IBR and complication rates were plotted for all ages. Patients were divided into those with and those without complications. Patient demographics and co-morbidities were compared. Complications within each type of reconstruction were analyzed.

RESULTS

Of the 4450 BC and 1104 DCIS patients, 22.3% (BC) and 20.9% (DCIS) had complications. IBR decreased significantly with increased age (P < 0.00 in both cohorts), while complication rates remained stable across all ages (P = 0.32 in BC, P = 0.69 in DCIS patients). Patients were well matched in terms of demographics.

CONCLUSIONS

The rates of breast reconstruction decrease with increasing age. Despite increasing age, associated complication rates in IBR patients remained stable.

Does neoadjuvant chemotherapy affect morbidity, mortality, reoperations, or readmissions in patients undergoing lumpectomy or mastectomy for breast cancer?

BACKGROUND

The influence of neoadjuvant chemotherapy (NAC) prior to breast cancer surgery on postoperative complications is unclear. Our objective was to determine whether NAC was associated with postoperative outcomes in patients undergoing lumpectomy or mastectomy without reconstruction.

METHODS

Patients meeting inclusion criteria were identified from the National Surgical Quality Improvement Program (NSQIP) database participant user files from 2005 through 2012, after which NSQIP discontinued the NAC variable. Primary outcome measures included a composite measure of morbidity and mortality (M&M) and reoperations and readmissions within 30 days of the index procedure. Rates of postoperative complications stratified by receipt of NAC were compared by χ2. A logistic regression model was then built that included confounding factors for M&M.

RESULTS

There were 30,309 patients meeting inclusion criteria. NAC was not associated with any postoperative outcomes from 2005 through 2012, but it was associated with higher M&M in lumpectomy patients during 2011 to 2012 [P=0.011, odds ratio (OR) 2.579; 95% confidence interval (CI), 1.239-5.368].

CONCLUSIONS

The finding that NAC was associated with higher M&M in lumpectomy patients during 2011 to 2012 warrants further investigation. Therefore, we recommend that the NSQIP database reinstitute the NAC variable to allow monitoring during anticipated changes in chemotherapy agents and protocols.

The Effect of Timing on Breast Reconstruction Outcomes in Diabetic Women

Background:

This study examines the effect of timing (immediate vs delayed) on postoperative morbidity in diabetic women undergoing breast reconstruction after mastectomy.

Methods:

We reviewed the National Surgical Quality Improvement Program (NSQIP) databases from 2005 to 2012 for all diabetic women undergoing breast reconstruction. Multivariable logistic regression was used to estimate the risk of 30-day overall complications in the immediate versus delayed cohorts. Additionally, we retrospectively reviewed outcomes for all Johns Hopkins Hospital diabetic patients undergoing breast reconstruction from 2005 to 2014.

Results:

In the NSQIP, 1,408 diabetic women underwent breast reconstruction: 958 (68%) immediate and 450 (32%) delayed. In the immediate group, 10.75% of patients developed a 30-day overall complication, compared with 7.78% of patients in the delayed group. On multivariable analysis, the odds of developing 30-day overall complications were significantly higher (adjusted odds ratio = 1.68; P = 0.033) for the immediate compared with the delayed cohort. In the Johns Hopkins Hospital cohort, 114 reconstructions were performed in 52 diabetic women: 59 (51.8%) immediate and 55 (47.2%) delayed. On long-term follow-up (median = 16.5 months), 41.0% of immediate reconstructions developed a surgical complication compared with 27.8% of delayed reconstructions. Deep infections (P = 0.026), seroma formation (P = 0.003), reconstruction failure (P = 0.001), and reoperation rates (P = 0.001) were significantly increased in the immediate cohort.

Conclusions:

Among diabetics seeking breast reconstruction, delaying the reconstructive surgery from the mastectomy is associated with decreased postoperative morbidity. It also appears that the 30-day postoperative time point available in the NSQIP does not fully reflect the magnitude of the long-term complications these diabetic patients will develop.

