John Y. S. Kim

A meta-analysis of human acellular dermis and submuscular tissue expander breast reconstruction

Background: Human acellular dermal matrix has become an increasingly used adjunct to traditional submuscular tissue expander/implant breast reconstruction, but there is no strong consensus regarding complication outcomes. This study stratified outcomes based on a meta-analysis of complications. Methods: A query of the MEDLINE database for articles on human acellular dermal matrix and submuscular tissue expander breast reconstruction yielded 901 citations. Two levels of screening identified 48 relevant studies. The DerSimonian and Laird random-effects model was used to perform the meta-analysis. Risk ratios and pooled complication rates were calculated for each outcome of interest. Results: Nineteen studies reporting human acellular dermal matrix (n = 2037) and 35 reporting submuscular outcomes (n = 12,847) were used to estimate complication rates. Rates were generally higher in acellular dermis patients: total complications, 15.4 versus 14.0 percent; seroma, 4.8 versus 3.5 percent; infection, 5.3 versus 4.7 percent; and flap necrosis, 6.9 versus 4.9 percent. Six studies reporting both acellular dermis and submuscular outcomes were used to estimate relative risks. There was an increased risk of total complications (relative risk, 2.05; 95 percent CI, 1.55 to 2.70), seroma (relative risk, 2.73; 95 percent CI, 1.67 to 4.46), infection (relative risk, 2.47; 95 percent CI, 1.71 to 3.57), and reconstructive failure (relative risk, 2.80; 95 percent CI, 1.76 to 4.45) in acellular dermis patients. Conclusions: The meta-analysis suggests that the use of human acellular dermal matrix increases complication rates vis-à-vis submuscular expander/implant reconstruction. This must be weighed against its reported advantages in enhancing cosmesis and ameliorating contracture. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

An Innovative Technique of Vertebral Body Stapling for the Treatment of Patients With Adolescent Idiopathic Scoliosis : A Feasibility, Safety, and Utility Study

Study Design. Retrospective review. Objectives. To report the feasibility, safety, and utility of vertebral body stapling without fusion as an alternative treatment for adolescent idiopathic scoliosis. Summary of Background Data. The success rate of brace treatment of adolescent idiopathic scoliosis ranges from 50% to 82%. However, poor self-image and brace compliance are issues for the patient. An alternative method of treatment such as a motion-preserving vertebral body stapling to provide curve stability would be desirable. Methods. We retrospectively reviewed 21 patients (27 curves) with adolescent idiopathic scoliosis treated with vertebral body stapling. Patients were immature as defined by Risser sign ≤2. Results. The concept of vertebral body stapling of the convex side of a patient with adolescent idiopathic scoliosis is feasible. The procedure was safe, with no major complications and three minor complications. One patient had an intraoperative segmental vein bleed resulting in an increased estimated blood loss of 1500 cc as compared to the average estimated blood loss of 247 cc for all patients. One patient had a chylothorax and one pancreatitis. No patient has had a staple dislodge or move during the follow-up period (mean 11 months, range 3–36 months), and no adverse effects specifically from the staples have been identified. Utility (defined as curve stability) was evaluated in 10 patients with stapling with greater than 1-year follow-up (mean 22.6 months) and preoperative curve <50°. Progression of ≥6° or beyond 50° was considered a failure of treatment. Of these 10 patients, 6 (60%) remained stable or improved and 4 (40%) progressed. One of 10 (10%) in the stapling group had progressed beyond 50° and went on to fusion. Six patients required stapling of a second curve, three as part of the primary surgery, and three as a second stage, because a second untreated curve progressed. The results need to be considered with caution, as the follow-up is still short. Conclusions. The data demonstrate that vertebral body stapling for the treatment of scoliosis in the adolescent was feasible and safe in this group of 21 patients. In the short-term, stapling appears to have utility in stabilizing curves of progressive adolescent idiopathic scoliosis.

