j o u r n a l o f s u r g i c a l r e s e a r c h 1 9 9 ( 2 0 1 5 ) 2 7 4 e2 7 9
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofSurgicalResearch.com
Association for Academic Surgery
Latissimus dorsi flap versus pedicled transverse rectus abdominis myocutaneous breast reconstruction: outcomes Laura F. Teisch, BS, David J. Gerth, MD, Jun Tashiro, MD, MPH, Samuel Golpanian, MD, and Seth R. Thaller, MD, DMD* Division of Plastic, Aesthetic & Reconstructive Surgery, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
article info
abstract
Article history:
Background: Pedicled breast reconstruction is a mainstay treatment for plastic surgeons.
Received 3 January 2015
Although indications vary for each breast reconstruction technique, there exist some over-
Received in revised form
lapping characteristics that may determine a successful outcome. We aimed to determine
25 March 2015
the impact flap selection has on postoperative outcomes and resource utilization.
Accepted 2 April 2015
Materials and methods: Nationwide Inpatient Sample database (2010e2011) was reviewed for
Available online 8 April 2015
cases of latissimus dorsi (LD; International Classification of Diseases, Ninth Revision, Clinical Modification, 85.71) and pedicled transverse rectus abdominis myocutaneous
Keywords:
(pTRAM; 85.72) breast reconstruction. Males were excluded. Demographic, socioeconomic,
Autologous breast reconstruction
clinical factors, postoperative complications, length of stay (LOS), and total charges (TC)
Latissimus dorsi flap
were assessed. Chi-squared and multivariate analyses were performed to identify inde-
Pedicled TRAM flap
pendent risk factors of resource utilization and postoperative complications.
Cost utilization
Results: A total of 29,074 cases were identified; 17,670 (61%) LD and 11,405 (39%) pTRAM. 74%
Length of stay
percent were Caucasian, 94% insured, and 66% were treated in teaching hospitals. There
Postoperative complications
were 24 mortalities (15 LD, 9 pTRAM). LD patients were more likely to be obese (odds ratio [OR] ¼ 1.3), suffer from flap loss (OR ¼ 1.4), wound infection (OR ¼ 1.6), wound dehiscence (OR ¼ 2.2), and hematoma (OR ¼ 1.3), P < 0.05. Patients undergoing pTRAM were more likely to undergo surgical revision (OR ¼ 6.9), suffer from systemic infection (OR ¼ 1.8), pneumonia (OR ¼ 5.0), or pulmonary embolism (OR ¼ 29.2), P < 0.05. Risk-adjusted multivariate analysis demonstrated LD was an independent risk factor for postoperative complication (OR ¼ 1.4) and increased TC (OR ¼ 1.3), P < 0.001. Conversely, undergoing pTRAM was an independent risk factor for increased LOS (OR ¼ 6.3), P < 0.001. Conclusions: Analysis of a national database found LD breast reconstruction to have higher TC and increased risk for surgical site complications. Patients undergoing pTRAM had increased risk for pulmonary complications and LOS. Procedure selection may be refined as additional characteristics are discovered using outcomes-based research. ª 2015 Elsevier Inc. All rights reserved.
* Corresponding author. Division of Plastic, Aesthetic & Reconstructive Surgery, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, 1120 N.W. 14th Street, 4th Floor, Miami, FL 33136. Tel.: þ1 305 243 4500; fax: þ1 305 243 4535. E-mail address: [email protected] (S.R. Thaller). 0022-4804/$ e see front matter ª 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2015.04.011
j o u r n a l o f s u r g i c a l r e s e a r c h 1 9 9 ( 2 0 1 5 ) 2 7 4 e2 7 9
1.