Obesity and Breast Cancer Prognosis: Evidence, Challenges, and Opportunities

Purpose To summarize the evidence of an association between obesity and breast cancer prognosis. Methods We reviewed the literature regarding overweight and obesity and breast cancer survival outcomes, overall and with regard to breast cancer subtypes, breast cancer therapies, biologic mechanisms, and possible interventions. We summarize our findings and provide clinical management recommendations. Results Obesity is associated with a 35% to 40% increased risk of breast cancer recurrence and death and therefore poorer survival outcomes. This is most clearly established for estrogen receptor-positive breast cancer, with the relationship in triple-negative and human epidermal growth factor receptor 2-positive subtypes less well established. A range of biologic mechanisms that may underlie this association has been identified. Weight loss and lifestyle interventions, as well as metformin and other obesity-targeted therapies, are promising avenues that require further study. Conclusion Obesity is associated with inferior survival in breast cancer. Understanding the nature and mechanisms of this effect provides an important opportunity for interventions to improve the diagnosis, treatment, and outcomes of obese patients with breast cancer.

Effect of Patient Age on Outcomes in Breast Reconstruction: Results from a Multicenter Prospective Study

BACKGROUND

Although >40% of new breast cancer diagnoses in the US are in older women, few studies have assessed the outcomes of post-mastectomy reconstruction in this population. Our objective was to evaluate age effects on postoperative complications and patient-reported outcomes in women undergoing breast reconstruction, and to investigate whether age effects differ between reconstructive procedure types.

STUDY DESIGN

Eligible patients in the Mastectomy Reconstruction Outcomes Consortium study from 11 institutions (57 providers) in North America were analyzed. Two-year complications and patient-reported outcomes via BREAST-Q domains were compared across younger (younger than 45 years), middle-aged (45 to 60 years), and older (older than 60 years) women. Mixed-effects regression models were used, controlling for a range of demographic and clinical covariates.

RESULTS

A total of 1,531 patients were studied: 494 younger, 803 middle-aged, and 234 older. Age was not a significant predictor of complications. For sexual well-being 2 years post-reconstruction, older women reported 4.25 (p = 0.04) higher mean scores with implant procedures, and 10.39 (p < 0.01) higher mean scores with autologous procedures compared with younger women. No age effect was seen with implant procedures with regard to physical and psychosocial well-being; however, older women who underwent autologous procedures reported 6.07 (p < 0.01) higher physical, and 8.21 (p < 0.01) higher psychosocial well-being scores than younger women.

CONCLUSIONS

Age did not significantly affect complication rates. Older women demonstrated higher sexual well-being for both procedures, and better satisfaction and physical and psychosocial well-being than younger women with autologous procedures. Post-mastectomy reconstruction is a viable option for older patients, with risks and benefits comparable with those in younger women.

Relationship Between Comorbid Conditions and Utilization Patterns of Immediate Breast Reconstruction Subtypes Post-mastectomy

There is limited information on the influence of a patient's comorbid status on the type of immediate breast reconstruction (IBR) selected. Our aim was to provide a population-based review of the relationship between baseline comorbid conditions and IBR subtype selected. This is a retrospective cohort study using the National Surgical Quality Improvement Program database to identify IBR recipients. Multivariable regression analyses was performed to identify the association between comorbidity and IBR subtype selection (prosthetic, pedicled, and free autologous). A total of 48,096 mastectomy patients were identified, of which 17,404 patients received IBR. IBR patients were younger (51 ± 10.4 versus 61.5 ± 13.6 years) and had a lower body mass index (27.1 ± 6.4 versus 28.9 ± 7.3) relative to patients who did not pursue IBR (p < 0.001 for all). Overall, IBR patients had a significantly lower incidence of comorbid conditions. In adjusted models, patients aged 45-64 years were more likely to pursue pedicled-autologous reconstruction (OR: 1.43, p < 0.001) and those older than 65 years were less likely to undergo free-autologous reconstruction (OR: 0.64, p = 0.02). Class I and II obesity was associated with pedicled (class I OR: 1.57, class II OR: 1.41) and free transfer (class I OR: 1.81, class II OR: 1.66) autologous IBR utilization (all p < 0.001). Also, smoking was related to increased chance of prosthetic reconstruction while preoperative radiotherapy was linked to free-autologous IBR. IBR patients were noted to be healthier than their non-IBR counterparts, and each IBR subtype was associated with a particular comorbidity profile. This has significant implications with regard to creation of an IBR-predictive model. Such a tool will improve preoperative counseling and decision making.