Injectable fillers for facial rejuvenation: a review

Health care practices are moving toward a more preventative focus. In addition to leading healthier lives and seeking help to eradicate disease, patients are enlisting the help of plastic surgeons to reduce the visible signs of aging. Traditionally, facial rejuvenation focused on skin tightening through resection and resurfacing. In recent years, increasing emphasis has been placed on minimally invasive cosmetic improvement. Today, plastic surgeons combat the effects of aging with a variety of non-incisional methods such as soft-tissue augmentation with facial fillers. A multitude of soft-tissue fillers exist, each with their own chemical constituents, indications, and effectiveness. It is imperative that plastic surgeons understand these agents when treating patients with cosmetic complaints.

Tissue Expander Breast Reconstruction Using Prehydrated Human Acellular Dermis

Introduction:Human acellular dermal matrices help facilitate immediate tissue expander-implant breast reconstruction by providing support to the inferolateral pole, improving control of implant position, and enhancing early volume expansion. Although several freeze-dried human acellular dermal products have demonstrated reasonable safety and efficacy in immediate tissue expander-implant breast reconstruction, no dedicated studies have evaluated clinical outcomes of prehydrated human acellular dermal matrix (PHADM) in breast reconstruction. Methods:The outcomes of 121 consecutive tissue expander reconstructions performed by the senior author using PHADM were evaluated. Results:Mean intraoperative tissue expander fill volume was 256.6 ± 133 mL, 60% of final expander volume. Patients required an average of 3.2 additional expansions prior to tissue expander-to-implant exchange. Mean follow-up period after reconstruction was 44 ± 26.5 weeks. Complications occurred in 20 (16.5%) breasts, including 9 (7.4%) soft-tissue infections, 8 (6.6%) partial mastectomy flap necroses, and 2 (1.7%) seromas. Eleven (9.1%) breasts ultimately required explantation. Patients receiving radiation demonstrated a strong trend toward greater complications (30.8% vs. 13.7%, P = 0.0749). Conclusions:The outcomes and complication rates of PHADM tissue expander breast reconstruction are comparable to those reported with freeze-dried human acellular dermis.

Surgical Duration and Risk of Venous Thromboembolism

IMPORTANCE There is a paucity of data assessing the effect of increased surgical duration on the incidence of venous thromboembolism (VTE). OBJECTIVE To examine the association between surgical duration and the incidence of VTE. DESIGN, SETTINGS, AND PARTICIPANTS Retrospective cohort of 1,432,855 patients undergoing surgery under general anesthesia at 315 US hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program from 2005 to 2011. EXPOSURE Duration of surgery. MAIN OUTCOMES AND MEASURES The rates of deep vein thrombosis (DVT), pulmonary embolism (PE), and VTE within 30 days of the index operation. Surgical duration was standardized across Current Procedural Terminology codes using a z score. Outcomes were compared across quintiles of the z score. Multiple logistic regression models were developed to examine the association while adjusting for patient demographics, clinical characteristics, and comorbidities. RESULTS The overall VTE rate was 0.96% (n = 13,809); the rates of DVT and PE were 0.71% (n = 10,198) and 0.33% (n = 4772), respectively. The association between surgical duration and VTE increased in a stepwise fashion. Compared with a procedure of average duration, patients undergoing the longest procedures experienced a 1.27-fold (95% CI, 1.21-1.34; adjusted risk difference [ARD], 0.23%) increase in the odds of developing a VTE; the shortest procedures demonstrated an odds ratio of 0.86 (95% CI, 0.83-0.88; ARD, -0.12%). The robustness of these results was substantiated with several sensitivity analyses attempting to minimize the effect of outliers, concurrent complications, procedural differences, and unmeasured confounding variables. CONCLUSIONS AND RELEVANCE Among patients undergoing surgery, an increase in surgical duration was directly associated with an increase in the risk for VTE. These findings may help inform preoperative and postoperative decision making related to surgery.

