Minutes that Matter? The Significance of Operative Time in Immediate Unilateral and Bilateral Free Flap Breast Reconstruction.

There is an increasing trend toward bilateral breast reconstruction. Using the National Surgical Quality Improvement Program (NSQIP) database, we sought to understand the association between unilateral and bilateral free flap breast reconstruction and operative time and flap failure. We selected a cohort of patients undergoing free flap breast reconstruction using the 2005 to 2010 NSQIP database. Cases were divided into unilateral and bilateral reconstruction. Subgroup analyses were performed dividing cases into delayed and immediate reconstruction. The effect of patient characteristics including age, body mass index (BMI), history of diabetes, and the American Society of Anesthesiologists' classification on operative time and flap failure was examined using univariable and multivariable regression models. Rates and odds ratios (OR) were reported using the multivariable gamma and logistic regression models, respectively. There were 691 free flap breast reconstructions performed in the cohort and 29.1% were bilateral cases. There was a 78-minute increase in the median operative time when comparing unilateral and bilateral reconstruction (p = 0.005). Patients undergoing bilateral reconstructions were generally younger and had fewer comorbidities compared with unilateral reconstructions. There was no significant association between bilateral reconstruction and flap failure. Immediate bilateral reconstructions had a significant increase in median operative time compared with immediate unilateral reconstructions (563 versus 480 minutes, p = 0.002) but no significant increase in operative time was noted when comparing delayed unilateral and delayed bilateral reconstructions. Prolonged operative time was associated with flap failure after adjusting for age and BMI (OR 1.17, p < 0.001). Bilateral free flap breast reconstruction can be performed safely despite an increase in operative time when compared with unilateral reconstruction.

Simultaneous free flap breast reconstruction combined with contralateral mastopexy or breast reduction can increase patient satisfaction and minimize the need for a second procedure. Surgeon concerns of increases in operative time, postoperative complications, and final breast symmetry may decrease the likelihood of these procedures being done concurrently. This study analyzed postoperative outcomes of simultaneous contralateral mastopexy or breast reduction with free flap breast reconstruction. By using the American College of Surgeons National Surgical Quality Improvement Program database (2010-2020), we analyzed 2 patient cohorts undergoing (A) free flap breast reconstruction only and (B) free flap breast reconstruction combined with contralateral mastopexy or breast reduction. The preoperative variables assessed included demographic data, comorbidities, and perioperative data. Using a neighbor matching algorithm, we performed a 1:1 propensity score matching of 602 free flap breast reconstruction patients and 621 with concurrent contralateral operation patients. Bivariate analysis for postoperative surgical and medical complications was performed for outcomes in the propensity-matched cohort. We identified 11,308 cases who underwent microsurgical free flap breast reconstruction from the American College of Surgeons National Surgical Quality Improvement Program database from the beginning of 2010 to the end of 2020. A total of 621 patients underwent a free flap breast reconstruction combined with contralateral mastopexy or breast reduction. After propensity score matching, there were no significant differences in patient characteristics, perioperative variables or postoperative medical complications between the 2 cohorts. Simultaneous free flap breast reconstruction combined with contralateral mastopexy or breast reduction can be performed safely and effectively without an increase in postoperative complication rates. This can improve surgeon competence in offering this combination of procedures as an option to breast cancer survivors, leading to better patient outcomes in terms of symmetrical and aesthetically pleasing results, reduced costs, and elimination of the need for a second operation.

