Stephen J. Kovach

Impact of Obesity on Outcomes in Breast Reconstruction: Analysis of 15,937 Patients from the ACS-NSQIP Datasets

BACKGROUND Obesity is a growing epidemic in the United States (US) affecting more than 33% of adults. We aimed to use the World Health Organization (WHO) obesity stratification scheme to assess the overall risk of obese patients undergoing breast reconstruction using the ACS-NSQIP database from 2005 to 2010. STUDY DESIGN We reviewed the 2005 to 2010 ACS-NSQIP databases identifying encounters for Current Procedural Terminology (CPT) codes including either implant-based reconstruction (immediate, delayed, and tissue expander) or autologous reconstruction (pedicled transverse rectus abdominis myocutaneous [pTRAM], free TRAM, and latissimus dorsi flap with or without implant). Patients were classified and compared based on WHO obesity criteria: nonobese (body mass index [BMI] = 20 to 29.9 kg/m(2)), class I (BMI = 30 to 34.9 kg/m(2)), class II (BMI = 35 to 39.9 kg/m(2)), and class III (BMI > 40 kg/m(2)). RESULTS During the study period 15,937 breast reconstructions were performed. The majority of reconstructions were immediate reconstructions (85.0%) and implant-based (79.1%). The incidence of obesity was 27.1%, with 16.3% defined as class I obese, 6.9% defined as class II obese, and 4.0% defined as class III obese. The WHO-classified obese patients tended to have a progressively higher incidence of comorbid conditions, higher American Society of Anesthesiologists (ASA) physical status (p < 0.001), longer operative times (p = 0.0001), and greater lengths of hospital stay (p = 0.0001). Progressively higher BMIs were associated with higher rates of complications, including wound (p < 0.001), medical (p < 0.001), infections (p < 0.001), major surgical (p < 0.001), graft and prosthesis loss (p < 0.001), and return to the operating room (p < 0.001). CONCLUSIONS This study characterized the effect of progressive obesity on the incidence of surgical and medical complications after breast reconstruction using a large, prospective multicenter dataset. Increasing obesity is associated with increased perioperative morbidity. Data derived from this cohort study can be used to risk-stratify patients, enhance risk counseling, and advocate for institutional reimbursement in obese patients undergoing breast reconstruction.

1000 consecutive venous anastomoses using the microvascular anastomotic coupler in breast reconstruction.

Background: Microvascular anastomosis is one of the more critical aspects of free flap surgery. A safe, effective, and expedient method for venous anastomosis minimizes flap ischemia time, is easier on the surgical team, and saves costly operating room time. The authors report on their experience using the Synovis microvascular anastomotic coupling device in 1000 consecutive venous anastomoses in free flap breast reconstruction. Methods: The authors retrospectively reviewed 1000 consecutive venous anastomoses that were performed using the microvascular anastomotic coupler between July of 2002 and July of 2008. Data were obtained on flap type, recipient vessel, coupler size, incidence of venous thrombosis, timing of venous thrombosis, and morbidity as a result of venous thrombosis. Results: All anastomoses were performed in an end-to-end fashion. There were 460 unilateral cases and 270 bilateral cases of breast reconstruction. Flap types included muscle-sparing free transverse rectus abdominis myocutaneous, deep inferior epigastric perforator, superficial inferior epigastric artery, superior gluteal artery perforator, and inferior gluteal artery perforator. The vast majority of the recipient vessels were the internal mammary or thoracodorsal vessels. Most of the couplers that were used were either 3 or 2.5 mm in diameter. Overall, there were six instances of venous thrombosis (rate of 0.6 percent). There were no total flap losses due to venous thrombosis in this series, although two patients had partial flap necrosis. Conclusions: The patency rate for venous anastomoses performed with the microvascular coupler is excellent when compared with standard suture techniques and has the advantage of overall easier application.

Comprehensive outcome and cost analysis of free tissue transfer for breast reconstruction: an experience with 1303 flaps.

Background: Free tissue transfer is standard for postoncologic reconstruction, yet it entails a lengthy operation and significant recovery. The authors present their longitudinal experience of free tissue breast reconstructions with an emphasis on predictors of major surgical and medical complications. Methods: The authors reviewed their prospectively maintained free flap database and identified oncologic breast reconstruction patients from 2005 to 2011. Factors associated with surgical and medical complications were identified using univariate analyses and logistic regression to determine predictors of complications. Results: Complications included major immediate surgical complications [n = 34 (4.0 percent)], major delayed surgical complications [n = 54 (6.4 percent)], minor surgical complications [n = 404 (47.6 percent)], and medical complications [n = 50 (5.9 percent)]. Obesity (p = 0.034), smoking (p = 0.06), flap type (p = 0.005), and recipient vessels (p < 0.001) were associated with immediate complications. Similarly, delayed surgical complications were associated with obesity (p < 0.001), chronic obstructive pulmonary disease (p < 0.001), hypertension (p < 0.001), and prior radiation therapy (p = 0.06). Regression analysis demonstrated that flap choice (p = 0.024) was independently associated with major immediate complications, and patient comorbidities such as chronic obstructive pulmonary disease (p = 0.001) and obesity (p < 0.0001) were associated with delayed complications. Patients who developed an immediate surgical complication experienced longer hospital stays (p < 0.0001), higher operating costs (p < 0.001), and greater hospital costs (p < 0.001). Conclusions: Early major complications are related to flap selection, whereas late major complications are associated with patient comorbidities. Overall, major surgical and medical complications are associated with increased hospital length of stay and greater cost in autologous breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Breast reconstruction with free tissue transfer from the abdomen in the morbidly obese.