Introduction
Autologous breast reconstruction offers patients the option of having their own tissue, avoiding the need for prosthesis placement and associated complications [1]. Although autologous reconstruction includes the drawback of an additional donor site and donor-site morbidity, it still carries the advantage of increased patient satisfaction while eliminating prosthesis complications [1,2]. Latissimus dorsi (LD) flap has been used as both a pedicled and free flap in many types of reconstructive surgery and its ideal location adjacent to the chest wall allows for reliable reconstruction postmastectomy with minimal functional deficit [3,4]. Because reconstruction using the LD pedicled flap has been limited by inadequate tissue volume, its use has been combined with implant placement and modified with the development of the extended latissimus flap [5,6]. Pedicled transverse rectus abdominis myocutaneous (pTRAM) flap, initially popularized by Hartrampf [7], has also gained interest by many plastic surgeons for reconstruction of the breast. In fact, the use of the pTRAM for autologous breast reconstruction has been favored over the free transverse rectus abdominis myocutaneous (fTRAM) flap by most surgeons [8]. Although it has the disadvantage of causing potential fat necrosis and/or abdominal wall hernia, this reconstructive method has been successful in creating aesthetic breast mounds [8,9]. Although these reconstructive techniques differ in terms of their indications, there is considerable overlap in the types of defect they can help reconstruct. Furthermore, there are differences in the complications and costs that each flap can incur. Therefore, our goal in this study was to determine the impact flap selection, using either the LD flap or pTRAM, had on postoperative outcomes and resource utilization.
2.
Methods
We reviewed the Nationwide Inpatient Sample (NIS) database (2010e2011) for cases of latissimus dorsi (LD; International Classification of Diseases, Ninth Revision, Clinical Modification, 85.71) and pTRAM; 85.72 breast reconstruction. The NIS data set samples up to 1051 hospitals for approximately 8 million unweighted cases per annual release. Thus, weighted national estimates represent approximately 40 million cases. Males were excluded from the analysis. Demographic, socioeconomic, and clinical factors were assessed, along with postoperative complications, including reoperation, hemorrhage, hematoma, seroma, pulmonary embolus, wound infection, and flap loss. Clinical end points also included total charges (TC) and length of stay (LOS). Chi-squared and multivariate analyses were performed to identify independent risk factors of higher resource utilization and postoperative complications after reconstructive surgery. Cases were weighted to represent national estimates. P < 0.05 was considered statistically significant.
3.
275
Results
A total of 29,074 patients who underwent either pTRAM or LD breast reconstruction were identified during the study period. Of these cases, 17,670 (61%) were LD patients and 11,404 (39%) were pTRAM patients. Patient demographics and clinical data are summarized in Table 1. Seventy-four percent of the cohort was composed of Caucasian patients. Majority of patients in the cohort (94%) were insured. Seventy-one percent were insured by private insurance/health maintenance organization. Medicare and Medicaid patients comprised 21% of the cohort. Eighteen percent were in the first quartile for household income and 31% were in the fourth quartile for household income. Most of the cases (66%) in the study cohort were treated at a large, urbanteaching hospital setting with a predominant distribution in the southern United States. There were 24 inhospital mortalities (15 LD, 9 pTRAM). LD patients were more likely to be obese (odds ratio [OR] ¼ 1.3), suffer from flap loss (OR ¼ 1.4), wound infection (OR ¼ 1.6), wound dehiscence (OR ¼ 2.2), and hematoma (OR ¼ 1.3), P < 0.05. Patients undergoing pTRAM were