Immediate Reconstruction After Colorectal Cancer Resection: A Cohort Analysis Through the National Surgical Quality Improvement Program and Outcomes Review.

BACKGROUND: Colorectal cancer is one of the most common and fatal malignancies in the United States. When localized to the distal gastrointestinal tract, surgical therapy includes abdominoperineal resection (APR) or pelvic exenteration (PEX). Subsequent ablative defects are considerable, impart concerning morbidity, and often necessitate autologous reconstruction. The aim of this study was to assess postoperative outcomes after reconstruction of APR and PEX defects. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (2005-2017) was queried for patients undergoing APR for lower gastrointestinal malignancies with concurrent autologous reconstructions. Cases of disseminated cancer were excluded. Postoperative adverse event profiles, including rates of wound and systemic complications, were evaluated. Multivariate regression analysis controlling for age, sex, body mass index, and operative time was performed to calculate adjusted odds ratios (ORs). RESULTS: A total of 1309 patients were identified as undergoing APR/PEX with concomitant reconstruction. The majority (96.9%) of reconstructions consisted of muscle, myocutaneous, fasciocutaneous, or omental pedicled flaps. Of the cohort, 45.7% experienced at least 1 all-cause complication within 30-days of the procedure. Having a limited or moderate frailty (frailty index of "1" or "2") was identified as a predictor of all-cause complications [OR, 1.556; 95% confidence interval (CI), 1.187-2.040, P = 0.001; and OR, 1.741; 95% CI, 1.193-2.541, P = 0.004, respectively], whereas smoking was a predictor of wound complications (OR, 1.462; 95% CI, 1.070-1.996, P = 0.017) and steroid use was a predictor of mild systemic complications (OR, 2.006; 95% CI, 1.058-3.805, P = 0.033). CONCLUSION: Anorectal cancer resection often necessitates reconstruction secondary to postexenteration perineal defects. The incidence of postoperative complications is relatively high, and several risk factors are identified to help refine patient optimization.

Impact of Obesity on Outcomes in Breast Reconstruction: A Systematic Review and Meta-Analysis.

BACKGROUND: Increased rates of both breast cancer and obesity have resulted in more obese women seeking breast reconstruction. Studies demonstrate that these women are at increased risk for perioperative complications. A systematic review was conducted to assess the outcomes in obese women who underwent breast reconstruction following mastectomy. METHODS: Cochrane, PUBMED, and EMBASE electronic databases were screened and data were extracted from included studies. The clinical outcomes assessed were surgical complications, medical complications, length of postoperative hospital stay, reoperation rate, and patient satisfaction. RESULTS: Out of 33 studies met the inclusion criteria for the review and 29 provided enough data to be included in the meta-analysis (71,368 patients, 20,061 of whom were obese). Obese women (body mass index > 30 kg/m2) were 2.29 times more likely to experience surgical complications (95% confidence interval (CI) 2.19-2.39; p < 0.00001), 2.89 times more likely to have medical complications (95% CI 2.50-3.35; p < 0.00001), and had a 1.91 times higher risk of reoperation (95% CI 1.75-2.07; p < 0.00001). The most common complication, wound dehiscence, was 2.51 times more likely in obese women (95% CI 1.80-3.52; p < 0.00001). Sensitivity analysis confirmed that obese women were more likely to experience surgical complications (risk ratio 2.36, 95% CI 2.22-2.52; p < 0.00001). CONCLUSIONS: This study provides evidence that obesity increases the risk of complications in both implant-based and autologous reconstruction. Additional prospective and observational studies are needed to determine if the weight reduction prior to reconstruction reduces the perioperative risks associated with obesity.

Transfusions in autologous breast reconstructions: an analysis of risk factors, complications, and cost.