Background: There are national trends of increasing incidence of morbid obesity and autologous breast reconstruction with free tissue transfer from the abdomen. The purpose of this study was to assess the safety and efficacy of free flap breast reconstruction in the morbidly obese population. Methods: A retrospective review was conducted on all patients who underwent transverse rectus abdominis myocutaneous, deep inferior epigastric perforator, or superficial inferior epigastric artery flap breast reconstructions between July of 2006 and October of 2008. Data from all patients with a body mass index greater than 40 were compared with those of patients with a body mass index less than 40. A p value less than 0.05 was considered significant. Significant findings were then analyzed in a post hoc fashion to examine trends with increasing body mass index. Results: Four hundred four patients underwent 612 free flap breast reconstructions during the study period. Twenty-five of these patients (6 percent) had a body mass index greater than 40. The morbidly obese group had significantly higher rate of total flap loss (p = 0.02), total major postoperative complications (p = 0.05), and delayed wound healing (p = 0.006). Conclusions: Free flap breast reconstruction in the morbidly obese is associated with a higher risk of total flap loss, total major postoperative complications, and delayed abdominal wound healing. However, the overall incidence of complications is low, making free tissue transfer from the abdomen an acceptable method of breast reconstruction in this patient population.

Free flap take-back following postoperative microvascular compromise: predicting salvage versus failure.

Background: The purpose of this study is twofold: (1) to stratify preoperative risk factors that predict successful free flap salvage and (2) to identify perioperative strategies that correlate with successful salvage. Methods: A retrospective chart review was performed on all free flaps performed from January of 2005 to April of 2011. The time until salvage was defined as the end of the initial procedure until the initiation of the salvage attempt. The primary endpoint, successful salvage, was defined as any flap that did not result in total loss. Results: A total of 2260 free flaps were reviewed, and 47 take-backs for delayed microvascular compromise were identified. Twenty-three of 47 flaps (49 percent) were salvaged. The mean time until take-back, presence of thrombophilia, and preoperative platelet counts were factors predictive of unsuccessful salvage. Preoperative platelet counts above 300 were associated with the lowest rates of salvage. Intraoperative maneuvers were examined, and surgeon experience (defined as >5 years in practice) was the only factor that was significant; however, intraoperative heparin anticoagulation and complete mechanical thrombectomy trended toward significance. The type of thrombolytic agent used was not found to result in a statistically significant difference. Conclusions: There is evidence to suggest that there may be preoperative factors predictive of flap salvage success, including thrombophilia and routine preoperative platelet values. Shorter time to take-back and surgeon experience may improve salvage, whereas intraoperative heparin anticoagulation and complete mechanical removal of the thrombus demonstrate preliminary evidence as effective intraoperative strategies. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Free tissue transfer in the obese patient: an outcome and cost analysis in 1258 consecutive abdominally based reconstructions.

Background: The authors’ institution has seen an increase in obese and morbidly obese patients seeking autologous breast reconstruction. The authors provide a comprehensive outcome analysis of patients undergoing abdominally based autologous breast reconstruction. Methods: The authors identified obese patients receiving free tissue transfer for breast reconstruction. World Health Organization body mass index criteria were used: nonobese (body mass index, 20 to 29.9 kg/m2), class I (30 to 34.9 kg/m2), class II (35 to 39.9 kg/m2), and class III (>40 kg/m2). Patient comorbidities, body mass index, complications (medical and surgical), and hospital resource use were examined. Results: Eight-hundred twelve patients undergoing 1258 free tissue transfers for breast reconstruction were included. Overall, 66.5 percent (n = 540) were considered nonobese, 22.9 percent (n = 186) had class I obesity, 5.0 percent (n = 41) had class II, and 5.7 percent (n = 45) had class III. Obesity was associated with a significant increase in minor (p = 0.001) and major (p = 0.013) complications. Morbidly obese patients had significantly higher rates of total flap loss (p = 0.006) and longer operative times (p = 0.0002). Complications translated into greater cost and resource consumption (p < 0.001). Muscle-sparing transverse rectus abdominis myocutaneous flap experienced a significantly higher rate of hernia compared with other flaps (p = 0.02), without a difference in flap loss rate (p = 0.61). Conclusions: Increasing obesity is associated with increased perioperative risk in free abdominally based autologous breast reconstruction, which translated into greater perioperative morbidity, higher hospital cost, and increased health care resource consumption. Higher body mass index is directly related to intraoperative technical difficulty, flap loss, donor-site morbidity, and cost use. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

A Risk Model and Cost Analysis of Incisional Hernia After Elective, Abdominal Surgery Based Upon 12,373 Cases: The Case for Targeted Prophylactic Intervention