Autologous Options for Postmastectomy Breast Reconstruction: A Comparison of Outcomes Based on the American College of Surgeons National Surgical Quality Improvement Program

BACKGROUND The postmastectomy patient faces a plethora of choices when opting for autologous breast reconstruction; however, multi-institutional data comparing the available techniques are lacking. The National Surgical Quality Improvement Program (NSQIP) database provides a robust patient cohort for comparing outcomes and determining independent predictors of complications for each autologous method. STUDY DESIGN The NSQIP database was retrospectively reviewed from 2006 to 2010, identifying 3,296 autologous breast reconstruction patients. Univariate analyses compared complication and reoperation rates. Multivariable logistic regression analyses of 4 cohorts (free flaps, pedicled transverse rectus abdominis myocutaeous (TRAM) flaps, latissimus, and all flaps in aggregate) determined complication rates and independent risk factors for complications and specific outcomes of interest (surgical site infection [SSI], flap failure, reoperation) in all flap types. RESULTS American Society of Anesthesiologists (ASA) classification ≥ 3, body mass index > 30 kg/m(2), recent surgery, delayed reconstruction, and prolonged operative times are significant predictors of increased complications in autologous reconstructions. Rates of complications, flap failure, and reoperation were highest in the free tissue transfer group (p < 0.001). Latissimus flaps showed significantly lower rates of complications than other autologous methods (p < 0.001). Pedicled TRAM patients had the highest incidences of venous thromboembolic disease and SSI. CONCLUSIONS This large-scale, multicenter evaluation of outcomes in autologous breast reconstruction found that free flaps have the highest captured 30-day complication and reoperation rates of any autologous reconstructive method; complications in latissimus flaps were surprisingly few. Pedicled TRAM and latissimus flaps remain the most commonly used autologous reconstructive methods. In addition to providing statistically robust outcomes data, this study contributes significantly to patient education and preoperative planning discussions.

Operative duration as an independent risk factor for postoperative complications in single-level lumbar fusion: an analysis of 4588 surgical cases.

Study Design. Multicenter retrospective cohort study. Objective. To estimate the impact of increasing surgical duration on outcomes after single-level lumbar fusion. Summary of Background Data. Lumbar fusion is a widely used practice for the treatment of disability and chronic low back pain. Longer operative duration is shown to correlate with increased morbidity and mortality in various surgical disciplines, but no large-scale study has been performed to validate this relationship in lumbar spine surgery. Methods. The American College of Surgeons National Surgical Quality Improvement Program was retrospectively reviewed to identify all patients who underwent lumbar fusion procedures during 2006 to 2011. Thirty-day morbidity and mortality rates were reported on the basis of operative time, whereas multivariate logistic regression model was used to examine operative duration as an independent risk factor for outcomes. Results. A total of 4588 patients were included in the analysis. The mean operative duration for all patients was 197 ± 105 minutes. Our multivariate risk-adjusted regression models demonstrated that increasing operative time was associated with step-wise increase in risk for overall complications (odds ratio [OR], 2.09–5.73), medical complications (OR, 2.18–6.21), surgical complications (OR, 1.65–2.90), superficial surgical site infection (OR, 2.65–3.97), and postoperative transfusions (OR, 3.25–12.19). Operative duration of 5 hours or more was also associated with increased risk of reoperation (OR, 2.17), organ/space surgical site infection (OR, 9.72), sepsis/septic shock (OR, 4.41), wound dehiscence (OR, 10.98), and deep vein thrombosis (OR, 17.22). Conclusion. Our data suggest that increasing operative duration is associated with a wide array of complications. Operative duration is, therefore, an important quality metric in the performance of lumbar fusion. Strategies to reduce operative time and further research to identify risk factors that are associated with longer surgical duration are needed for improved patient outcomes. Level of Evidence: 3

Predictors of unplanned readmission in patients undergoing lumbar decompression: multi-institutional analysis of 7016 patients.