PURPOSE: Free tissue transfer requires lengthy operative times and can be associated with significant blood loss. The goal of our study was to determine independent risk factors for blood transfusions and transfusion-related complications and costs. METHODS: We reviewed our prospectively maintained free flap database and identified all patients undergoing breast reconstruction receiving blood transfusions. These patients were compared with those not receiving a postoperative transfusion. We examined baseline patient comorbidities, preoperative and postoperative hemoglobin (HgB) levels, intraoperative and postoperative complications, and blood transfusions. Factors associated with transfusion were identified using univariate analyses, and multivariate logistic regression was used to determine independently associated factors. RESULTS: A total of 70 (8.2%) patients received postoperative blood transfusions. Multivariate analysis revealed associations between length of surgery (P=0.01), intraoperative arterial thrombosis [odds ratio (OR), 6.75; P=0.01], major surgical complications (OR, 25.9; P<0.001), medical complications (OR, 7.2; P=0.002), and postoperative HgB levels (OR, 0.2; P<0.001). Transfusions were independently associated with higher rates of medical complications (OR, 2.7; P=0.03). A significantly lower rate of medical complications was observed when a restrictive transfusion (HgB level, <7 g/dL) was administered (P=0.04). A cost analysis demonstrated that each blood transfusion was independently associated with an added $1,500 in total cost. CONCLUSIONS: Several key perioperative factors are associated with allogenic transfusion, including intraoperative complications, operative time, HgB level, and postoperative medical and surgical complications. Blood transfusions were independently associated with greater morbidity and added hospital costs. Overall, a restrictive transfusion strategy (HgB level, <7 g/dL or clinically symptomatic) may help minimize medical complications. LEVEL OF EVIDENCE: Prognostic/risk category, level III.

Optimizing the fascial closure: an analysis of 1261 abdominally based free flap reconstructions.

BACKGROUND: Donor-site morbidity continues to be a significant complication in patients undergoing abdominally based breast reconstruction. The purposes of our study were to critically examine abdominal donor-site morbidity and to present our algorithm for optimizing donor site closure to reduce these complications. METHODS: We performed a retrospective cohort study examining all patients undergoing abdominally based free tissue transfer for breast reconstruction from 2005 to 2011 at our institution. Data were analyzed for overall donor site morbidity, as defined by hernia/bulge or reoperation for debridement and/or mesh removal and for hernia/bulge alone. RESULTS: A total of 812 patients underwent 1261 free tissue transfers. Fifty-three patients (6.5%) experienced donor-site morbidity, including 27 hernias/bulges (3.3%). No significant difference in overall abdominal morbidity was found between unilateral and bilateral reconstructions (P = 0.39) or the use of muscle in the flap (P = 0.11 unilateral msfTRAM, P = 0.76 bilateral). Prior lower abdominal surgery was associated with higher rates of donor-site morbidity (P = 0.04); hypertension (P = 0.012) and multiple medical comorbidities (P < 0.001) were also significantly more common in these patients. Obesity was the only patient characteristic associated with higher rates of hernia/bulge (P = 0.04). Delayed abdominal would healing was associated with hernia/bulge (P < 0.001); these patients were significantly more likely to develop this complication (odds ratio = 6.3, P < 0.001). CONCLUSIONS: Particular attention must be provided to donor-site closure in obese patients and those with hypertension and multiple medical comorbidities. Low rates of abdominal wall morbidity result from meticulous fascial reconstruction and reinforcement and careful attention to tension-free soft tissue closure.

A 15-year experience of complex scalp reconstruction using free tissue transfer-analysis of risk factors for complications.

PURPOSE: Large, complex scalp defects represent a significant reconstructive challenge, thus a variety of free tissue transfer techniques have been employed to optimally provide soft tissue coverage. The aim of this study is to determine factors associated with complications. METHODS: A retrospective cohort study was performed on patients undergoing free tissue transfer for scalp defects from 1997 to 2011. Patients were compared with respect to demographics, defect characteristics, intraoperative factors, flap choice, and postoperative complications. RESULTS: Forty-three flaps were performed in 37 patients with a success rate of 97.7%. Multivariate regression demonstrated that defect characteristics (size of defect) and patient-related factors (age and smoking) were associated with wound complications in scalp reconstruction. Outcomes were similar between the latissimus dorsi (LD) and anterolateral thigh (ALT) groups and the immediate cranioplasty patients with respect to all forms of complications. CONCLUSIONS: We report a 98% success rate using free tissue transfer for complex scalp defects and identify defect size, patient age, and smoking as factors associated with wound complications. Patient comorbidities were associated with major complications. We report equal efficacy in using the ALT and LD, as well as immediate cranioplasty. LEVEL OF EVIDENCE: Prognostic/risk, level III.

Impact of obesity on outcomes in breast reconstruction: A systematic review protocol.

