Safe perioperative tamoxifen use in autologous breast free flap reconstruction: systematic review and meta-analysis.

BACKGROUND: Perioperative tamoxifen remains a valuable therapeutic modality for breast cancer patients. Studies in the existing literature have suggested a potential increased risk of thrombotic complications in autologous breast free flap reconstruction patients exposed to tamoxifen perioperatively. However, several recent publications have questioned the validity of these associations. Therefore, we aim to perform a systematic appraisal of the existing literature to determine if perioperative tamoxifen exposure increases the risk of flap complications in autologous breast-free flap reconstruction patients. METHODS: A systematic literature search was performed using: PubMed, EMBASE, Cochrane Central, Web of Science, EBSCOHost, ClinicalTrials.gov, and TRIP databases from their inception up to April 2021. Articles analyzing the impact of perioperative tamoxifen in autologous breast free flap patients were included. The outcomes assessed were total flap loss, overall flap complications, thrombotic flap complications, which was defined as the sum of arterial and venous flap thrombi, and systemic venous thromboembolism (VTE). Pooled estimates and relative risk were calculated using a random effects model. RESULTS: 9294 Articles were screened and 7 were selected for analysis, which included 3669 flaps in 2759 patients. Compared to patients who did not receive tamoxifen perioperatively, those who received tamoxifen did not have an increased risk of thrombotic flap complications (pooled RR 1.06; 95% CI 0.61-1.84), total flap loss (pooled RR 2.17; 95% CI 0.79-5.95), overall flap complications (pooled RR 1.04; 95% CI 0.76-1.41), or systemic VTE (pooled RR 1.93; 95% CI 0.72-5.13). The heterogeneity of the studies was not significant for any of the outcomes. CONCLUSIONS: The purpose of this study was to update the current understanding of the impact of perioperative tamoxifen on autologous breast free flap reconstruction outcomes. The existing literature supports that the perioperative continuation of tamoxifen in breast free flap patients is not associated with an increased risk of thrombotic flap complications, total flap loss, overall flap complications, or systemic VTE.

Optimizing Abdominoplasty Surgical Site Morbidity Profiling Through an Effective and Nationally Validated Risk Scoring System.

BACKGROUND: Abdominoplasty complication rates are among the highest for cosmetic surgery. We sought to create a validated scoring system to predict the likelihood of wound complications after abdominoplasty using a national multi-institutional database. METHODS: Patients who underwent abdominoplasty in the American College of Surgeons National Surgical Quality Improvement Program 2007-2019 database were analyzed for surgical site complications, a composite outcome of wound disruption, and surgical site infections. The cohort was randomly divided into a 60% testing and a 40% validation sample. Multivariable logistic regression analysis was performed to identify independent predictors of complications using the testing sample (n = 11,294). The predictors were weighted according to ß coefficients to develop an integer-based clinical risk score. This system was validated using receiver operating characteristic analysis of the validation sample (n = 7528). RESULTS: A total of 18,822 abdominoplasty procedures were identified. The proportion of patients who developed a composite surgical site complication was 6.8%. Independent risk factors for composite surgical site complication included inpatient procedure (P < 0.01), smoking (P < 0.01), American Society of Anesthesiologists class ≥3 (P < 0.01), and body mass index ≥25.0 and ≤18.0 kg/m2 (P < 0.01). African American race was a protective factor against surgical site complications (P < 0.01). The factors were integrated into a scoring system, ranging from -5 to 42, and the receiver operating characteristic analysis revealed an area under the curve of 0.71. CONCLUSIONS: We present a validated scoring system for postoperative 30-day surgical site morbidity after abdominoplasty. This system will enable surgeons to optimize patient selection to decrease morbidity and unnecessary healthcare expenditure.

Nationally Validated Scoring System to Predict Unplanned Reoperation and Readmission after Breast Reduction.