OBJECT Unplanned hospital readmission represents a large financial burden on the Centers for Medicare and Medicaid Services, commercial insurance payers, hospitals, and individual patients, and is a principal target for cost reduction. A large-scale, multi-institutional study that evaluates risk factors for readmission has not been previously performed in patients undergoing lumbar decompression procedures. The goal of this multicenter retrospective study was to find preoperative, intraoperative, and postoperative predictive factors that result in unplanned readmission (UR) after lumbar decompression surgery. METHODS The National Surgical Quality Improvement Program (NSQIP) database was retrospectively reviewed to identify all patients who received lumbar decompression procedures in 2011. Risk-adjusted multivariate logistic regression analysis was performed to estimate independent predictors of UR. RESULTS The overall rate of UR among patients undergoing lumbar decompression was 4.4%. After multivariate logistic regression analysis, anemia (odds ratio [OR] 1.48), dependent functional status (OR 3.03), total operative duration (OR 1.003), and American Society of Anesthesiologists Physical Status Class 4 (OR 3.61) remained as independent predictors of UR. Postoperative complications that were significantly associated with UR included overall complications (OR 5.18), pulmonary embolism (OR 3.72), and unplanned reoperation (OR 56.91). CONCLUSIONS There were several risk factors for UR after lumbar spine decompression surgery. Identification of high-risk patients and appropriate allocation of resources to reduce postoperative incidence may reduce the readmission rate.

Outcomes of tissue expander/implant breast reconstruction in the setting of prereconstruction radiation.

Background: Although the effects of postoperative radiation on tissue expander breast reconstruction are well documented, few data exist regarding the effects of prereconstruction radiation. This study evaluates the outcomes of tissue expander breast reconstruction in women with prereconstruction radiation. Methods: This study retrospectively evaluated two treatments: (1) mastectomy without reconstruction followed by postoperative radiation and delayed reconstruction (10 patients) and (2) failed breast-conserving therapy (lumpectomy plus radiotherapy) necessitating mastectomy and immediate reconstruction (66 patients). Procedures were performed at Northwestern Memorial Hospital between August of 1999 and July of 2008. Average follow-up was 35 months. Results: In both groups, approximately 60 percent of patients successfully completed two stages of reconstruction. Overall complication rates, including major and minor complications, were 70 percent per reconstruction (37 percent first stage, 45 percent second stage) for immediate reconstruction and 50 percent per reconstruction (20 percent first stage, 38 percent second stage) for delayed reconstruction. No differences in complication rates were observed based on age, smoking status, body mass index, or timing between radiation and surgery (p > 0.05). Conclusions: When discussing expander/implant reconstruction with patients who have a history of prior breast radiotherapy, a frank discussion of the risks, benefits, and alternatives should occur. If a 40 percent total explantation or conversion to flap rate is truly understood by the patient, and if immediate autologous breast reconstruction is to be avoided, then the patient may proceed with tissue expander breast reconstruction. For patients who wish to avoid additional scars or more invasive procedures, however, this study demonstrates that they have a 60 percent chance of success. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

ASA class is a reliable independent predictor of medical complications and mortality following surgery

METHODS The American Society of Anesthesiologists Physical Status classification system (ASA PS) is a method of characterizing patient operative risk on a scale of 1-5, where 1 is normal health and 5 is moribund. Every anesthesiologist is trained in this measure, and it is performed before every procedure in which a patient undergoes anesthesia. We measured the independent predictive value of ASA-PS for complications and mortality in the ACS-NSQIP database by multivariate regression. We conducted analogous regressions after standardizing ASA-PS to control for interprocedural variations in risk in the overall model and sub-analyses by surgical specialty and the most common procedures. RESULTS For 2,297,629 cases (2005-2012; median age 55, min = 16, max > 90 [90 and above are coded as 90+]), at increasing levels of ASA-PS (2-5), odds ratios (ORs) from 2.05 to 63.25 (complications, p < 0.001) and 5.77-2011.92 (mortality, p < 0.001) were observed, with non-overlapping 95% confidence intervals. Standardization of ASA-PS (OR = 1.426 [per standard deviation above the mean ASA-PS per procedure], p < .001) and subgroup analyses yielded similar results. DISCUSSION ASA PS was not only found to be associated with increased morbidity and mortality, but independently predictive when controlling for other comorbidities. Even after standardization based on procedure type, increases in ASA predicted significant increases in complication rates for morbidity and mortality post-operatively. CONCLUSIONS ASA PS has strong, independent associations with post-operative medical complications and mortality across procedures. This capability, along with its simplicity, makes it a valuable prognostic metric.