INTRODUCTION: The worldwide obesity epidemic is creating new challenges for surgeons involved in breast reconstruction. This systematic review aims to summarise the research available in order to determine the surgical and medical complications, the duration of surgery and post-operative hospital stay and the likelihood of reoperation in each of the different techniques of breast reconstruction in women with obesity. To our knowledge, no systematic review is currently available that assesses the impact of obesity on breast reconstruction outcomes. METHODS AND ANALYSIS: Electronic searches will be conducted on Cochrane, PUBMED and EMBASE, from their inception to 1 June 2016. All cohort studies, case series, randomised controlled trials, and case-control studies on women undergoing breast reconstruction post mastectomy for oncological reasons will be included. Articles must mention at least one of the primary outcomes of interest. Full exclusion and inclusion criteria are described within this protocol. Primary and secondary outcomes are described within this protocol. The search strategy, described within this protocol, aims to identify all articles on "obesity and breast reconstruction." DISCUSSION: This paper outlines the study protocol for a systematic literature review that will identify and summarise currently available evidence on the effectiveness and complications of breast reconstructive procedures in women with a BMI >30 kg/m2. This review aims to provide an overview of the evidence in order to create a guide for healthcare professionals involved in the breast reconstruction of obese women. DISSEMINATION: This review will be published in a peer-reviewed journal and will be presented at various national and international conferences.

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 modality outcome study: a comparison of expander/implants and free flaps in select patients.

BACKGROUND: Choosing a breast reconstructive modality after mastectomy is a critical step involving complex decisions. The authors provide outcomes data comparing two common reconstructive modalities to assist patients and surgeons in preoperative counseling and discussions. METHODS: A prospectively maintained database was queried identifying select patients undergoing expander/implant and abdominally based free flaps for breast reconstruction between 2005 and 2008. Variables evaluated included comorbidities, operations, time to reconstruction, complications, overall outcome, clinic visits, revisions, and costs. RESULTS: One hundred forty-two patients received free flaps and 60 received expander/implants. Expander/implant patients required more procedures (p < 0.001) but had shorter overall hospital lengths of stay (p < 0.001). The two cohorts experienced a similar rate of revision (p = 0.17). Free flap patients elected to undergo nipple-areola reconstruction more frequently (p = 0.01) and were able to sooner (p < 0.0001). Patients undergoing expander/implant reconstruction had a higher rate of failure (7.3 versus 1.3 percent, p = 0.008). Free flap patients achieved a stable reconstruction significantly faster (p = 0.0005), with fewer visits (p = 0.02). Cost analysis demonstrated total cost trended toward significantly lower in the free flap cohort (p = 0.15). Reconstructive modality was the only independent factor associated with time to stable reconstruction and reconstructive failure (p < 0.001 and p = 0.05, respectively). CONCLUSIONS: The authors' analysis revealed that free flap reconstructions required fewer procedures, had lower rates of complications and failures, had fewer clinic visits, and achieved a final, complete reconstruction faster than expander/implant reconstructions. Although autologous reconstruction is still not ideal for every patient, these findings can be used to enhance preoperative discussions when choosing a reconstructive modality. CLINICAL QUESTION/LEVEL OF EVIDENCE: : Therapeutic, 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/m), class I (30 to 34.9 kg/m), class II (35 to 39.9 kg/m), and class III (>40 kg/m). 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.

Outcome analysis of 244 consecutive flaps for managing complex groin wounds.

BACKGROUND: Complex groin wounds present a significant challenge to the reconstructive surgeon. We present a large experience of flaps for managing complex groin wounds. The purpose of our study was to assess outcomes with respect to flap selection and indication (prophylactic versus salvage). PATIENTS AND METHODS: A retrospective review of all patients receiving flaps for complex groin wounds between 2005 and 2011 was performed. Two types of procedures were evaluated: prophylactic muscle flaps (PMFs) and salvage flaps. We performed an outcome analysis of complications based on flap timing and selection. RESULTS: A total of 244 flaps were performed during the study period: 146 flaps for salvage and 98 for prophylaxis. Flaps included: sartorius muscle flap (SMF) (N=132), rectus femoris flap (RFF) (N=99), and antero-lateral thigh (ALT) (N=13). Salvaged wounds had higher rates of major wound dehiscence compared to prophylactic wounds (P=0.002). The SMF (N=132) and RFF (N=99) cohorts were similar with respect to patient and operative characteristics, however, the RFF cohort tended to be obese (P=0.002), used for salvage (P=0.0005), endarterectomy procedures (P=0.018), and culture positive wounds (P=0.09). Major limb related complications (graft loss, limb loss, and reoperation) were significantly lower in the RFF group (P=0.03). CONCLUSIONS: Muscle flaps for complex groin wounds can be safely performed with excellent outcomes. We suggest use of the SMF in the prophylactic setting and for smaller salvage wounds. The RFF may be better suited to address larger, more complex wounds. PMFs in select, high-risk patients optimize wound healing relative to patients undergoing groin wound salvage. LEVEL OF EVIDENCE: Prognostic/risk category, level III.