Prolonged operative time during synchronous colorectal cancer with liver metastases resections may increase postoperative morbidity. To evaluate the relationship between operative time and 30-day morbidity in synchronous colorectal cancer with liver metastases resections, and to identify the optimal operative time cutoff that may inform the decision to pursue a staged surgical approach. Retrospective cohort study. Data were collected from the American College of Surgeons National Surgical Quality Improvement Program database for the years 2013 through 2022. Adult patients undergoing simultaneous colorectal cancer and liver metastasis resection were included. Rates of 30-day overall and serious morbidity. Among 2306 patients, 58.1% were men, 64.7% were of White race, and the median age was 60 years. Most procedures were open (79.4%). The median operative time was 306 minutes (372 for robotic, 318.5 for laparoscopic, and 301 minutes for open surgeries). The 30-day overall morbidity rate was 36.6% (29.7% for minimally invasive surgeries and 38.4% for open surgeries), with serious morbidity at 20.1%. Based on the continuous (Youden Index) and binary (area under the curve) exploration of optimal operative time cutoff, the following operative time categories were created: <5, 5 to 6, 6 to 7, 7 to 8, and ≥8 hours. Multivariable analysis revealed increased risk of morbidity for operative durations >6 hours (OR 1.48; 95% CI, 1.13-1.96; p = 0.004), which rose with rising operative times. Minimally invasive cases had an increased risk of morbidity starting at ≥8 hours, whereas open resections demonstrated increased risk starting at 6 hours. Additional factors linked with morbidity included age 70 years or older, ASA classification III or IV, functional dependence, smoking, steroid use, and open approach. Retrospective design and limitations of data from the American College of Surgeons National Surgical Quality Improvement Program database. This study demonstrates that 30-day morbidity increases after 6 hours in colorectal cancer with liver metastases resections, with a 2-hour difference in risk threshold between minimally invasive surgeries and open cases. These results highlight the need to manage operative duration and approach to improve outcomes for these patients. See Video Abstract . ANTECEDENTES:El tiempo quirúrgico prolongado durante la resección de cáncer colorrectal sincrónico con metástasis hepáticas puede aumentar la morbilidad posoperatoria.OBJETIVO:Evaluar la relación entre el tiempo quirúrgico y la morbilidad a los 30 días en la resección de cáncer colorrectal sincrónico con metástasis hepáticas, e identificar el tiempo quirúrgico óptimo que pueda servir de base para decidir si se debe seguir un enfoque quirúrgico por etapas.DISEÑO:Estudio de cohorte retrospectivo.ENTORNO:Los datos se recopilaron de la base de datos del Programa Nacional de Mejora de la Calidad Quirúrgica del Colegio Americano de Cirujanos para los años 2013 a 2022.PRINCIPAL MEDIDA DE RESULTADO:Tasas de morbilidad general y grave a los 30 días.RESULTADOS:De los 2306 pacientes, el 58,1 % eran hombres, el 64,7 % eran blancos y la mediana de edad era de 60 años. La mayoría de las intervenciones fueron abiertas (79,4 %). La mediana del tiempo quirúrgico fue de 306 minutos (372 para la cirugía robótica, 318,5 para la laparoscópica y 301 minutos para la abierta). La tasa de morbilidad global a los 30 días fue del 36,6 % (29,7 % para las cirugías mínimamente invasivas y 38,4 % para las abiertas), con una morbilidad grave del 20,1 %. A partir de la exploración continua (índice de Youden) y binaria (área bajo la curva) del tiempo quirúrgico óptimo, se crearon las siguientes categorías de tiempo quirúrgico: <5 horas, 5-6 horas, 6-7 horas, 7-8 horas y ≥8 horas. El análisis multivariable reveló un aumento del riesgo de morbilidad para duraciones quirúrgicas >6 horas (odds ratio: 1,48; intervalo de confianza del 95 %, 1,13-1,96; p = 0,004), que aumentaba con el aumento de la duración de la intervención. Los casos mínimamente invasivos presentaron un mayor riesgo de morbilidad a partir de las 8 horas, mientras que las resecciones abiertas mostraron un mayor riesgo a partir de las 6 horas. Otros factores relacionados con la morbilidad fueron la edad ≥70 años, la clasificación III/IV de la Sociedad Americana de Anestesiólogos, la dependencia funcional, el tabaquismo, el uso de esteroides y el abordaje abierto.LIMITACIONES:Diseño retrospectivo y limitaciones de los datos de la base de datos del Programa Nacional de Mejora de la Calidad Quirúrgica del Colegio Americano de Cirujanos.CONCLUSIÓN:Este estudio demuestra que la morbilidad a los 30 días aumenta después de 6 horas en el cáncer colorrectal con metástasis hepáticas resecadas, con una diferencia de 2 horas en el umbral de riesgo entre las cirugías mínimamente invasivas y los casos abiertos. Estos resultados destacan la necesidad de controlar la duración de la operación y el abordaje para mejorar los resultados de estos pacientes. ( AI-generated translation ).

