A Nationwide Analysis Evaluating the Safety of Using Acellular Dermal Matrix with Tissue Expander-Based Breast Reconstruction

Background  In March 2021, the United States Food and Drug Administration (FDA) safety communication cautioned against the use of acellular dermal matrix (ADM) products in breast reconstruction and reiterated that the FDA does not approve ADM use in breast surgery. This study aims to assess the safety of ADM use in breast reconstruction. Methods  Women who underwent ADM and non-ADM assisted tissue expander (TE)-based breast reconstruction were identified using the National Surgical Quality Improvement Program database (2012-2019). Trends of ADM use over time, and 30-day outcomes of surgical site infection (SSI), dehiscence, and unplanned reoperation were assessed. Results  Of the 49,049 TE-based breast reconstructive cases, 42.4% were ADM assisted and 57.6% non-ADM assisted. From 2012 to 2019, the use of ADM increased from 26.1 to 55.6% (relative risk [RR] =1.10; p  < 0.01). Higher rates of SSI (3.9 vs. 3.4%; p  = 0.003) and reoperation (7.4 vs. 6.0%; p  < 0.001) were seen in the ADM cohort. There was no significant difference seen in dehiscence rates (0.7 vs. 0.7%; p  = 0.73). The most common reoperation within 30 days for the ADM group (17.6%) was removal of TE without insertion of implant (current procedural terminology: 11,971). ADM-assisted breast reconstruction was associated with increased relative risk of SSI by 10% (RR = 1.10, confidence interval [CI]: 1.01-1.21; p  = 0.03) and reoperation by 15% (RR = 1.15, CI: 1.08-1.23; p  < 0.001). Conclusions  ADM-assisted breast reconstruction more than doubled from 2012 to 2019. There are statistically higher complication rates of SSI (0.5%) and reoperation (1.4%) with ADM use in TE-based breast reconstruction, suggesting that reconstruction without ADM is safe when comparing immediate postoperative outcomes.

Analysis of Readmissions and Reoperations in Pediatric Microvascular Reconstruction

BACKGROUND

 Free tissue transfer is utilized as a reconstructive option for various anatomic defects. While it has long been performed in adults, reconstructive surgeons have used free tissue transfer to a lesser degree in children. As such, there are few analyses of factors associated with complications in free tissue transfer within this population. The aim of this study is to assess factors associated with readmission and reoperation in pediatric free flap patients utilizing the pediatric National Surgical Quality Improvement Program database.

METHODS

 Pediatric patients who underwent microvascular reconstruction between 2015 and 2020 were included. Patients were identified by five microvascular reconstruction Current Procedural Terminology codes and were then stratified by flap site (head and neck, extremities, trunk) and defect etiology (congenital, trauma, infection, neoplasm). Multivariate logistic regression was performed to identify factors associated with readmissions and reoperations.

RESULTS

 The study cohort consisted of 258 patients. The average age was 10.0 ± 4.7 years and the majority of patients were male (n = 149, 57.8%), were of white race (n = 164, 63.6%), and had a normal body mass index. Twenty-two patients (8.5%) experienced an unplanned readmission within 30 days of the initial operation, most commonly for wound disruption (31.8% of readmissions). The overall rate of unplanned reoperation within 30 days was 11.6% (n = 30) for all patients, with an average of 8.9 ± 7.5 days to reoperation. On multivariate regression analysis, each hour increase in operative time was associated with an increased odds of reoperation (odds ratio [OR]: 1.27; 95% confidence interval [CI]: 1.12, 1.45) and readmission (OR: 1.16; 95% CI: 1.02, 1.34).

CONCLUSION

 In pediatric patients undergoing free tissue transfer, higher readmission and reoperation risk was associated with longer operative duration. Overall, free tissue transfer is safe in the pediatric population with relatively low rates of readmission and reoperation.

Characterizing the volume of surgery and post-operative complications during the COVID-19 pandemic

PURPOSE

The COVID-19 pandemic led to unprecedented changes in volume and quality of surgery. Utilizing the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database, the current study assesses the impact of COVID-19 on surgical volume during each quarter of 2020 in comparison to 2019. Quality of surgical care during 2020 was also investigated by assessing postoperative complications, readmissions, and reoperations during 2020 in comparison to the previous 5 years.

MATERIALS AND METHODS

The NSQIP database was queried from 2015 to 2020. Descriptive statistics and a chi-squared test were utilized to compare demographic variables. A seasonal autoregressive integrated moving average time-series model was fit to assess the trend and seasonality of complications from 2015 to 2019 and was used to forecast the proportion of complications in the year 2020 and compared the forecast with the actual proportions graphically.

RESULTS

There were fewer patients operated on in 2020 compared to 2019, with the most dramatic drop in Q2 with a nearly 27% decrease. Patients with ASA class 3 or greater were operated on at a greater proportion in every quarter of 2020. Q2 of 2020 represented the highest proportion of any operative complications since 2015 at ~13%. Q4 of 2020 demonstrated a return to 2020 Q1 complication proportions.

CONCLUSION

Surgical volume was heavily affected in 2020, particularly in Q2. Patients during Q2 of 2020 were generally of a higher ASA class and had increased operative complications. Operative volume and overall surgical complication rate normalized over the next two quarters.

The Effects of Obesity and Bariatric Surgery on Rates of Upper Extremity Compression Neuropathies

Objectives

To estimate the effects of obesity on all types of upper extremity compression neuropathies (UECN) (carpal tunnel syndrome and other median nerve, radial nerve, and ulnar nerve compression neuropathies) and to assess whether bariatric surgery modifies these effects.

Background

UECN are increasingly prevalent and decrease the quality of life of affected individuals. Studies suggest obesity as a risk factor for carpal tunnel syndrome, the most common type of UECN.

Methods

A retrospective cohort study was conducted using the PearlDiver Mariner Database, an all-payor claims database containing claims for over 53 million patients from 2010 to 2019 in all 50 US states. Rates and odds of all types of UECN were compared between 1:1:1 exact matched cohorts of obese patients who were medically managed, obese patients who underwent bariatric surgery, and nonobese patients (111,967 patients in each cohort).

Results

Compared with nonobese patients, patients with obesity were significantly more likely to develop any UECN (odds ratio [OR], 1.13; 95% confidence interval [CI], 1.09-1.18), carpal tunnel syndrome (OR, 1.15; 95% CI, 1.10-1.30), and 2 or more UECN (OR, 1.34; 95% CI, 1.20-1.48). Compared with obese patients who were managed medically, obese patients who underwent bariatric surgery were significantly less likely to develop any UECN (OR, 0.87; 95% CI, 0.84-0.91) and carpal tunnel syndrome (OR, 0.85; 95% CI, 0.81-0.89).

Conclusions

Obese patients have higher odds of both single and concomitant UECN, specifically carpal tunnel syndrome, compared with nonobese patients. Bariatric surgery decreases the odds of developing UECN compared with obese patients not undergoing surgical intervention.