Incidence of Surgical Site Infection Following Mastectomy With and Without Immediate Reconstruction Using Private Insurer Claims Data

OBJECTIVE

The National Healthcare Safety Network classifies breast operations as clean procedures with an expected 1%-2% surgical site infection (SSI) incidence. We assessed differences in SSI incidence following mastectomy with and without immediate reconstruction in a large, geographically diverse population.

DESIGN

Retrospective cohort study.

PATIENTS

Commercially insured women aged 18-64 years with ICD-9-CM procedure or CPT-4 codes for mastectomy from January 1, 2004 through December 31, 2011 METHODS: Incident SSIs within 180 days after surgery were identified by ICD-9-CM diagnosis codes. The incidences of SSI after mastectomy with and without immediate reconstruction were compared using the χ2 test.

RESULTS

From 2004 to 2011, 18,696 mastectomy procedures among 18,085 women were identified, with immediate reconstruction in 10,836 procedures (58%). The incidence of SSI within 180 days following mastectomy with or without reconstruction was 8.1% (1,520 of 18,696). In total, 49% of SSIs were identified within 30 days post-mastectomy, 24.5% were identified 31-60 days post-mastectomy, 10.5% were identified 61-90 days post-mastectomy, and 15.7% were identified 91-180 days post-mastectomy. The incidences of SSI were 5.0% (395 of 7,860) after mastectomy only, 10.3% (848 of 8,217) after mastectomy plus implant, 10.7% (207 of 1,942) after mastectomy plus flap, and 10.3% (70 of 677) after mastectomy plus flap and implant (P<.001). The SSI risk was higher after bilateral compared with unilateral mastectomy with immediate reconstruction (11.4% vs 9.4%, P=.001) than without (6.1% vs 4.7%, P=.021) immediate reconstruction.

CONCLUSIONS

SSI incidence was twice that after mastectomy with immediate reconstruction than after mastectomy alone. Only 49% of SSIs were coded within 30 days after operation. Our results suggest that stratification by procedure type facilitates comparison of SSI rates after breast operations between facilities.

Advanced age is a predictor of 30-day complications after autologous but not implant-based postmastectomy breast reconstruction

BACKGROUND

Older breast cancer patients undergo postmastectomy breast reconstruction infrequently, in part because of a perception of increased surgical risk. This study sought to investigate the effects of age on perioperative complications after postmastectomy breast reconstruction.

METHODS

The American College of Surgeons National Surgery Quality Improvement Program Participant Use Files from 2005 to 2012 were used to identify women with breast cancer who underwent unilateral mastectomy alone or with immediate reconstruction. Thirty-day complication rates were compared between younger (<65 years) and older (≥65 years) women after implant-based reconstruction, autologous reconstruction, or mastectomy alone. Linear and logistic regression models were used to control for differences in comorbidities and age.

RESULTS

A total of 40,769 patients were studied, of whom 15,093 (37 percent) were aged 65 years or older. Breast reconstruction was performed in 39.5 percent of younger and 10.7 percent of older women. The attributable risks of breast reconstruction, manifested by longer hospital stays (p < 0.001), more frequent complications (p < 0.001), and more reoperations (p < 0.001), were similar in older and younger women. There were no differences in the adjusted complication rates between older and younger patients undergoing implant-based reconstruction. However, older women undergoing autologous reconstruction were more likely to suffer venous thromboembolism (OR, 3.67; p = 0.02).

CONCLUSIONS

The perioperative risks attributable to breast reconstruction are similar in older and younger women. Older patients should be counseled that their age does not confer an increased risk of complications after implant-based breast reconstruction. However, age is an independent risk factor for venous thromboembolism after autologous reconstruction. Special attention should be paid to venous thromboembolism prophylaxis in this group.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Predictors of complications in gynaecological oncological surgery: a prospective multicentre study (UKGOSOC-UK gynaecological oncology surgical outcomes and complications)

BACKGROUND

There are limited data on surgical outcomes in gynaecological oncology. We report on predictors of complications in a multicentre prospective study.