Prevention's Price-30-Day Outcomes of Risk-Reducing Mastectomy and Immediate Free Flap Breast Reconstruction.

Predictors of Operative Duration and Complications in Single-Level Posterior Interbody Fusions for Degenerative Spondylolisthesis

The modified five-item frailty index is a validated and effective tool for assessing risk in surgical candidates. The authors sought to compare the predictive ability of the modified five-item frailty index to established risk factors for complications in free flap breast reconstruction. The 2012 to 2018 American College of Surgeons National Surgical Quality Improvement Program database was queried for free flap breast reconstructive procedures. Univariate and multivariate regression analysis models were used to assess how modified five-item frailty index and factors commonly used to risk stratify (age, body mass index, American Society of Anesthesiologists classification, and history of smoking) were associated with complications. Of the total 10,550 cases, 24.1 percent experienced complications. A high modified five-item frailty index score is associated with a higher overall rate of postoperative complications (p < 0.001). This significant trend was demonstrated in both surgical (p < 0.001) and medical (p < 0.001) complications. When controlling for other risk factors commonly used for risk stratification such as age, body mass index, American Society of Anesthesiologists classification, and history of smoking, the modified five-item frailty index was significantly associated with medical (OR, 1.75; 95 percent CI, 1.37 to 2.22; p = 0.001) and any complications (OR, 1.58; 95 percent CI, 1.29 to 1.93; p < 0.001) and had the largest effect size. Assessing for specific complications, the modified five-item frailty index is the strongest independent predictor of reoperation (OR, 1.41; 95 percent CI, 1.08 to 1.81; p = 0.009). The modified five-item frailty index is a useful predictor of postoperative outcomes in patients undergoing free flap breast reconstruction when compared to other historically considered risk factors for surgical complications. Risk, III.

Oncoplastic Surgery Versus Mastectomy: Complications and Survival Outcomes.

Operative Time Longer Than 180 Minutes in Abdominal Hysterectomy is Predictive of 30-Day Perioperative Complications

Breast augmentation is a widely performed aesthetic surgery, yet the impact of operative time on postoperative outcomes remains unclear. While longer operative times have been linked to increased risks across a wide array of surgical disciplines, this association has not been thoroughly validated in breast augmentation. This multi-institutional study aims to investigate the relationship between operative time and outcomes after breast augmentation with implants. The American College of Surgeons National Surgical Quality Improvement Program database (2008-2022) was queried to identify adult female patients who underwent elective breast augmentation with implants. Preoperative, intraoperative, and postoperative variables, including operative time and 30-day complications, were evaluated. Multivariable logistic regression was used to assess the impact of operative time, analyzing it as both a continuous and a dichotomized variable. A total of 6531 female patients with a mean age of 34.9 ± 10.1 years and a mean body mass index of 22.9 ± 4.0 kg/m 2 were included. One hundred eighteen patients (1.8%) experienced complications, the majority of which were reoperations (n = 69; 1.1%) and surgical complications (n = 30; 0.5%). Multivariable analysis revealed a significant association between operative time and both surgical complications (odds ratio [OR] = 1.01, P = 0.0003) and any complications (OR = 1.01, P = 0.003). For every 10-minute increase in operative time, the risk of surgical and any complications increased by 7.2% and 4.5%, respectively. A critical threshold of 91 minutes was identified, beyond which the odds of complications increased significantly (OR = 1.93, P = 0.001). Prolonged operative time is associated with an increased risk of complications following breast implant augmentation. A threshold of 91 minutes was identified, implying that procedures exceeding this duration carry higher postoperative morbidity. These findings underscore the importance of optimizing surgical efficiency to minimize risks and enhance patient outcomes after breast augmentation.

