Risk Assessment Of Immediate Breast Reconstruction Relative To Mastectomy Alone - Analysis Of 30-day Complications Using The Acs-nsqip
Ari M. Wes, BA1, John P. Fischer, MD1, Charles T. Tuggle, MD MHS2, Jonas A. Nelson, MD1, Julia C. Tchou, MD PhD1, Joseph M. Serletti, MD1, Stephen J. Kovach, MD1, Liza C. Wu, MD1.
1Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA, 2Yale University School of Medicine, New Haven, CT, USA.
Immediate breast reconstruction (IBR) has become a more popular option for mastectomy patients. More generalizable outcomes data on the relative risk of IBR versus mastectomy alone has the ability to enhance risk counseling, patient selection, and overall management. The aim of this study is to use a national dataset to assess the added risk of IBR relative to mastectomy alone.
Women who underwent IBR (tissue expander (TE) or free tissue transfer (FF)) were compared to those who received mastectomy alone in the 2005 to 2011 ACS-NSQIP datasets. The three cohorts were propensity-score-matched using perioperative variables in order to correct for inherent differences between the groups. Specific complications examined included any, wound, and medical complications; all outcome variables were measured only during a 30 day period following the operation. Bivariate and multivariate analyses were performed to identify predictors of outcomes.
A total of 43,935 patients who underwent either mastectomy alone (N=30,440), mastectomy with immediate TE placement (N=12,383), or mastectomy with immediate FF reconstruction (N=1,112) were identified. Preoperative variables that differed significantly between the three unmatched cohorts included: age (P<0.001), race (P<0.001), functional status (P<0.001), smoking (P<0.001), ASA physical status (P<0.001), laterality of mastectomy and/or reconstruction (P<0.001), incidence of recent radiation (P<0.001), chemotherapy (P<0.001), and operation (P<0.001), the presence of cardiovascular (P<0.001), pulmonary (P<0.001), neurologic (P<0.001), and renal (P<0.001) comorbidities, as well as the incidence of diabetes (P<0.001) and hypertension (P<0.001). After propensity matching, the three cohorts were homogeneous with respect to all preoperative variables except BMI (P<0.001) and procedure laterality (P<0.001). Univariate analysis of the matched cohorts showed that the FF cohort experienced significantly higher rates of wound (P<0.001), medical (P<0.001), and any complication (P<0.001). Multivariate regression analyses showed that TE placement conferred no increased odds of wound (P=0.11) or medical (P=0.31) complications relative to the mastectomy only cohort. TE placement did however increase odds of surgical complication (P=0.002, OR=1.97). The FF reconstruction cohort experienced increased odds of wound (P=<0.001, OR=5.33), medical (P=<0.001, OR=8.14), and surgical (P=<0.001, OR=4.61) complications relative to the mastectomy alone cohort. When compared directly to the TE placement cohort, the FF cohort again experienced increased odds of wound (P=<0.001, OR=2.93), medical (P=<0.001, OR=5.67), and surgical (P=<0.001, OR=2.35) complications.
Undergoing IBR with FF reconstruction confers added risk of wound, medical, and surgical complications when compared to patients undergoing IBR with TE placement and those undergoing mastectomy alone. IBR with TE placement confers only added risk of surgical complication when compared to patients only undergoing mastectomy. This study shows a modality specific risk profile that can assist physicians in the setting of patient counseling, and reconstructive modality selection.
Figure 1. Incidences of wound, medical, and any complication in three propensity matched cohorts.
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