METHODS

Data on surgical procedures and resulting complications were contemporaneously recorded on consented patients in 10 participating UK gynaecological cancer centres. Patients were sent follow-up letters to capture any further complications. Post-operative (Post-op) complications were graded (I-V) in increasing severity using the Clavien-Dindo system. Grade I complications were excluded from the analysis. Univariable and multivariable regression was used to identify predictors of complications using all surgery for intra-operative (Intra-op) and only those with both hospital and patient-reported data for Post-op complications.

RESULTS

Prospective data were available on 2948 major operations undertaken between April 2010 and February 2012. Median age was 62 years, with 35% obese and 20.4% ASA grade ⩾3. Consultant gynaecological oncologists performed 74.3% of operations. Intra-op complications were reported in 139 of 2948 and Grade II-V Post-op complications in 379 of 1462 surgeries. The predictors of risk were different for Intra-op and Post-op complications. For Intra-op complications, previous abdominal surgery, metabolic/endocrine disorders (excluding diabetes), surgical complexity and final diagnosis were significant in univariable and multivariable regression (P<0.05), with diabetes only in multivariable regression (P=0.006). For Post-op complications, age, comorbidity status, diabetes, surgical approach, duration of surgery, and final diagnosis were significant in both univariable and multivariable regression (P<0.05).

CONCLUSIONS

This multicentre prospective audit benchmarks the considerable morbidity associated with gynaecological oncology surgery. There are significant patient and surgical factors that influence this risk.

Infections after breast surgery: potential ways to reduce infection rates

SUMMARY 

Breast infection rates are higher than expected for clean cases and are decreased with the use of prophylactic preoperative antibiotics. Surgical care bundles include evidence-based measures such as selection of preoperative antibiotics to cover skin flora, skin preparation, stopping antibiotics within 24 h, normothermia and hair removal. Glycemic control should be addressed but there is no additional benefit with tight control. Drain antisepsis provides a promising new approach to reducing infections in breast operations that use surgical drains. Other surgical disciplines have shown benefit with methicillin-resistant Staphylococcus aureus decolonization, vancomycin powder application and use of gentamicin-impregnated collagen plugs.

Mastectomy with or without immediate implant reconstruction has similar 30-day perioperative outcomes

BACKGROUND

Immediate breast reconstruction (IBR) using implants remains a favorable reconstructive option in breast cancer. Understanding the added risk associated with IBR continues to enhance the risk counseling process and management of these patients.

METHODS

Women undergoing mastectomy alone and mastectomy with tissue expander (TE) were identified in the ACS-NSQIP datasets. Specific complications examined included any, wound, medical complications, and deep infections. Bivariate and multivariate analyses were performed to identify predictors of outcomes, and propensity-matching was used to compare cohorts.

RESULTS

A total of 42,823 patients who underwent either mastectomy alone (N = 30,440) or mastectomy with immediate TE placement (N = 12,383) were identified. Notable independently associated perioperative differences between mastectomy and TE patients included: race (P < 0.001), comorbidity burden (P < 0.001), year of surgery (P < 0.001), ASA physical status (P < 0.001), functional status (P < 0.001), inpatient procedures (P < 0.001), bilateral procedures (P < 0.001), BMI (P < 0.001), age (P < 0.001), and lymphadenectomy (P < 0.001). IBR using TE was not found to be associated with greater risk of wound (3.3% vs. 3.2%, P = 0.855), medical (1.7% vs. 1.6%, P = 0.751), or overall (9.6% vs. 10.0%, P = 0.430) complications. TE placement was associated with higher rates of deep wound infections (2.0% vs. 1.0%, P < 0.001) and unplanned reoperations (6.9% vs. 6.1%, P = 0.025). Additionally, the rate of 30-day device loss was 0.8% in patients receiving reconstruction. Multivariate conditional (fixed-effects) logistic regression analysis failed to demonstrate significantly associated independent risk of wound, medical, or overall complications with the addition of TE.

CONCLUSIONS

Undergoing IBR with TE placement does not confer added risk of wound, medical, or overall morbidity relative to mastectomy alone based upon propensity-matched 30-day complication rates in 15,238 patients from the 2005-2011 ACS-NSQIP datasets. These findings further confirm the safety profile of prosthetic-based IBR.

LEVEL OF EVIDENCE

Prognostic/risk category, level II.