Impact of operative time on early joint infection and deep vein thrombosis in primary total hip arthroplasty.

There is a scarcity of externally valid data that investigate the utility of operative time, a common clinical parameter, as a predictor of free flap failures. Our aim was to assess whether prolonged operative time correlates with early flap failure following free tissue transfer in the acute care setting using the American College of Surgeons National Surgical Quality Improvement Program database. The 2005-2011 American College of Surgeons National Surgical Quality Improvement Program databases were reviewed for encounters that entailed a free tissue transfer via a CPT algorithm. Patients identified as having a flap loss were compared with people who did not with regards to operative time and patient comorbidities. Patients were subdivided into the following cohort groups with regards to operative time: <6 hours, 6-12 hours, and >12 hours. Secondary outcome was association between increasing operative time and postoperative complications. Of the 2,008 patients identified, 62 (3.1%) had early flap failure. After multivariable analysis, it was found that progressive operative time was associated with an increased risk of flap failure; 6-12 hours odds ratio was 4.64 and >12 hours odds ratio was 5.65 (P = 0.0140). Higher American Society of Anesthesiologists class (P = 0.0042) was also shown to be significantly associated with flap failure. On secondary analysis, increasing operative time was correlated with the following complications: pneumonia, blood transfusions, prolonged ventilation, wound dehiscence, and wound complications. Our results, one of the largest series in the literature, revealed that prolonged operative time was associated with a stepwise increase in the likelihood of early flap failure as well certain postoperative complications. © 2014 Wiley Periodicals, Inc. Microsurgery 37:12-20, 2017.

Literature addressing the risks associated with increasing body mass index (BMI) for patients undergoing free flap breast reconstruction is limited. Often, an arbitrary BMI cutoff (i.e., BMI of 30 kg/m2) is used to determine candidacy for a free flap without substantial backing evidence. This study utilized a national multi-institutional database to analyze outcomes of free flap breast reconstruction and stratified complications by BMI class. Using the 2010 to 2020 National Surgical Quality Improvement Program database, patients who underwent free flap breast reconstruction were identified. Patients were divided into six cohorts based on the World Health Organization BMI classes. Cohorts were compared by basic demographics and complications. A multivariate regression model was created to control for age, diabetes, bilateral reconstruction, American Society of Anesthesiologists class, and operative time. Surgical complications increased with each BMI class, with the highest rates occurring in class I, II, and III obesity, respectively. In a multivariable regression model, the risk for any complication was significant for class II and III obesity (odds ratio [OR]: 1.23, p < 0.004; OR: 1.45, p < 0.001, respectively). Diabetes, bilateral reconstruction, and operative time were independently associated with an increased risk of any complication (OR: 1.44, 1.14, 1.14, respectively, p < 0.001). This study suggests that the risks of postoperative complications following free flap breast reconstruction are highest for patients with a BMI greater than or equal to 35 kg/m2, having nearly 1.5 times higher likelihood of postoperative complications. Stratifying these risks by weight class can help guide preoperative counseling with patients and help physicians determine candidacy for free flap breast reconstruction.