more likely to undergo surgical revision (OR ¼ 6.9), suffer from systemic infection (OR ¼ 1.8), pneumonia (OR ¼ 5.0), or pulmonary embolism (OR ¼ 29.2), P < 0.05. There was no difference in rates of postoperative hemorrhage. We examined independent predictors of increased postsurgical complications via risk-adjusted analysis (Table 2). Race (P < 0.001) and self-paying patients (P ¼ 0.003) were independent risk factors for higher postoperative complications. When compared to the fourth quartile of income, being in the first, second, or third quartile were all independent risk factors for increased postsurgical complications (OR, 1.41, [95% confidence interval, 1.18e1.67; P < 0.001], OR, 1.44 [1.22e1.69; P < 0.001], and OR, 1.68 [1.45e1.94; P < 0.001], respectively). Obesity was also an independent risk factor for postsurgical complications (OR, 1.57 [1.32e1.88; P < 0.001]). LD breast reconstruction was a risk factor for postsurgical complications when compared with pTRAM (OR, 1.39 [1.24e1.57; P < 0.001]). Risk-adjusted multivariate analysis of LOS (Fig. 1) demonstrated that pTRAM was an independent predictor for increased LOS (OR, 0.16 [0.15e0.17; P < 0.001]). In this analysis, flap loss (OR, 3.30 [2.61e4.17; P < 0.001]), hematoma (OR, 4.50 [3.61e5.62; P < 0.001]), seroma (OR, 1.42 [1.13e1.78; P ¼ 0.003]), wound infection (OR, 16.86 [12.48e22.78; P < 0.001]), and wound dehiscence (OR, 1.42 [1.09e1.85; P < 0.001]) were all independent predictors for increased LOS. On a risk-adjusted multivariate analysis for TCs (Fig. 2), independent predictors for increased TC included LD breast reconstruction (OR, 1.28 [1.21e1.34; P < 0.001]) and hematoma (OR, 1.40 [1.13e1.73; P ¼ 0.002]).
4.
Discussion
Main findings of the study demonstrated that the LD flap was associated with higher cost utilization and an increased risk for surgical site complications. In contrast, patients
276
j o u r n a l o f s u r g i c a l r e s e a r c h 1 9 9 ( 2 0 1 5 ) 2 7 4 e2 7 9
Table 1 e Demographics of cohort. Category Age, y LOS, d TCs, $ Vital status, n (%) Survivor Mortality Race, n (%) Caucasian African American Hispanic Asian/Pacific Islander Native American Other Primary payer, n (%) Medicare Medicaid Private insurance/health maintenance organization Self-pay No charge Other Median household income, n (%) First quartile Second quartile Third quartile Fourth quartile Hospital bed size, n (%) Small Medium Large Hospital location/teaching status, n (%) Rural Urban nonteaching Urban teaching Hospital region, n (%) Northeast Midwest South West
Lat. Dorsi Flap n ¼ 17,670
Pedicled TRAM n ¼ 11,404
Overall n ¼ 29,074
52 (15) 2 (1) 40,127 (32,168)
52 (14) 4 (2) 44,579 (37,224)
52 (14) 3 (2) 41,771 (33,565)
17,654 (99.9) 15 (0.1)
11,396 (99.9) 9 (0.1)
29,050 (99.9) 24 (0.1)
2343 (76) 380 (12) 239 (8) 55 (2) 9 (0) 68 (2)
1520 281 201 64 9 61
584 (16) 330 (9) 2490 (70)
257 (11) 223 (10) 1719 (74)
841 (14) 553 (9) 4209 (71)
41 (1) 15 (0) 106 (3)
46 (2) 3 (0) 76 (3)
87 (1) 18 (0) 182 (3)
667 (19) 763 (22) 982 (28) 1092 (31)
390 519 657 709
(71) (13) (9) (3) (0) (3)
(17) (23) (29) (31)
3863 661 440 119 18 129
1057 1282 1639 1801
(74) (13) (8) (2) (0) (2)
(18) (22) (28) (31)
535 (15) 686 (19) 2297 (65)
324 (14) 425 (18) 1555 (67)
859 (15) 1111 (19) 3852 (66)
70 (2) 1189 (34) 2259 (64)
65 (3) 652 (28) 1587 (69)
135 (2) 1841 (32) 3846 (66)
559 (16) 825 (23) 1479 (41) 709 (20)
undergoing pTRAM had an increased risk for pulmonary complications and longer LOS. Postoperative seroma has been found to occur in 70%e95% of cases after LD breast reconstruction [10e12] and 2%e13.5% of cases after pTRAM [13e16]. Furthermore, wound infection, flap loss, and wound dehiscence are all known complications of LD breast reconstruction [17e19]. This is supportive of our finding that LD breast reconstruction is associated with higher surgical site complications. Of note, pTRAM procedures often prove difficult because of the risk of vascular compromise leading to poor perfusion of the flap [20]. Our study, however, showed that pTRAM procedures had a lower rate of flap loss in comparison with LD breast reconstruction. Management of surgical site complications status post-LD breast reconstruction could be a causative factor of increased costly hospitalizations. Israeli et al. [21] found that patients sought more care for treatment of complications after TRAM, but it did not translate into higher cost of medical care in comparison with LD breast reconstruction. This study was consistent with our findings that LD breast reconstruction was associated with higher rates of surgical