Objectives:Incisional hernia (IH) remains a common, highly morbid, and costly complication. Modest progress has been realized in surgical technique and mesh technology; however, few advances have been achieved toward understanding risk and prevention. In light of the increasing emphasis on prevention in todays health care environment and the billions in costs for surgically treated IH, greater focus on predictive risk models is needed. Methods:All patients undergoing gastrointestinal or gynecologic procedures from January 1, 2005 to June 1, 2013, within the University of Pennsylvania Health System were identified. Comorbidities and operative characteristics were assessed. The primary outcome was surgically treated IH after index procedures. Patients with prior hernia, less than 1-year follow-up, or emergency surgical procedures were excluded. Cox hazard regression modeling with bootstrapped validation, risk factor stratification, and assessment of model performance were conducted. Results:A total of 12,373 patients with a 3.5% incidence of surgically treated IH (follow-up 32.2 ± 26.6 months) were identified. The cost of surgical treatment of IH and management of associated complications exceeded

Does previous chest wall irradiation increase vascular complications in free autologous breast reconstruction

17.5 million. Notable independent risk factors for IH were ostomy reversal (HR = 2.76), recent chemotherapy (HR = 2.04), bariatric surgery (HR = 1.78), smoking history (HR = 1.74), liver disease (HR = 1.60), and obesity (HR = 1.96). High-risk patients (20.6%) developed IH compared with 0.5% of low-risk patients (C-statistic = 0.78). Conclusions:This study demonstrates an internally validated preoperative risk model of surgically treated IH after 12,000 elective, intra-abdominal procedures to provide more individualized risk counseling and to better inform evidence-based algorithms for the role of prophylactic mesh.

Complications in body contouring procedures: an analysis of 1797 patients from the 2005 to 2010 American College of Surgeons National Surgical Quality Improvement Program databases.

Background: Prior radiation therapy to the chest, in theory, has a detrimental impact on the recipient vessels in breast reconstruction and may impact microvascular success. The purpose of this study was to determine whether prereconstruction radiation therapy affects the rate of vascular complications in free flap breast reconstruction. Methods: This was a retrospective review of free flap breast reconstruction performed between 2005 and 2009 by the senior authors. In addition to medical and surgical history, vascular complications were recorded, including intraoperative and postoperative thromboses and technical difficulties resulting in a variation of the standard approach. Results: In total, 226 flaps were placed into an irradiated field, whereas 799 were transposed into a radiation-naive defect. Vascular complications as a whole were more prevalent in the irradiated group (9.6 percent versus 17.3 percent; p = 0.001). In regression modeling, radiation therapy was identified as an independent risk factor (odds ratio, 1.68; 95 percent confidence interval, 1.04 to 2.70). In subanalysis, there is a significantly higher rate of intraoperative vascular complications (7.6 percent versus 14.2 percent; p = 0.003), although individual outcomes did not reach formal significance. Previous irradiation had no effect on delayed vascular complications, flap loss, fat necrosis, infection, skin flap necrosis, hematoma, seroma, or delayed wound healing. Conclusions: Prereconstruction radiation therapy increases the rate of vascular complications in free flap breast reconstruction, the majority of which appear intraoperatively. Although radiation does not hinder the overall success of reconstruction or contribute to postoperative complications, surgeons should be aware that working in a previously irradiated field carries additional technical risk.

Strategies for Recognizing and Managing Intraoperative Venous Congestion in Abdominally Based Autologous Breast Reconstruction

Background: The purpose of this study was to examine the incidence and predictors of surgical and medical morbidity following body contouring procedures. Methods: The authors reviewed the American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2010 for all identifiable body contouring cases including Current Procedural Terminology codes for brachioplasty, medial thigh lift, abdominoplasty, and suction-assisted lipectomy. Independent predictors of morbidity were determined. Results: A total of 1797 patients underwent body contouring during the study period, and most were female (n = 1600; 89.0 percent). The average body mass index was 31.6 kg/m2, and 239 were morbidly obese (body mass index ≥ 40 kg/m2). The most common area of intervention was the trunk region, with 1652 patients (91.9 percent) receiving abdominal contouring and/or contouring of the hips and buttocks. Minor wound complications occurred in 114 individuals (6.3 percent), 122 patients (6.8 percent) suffered a major surgical morbidity, and 40 (2.2 percent) experienced a medical complication. Multiple comorbidities (OR, 15.87; p = 0.014), presence of bleeding disorder (OR, 20.31; p = 0.026), preoperative albumin level (OR, 0.14; p = 0.003), and malnutrition (OR, 0.19; p = 0.065) were associated with an increased odds of minor wound complications. Inpatient procedures (OR, 4.64; p = 0.06) and functional status (OR, 9.71; p = 0.011) were associated with an increased odds of major surgical morbidity. Conclusions: This study characterizes the 30-day morbidity rates in patients undergoing body contouring procedures using a large, prospective, validated national data set, highlighting the critical importance of careful preoperative patient evaluation and underscoring the need for detailed preoperative counseling and risk stratification. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.