P36. Multilevel posterior cervical foraminotomy associated with increased perioperative infection rates relative to anterior cervical discectomy with fusion and cervical disc arthroplasty

Sir: In an ongoing analysis of the predictors of flap failure in autologous breast reconstruction, our team began to integrate the recently available 2013 American College of Surgeons National Surgical Quality Improvement Program Participant Use Data File to our database. Immediately, the incidence of flap failure in each type of reconstruction dropped. This was initially perceived as an immense improvement of microsurgical techniques, so we decided to look at the incidence of flap failure over time (Fig. 1). However, not a single flap failure was reported in any of the 2895 patients undergoing autologous breast reconstruction procedures in 2013. Backtracking, we looked at flap failure in all 651,940 surgical patients recorded in the 2013 American College of Surgeons National Surgical Quality Improvement Program Participant Use Data File: not a single complication of graft, prosthesis, or flap failure was reported.Fig. 1: Incidence of flap failure in autologous breast reconstruction over time.This finding can signify one of a few things: 2013 could have been the perfect year for American College of Surgeons National Surgical Quality Improvement Program microsurgeons, with not one flap failing in any of the reported cases. Flap failure may have been dropped from the list of reported variables that the American College of Surgeons National Surgical Quality Improvement Program collects. However, this is not described in the User Guide for the 2013 American College of Surgeons National Surgical Quality Improvement Program Participant Use Data File,1 and they continue to include it as a reported variable. By chance, the systematic sampling process that the American College of Surgeons National Surgical Quality Improvement Program uses for case inclusion missed all of the flap failures and only recorded the successful microsurgical patients. The incidence of flap failure is estimated to be around 2 percent,2,3 and the American Society of Plastic Surgeons reports that there were 19,511 total autologous breast reconstructions performed in 2013,4 so it can be estimated that there were 3902 flap failures in 2013. The chance of the 2013 National Surgical Quality Improvement Program database missing all of these flap failures is less than 0.001 percent. Flap failure was reported improperly in the 2013 American College of Surgeons National Surgical Quality Improvement Program Participant Use Data File. The American College of Surgeons National Surgical Quality Improvement Program Database has been validated and effectively used on countless occasions, producing important and thoughtful research. The power of this database is not to be underestimated. However, the use of this database has been criticized before, emphasizing the need for a clear statement of methods, data management, and limitations of these studies.5 The statement that the American College of Surgeons requires to be included with each National Surgical Quality Improvement Program article should not be brushed over, but should be genuinely integrated as a part of the critical reading of articles from this and similar databases: “The American College of Surgeons National Surgical Quality Improvement Program and the hospitals participating in the ACS NSQIP are the source of the data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors.” DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. Benjamin B. Massenburg, B.A. Paymon Sanati-Mehrizy, B.A. Peter J. Taub, M.D. Department of Surgery Division of Plastic and Reconstructive Surgery Icahn School of Medicine at Mount Sinai New York, N.Y.

The American College of Surgeons National Surgical Quality Improvement Program database was implemented to longitudinally track surgical 30-day surgical outcomes and complications. The authors analyze the program-reported outcomes for immediate breast reconstruction from 2007 to 2011, to assess whether longitudinal data collection has improved national outcomes and to highlight areas in need of continued improvement. The authors reviewed the database from 2007 to 2011 and identified encounters for immediate breast reconstruction using Current Procedural Terminology codes for prosthetic and autologous reconstruction. Demographics and comorbidities were tabulated for all patients. Postoperative complications analyzed included surgical-site infection, wound dehiscence, implant or flap loss, pulmonary embolism, and respiratory infections. A total of 15,978 patients underwent mastectomy and immediate reconstruction. Fewer smokers underwent immediate reconstruction over time (p=0.126), whereas more obese patients (p=0.001) and American Society of Anesthesiologists class 3 and 4 patients (p<0.001) underwent surgery. An overall increase in superficial surgical-site infection was noted, from 1.7 percent to 2.3 percent (p=0.214). Wound dehiscence (p=0.036) increased over time, whereas implant loss (p=0.015) and flap loss (p=0.012) decreased over time. Mean operative times increased over the analyzed years, as did all complications for prosthetic and autologous reconstruction. The American College of Surgeons National Surgical Quality Improvement Program data set has shown an increase in complications for immediate breast reconstruction over time, because of a longitudinally higher number of comorbid patients and longer operative times. This knowledge allows plastic surgeons the unique opportunity to improve patient selection criteria and efficiency. Therapeutic, III.