BACKGROUND: Reduction mammoplasty continues to be a commonly sought procedure with complication rates ranging from 4.3 to 8.2%. In the current study, we sought to identify the clinical and preoperative risk factors for unplanned reoperation and readmission within the first postoperative month on a national scale. METHODS: Patients who underwent reduction mammoplasty from the ACS-NSQIP 2012-2019 database were analyzed to determine rates of reoperation and readmission within 30 days of the initial breast surgery. The cohort was divided into 60 and 40% random testing and validation samples. A multivariable logistic regression analysis was then performed to isolate independent factors of unplanned readmission and reoperation using the testing sample (n = 22,743). The predictors were weighted according to beta coefficients to develop an integer-based clinical risk score predictive of complications. This system was then validated using receiver operating characteristics (ROC) analysis of the validation sample (n = 15,162). RESULTS: A total of 37,905 reduction mammoplasties were analyzed. 1.3% of patients had an unplanned readmission. Independent risk factors for unplanned readmission included age older than the median of 44 years (p < 0.01), inpatient procedure (p < 0.01), smoking (p < 0.01), hypertension (p = 0.01), COPD (p < 0.05), BMI ≥ 35 (p < 0.01), and operation time greater than the median of 142 minutes ( p < 0.01). The factors were integrated into a scoring system, ranging from 0 to 36, and an ROC analysis revealed an area under the curve of 0.66. 1.9% of patients underwent unplanned reoperation. Independent risk factors for unplanned reoperation in this population included age older than the median of 44 years (p < 0.01), inpatient status (p < 0.01), and a history of bleeding disorders (p < 0.05). The factors were integrated into a scoring system, ranging from 0 to 25, and the ROC analysis revealed an area under the curve of 0.61. CONCLUSIONS: We present a validated scoring system to better inform patients about their risk for unplanned reoperation and readmission following reduction mammoplasty. This system will enable surgeons to optimize patient selection and interventions in order to decrease morbidity and unnecessary health-care expenditure. LEVEL OF EVIDENCE IV: 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.

Contemporary Outcomes for Open Infrainguinal Bypass in the Endovascular Era.

BACKGROUND: The role of infrainguinal bypasses in this era of increasing endovascular interventions remains the subject of significant debate. In this study, we evaluate contemporary long-term outcomes of lower-extremity open revascularization for peripheral arterial disease (PAD). METHODS: We evaluated all patients who underwent infrainguinal bypass with autogenous vein conduits for claudication or critical limb ischemia in our institution between January 1st, 2007 and July 31st, 2014. Kaplan-Meier and Cox regression analyses were used to evaluate graft failure and identify its predictors. Outcomes were defined per the Society for Vascular Surgery standards. RESULTS: There were 428 autogenous vein grafts (femoro-popliteal: 32%, femoro-tibial: 39%, popliteo-tibial: 27%, and tibio-tibial: 2%) placed in 368 patients (mean age of 67 ± 11.4 years). Most patients were male (59%), white (73%), and presented with critical limb ischemia (81%). Sixty-five cases (15%) were redo bypasses. Arm veins and spliced vein conduits were used in 15% and 14% of cases, respectively. Primary patency at 1, 3, and 5 years was 66%, 59%, and 55%, respectively. Primary-assisted patency was 78%, 69%, and 64% at 1, 3, and 5 years, respectively. Secondary patency was 88%, 84%, and 82% at 1, 3, and 5 years, respectively. Patency was higher for grafts harvested from the lower versus upper extremities and for proximal versus distal bypass (all P < 0.05). Limb salvage rate was 88% after a mean follow-up of 2 ± 1.8 years. Significant predictors of graft failure were younger age, diabetes mellitus, and hyperlipidemia (all P < 0.05). CONCLUSIONS: In this contemporary cohort of patients, we have demonstrated that infrainguinal bypass for lower-extremity revascularization has good long-term outcomes in patients with symptomatic PAD. Patency and limb salvage rates are optimized with careful selection of autogenous conduits, close monitoring of high-risk groups and management of comorbidities.