653 436 857 381
(28) (19) (37) (16)
1212 1261 2336 1090
(21) (21) (40) (18)
site complications but their total cost analysis was not. However, this study examined the entire 18-mo period of follow-up when considering cost. Interestingly, their complication-related TC was lower for LD breast reconstruction than those for TRAM [21]. This discordance with our findings may have a few possible explanations. First, we looked at admissions retrospectively, without a longitudinal follow-up period. Second, their study cohort does not specifically look at pTRAM, as does ours. In contrast to surgical site complications, patients undergoing pTRAM had a significantly higher risk of developing pulmonary complications, including both thromboembolism and infection. Incidence of asymptomatic and symptomatic pulmonary thromboembolism postoperatively in pTRAM patients has been reported to vary from 0.7%e20.4% [22e25]. This is consistent with our rate of pulmonary thromboembolism after pTRAM (0.7%). Unfortunately, however, this reported number is most likely an underestimate of the true value because asymptomatic events may not have been identified and part of this data set. Both, LD and pTRAM, are associated with risk factors for
j o u r n a l o f s u r g i c a l r e s e a r c h 1 9 9 ( 2 0 1 5 ) 2 7 4 e2 7 9
277
Table 2 e Independent predictors of postsurgical complications. Indicator Alive (versus died) Year (versus 2011) 2008 2009 2010 Race (versus Caucasian) Black Hispanic Asian/Pacific Islander Native American Other Primary payer (versus private insurance/health maintenance organization) Medicare Medicaid Self-pay No charge Other Median income quartile (versus fourth) First Second Third Hospital location/teaching (versus urban teaching) Rural Urban nonteaching Hospital region (versus West) Northeast Midwest South Transferred (versus not transferred) Obesity (versus no obesity) Latissimus dorsi flap (versus pedicled TRAM)
Significance
OR (95% CI)
0.024 0.039 N.S. N.S. 0.006
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofSurgicalResearch.com
Association for Academic Surgery
Latissimus dorsi flap versus pedicled transverse rectus abdominis myocutaneous breast reconstruction: outcomes Laura F. Teisch, BS, David J. Gerth, MD, Jun Tashiro, MD, MPH, Samuel Golpanian, MD, and Seth R. Thaller, MD, DMD* Division of Plastic, Aesthetic & Reconstructive Surgery, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
article info
abstract
Article history:
Background: Pedicled breast reconstruction is a mainstay treatment for plastic surgeons.
Received 3 January 2015
Although indications vary for each breast reconstruction technique, there exist some over-
Received in revised form
lapping characteristics that may determine a successful outcome. We aimed to determine
25 March 2015
the impact flap selection has on postoperative outcomes and resource utilization.
Accepted 2 April 2015
Materials and methods: Nationwide Inpatient Sample database (2010e2011) was reviewed for
Available online 8 April 2015
cases of latissimus dorsi (LD; International Classification of Diseases, Ninth Revision, Clinical Modification, 85.71) and pedicled transverse rectus abdominis myocutaneous
Keywords:
(pTRAM; 85.72) breast reconstruction. Males were excluded. Demographic, socioeconomic,
Autologous breast reconstruction
clinical factors, postoperative complications, length of stay (LOS), and total charges (TC)
Latissimus dorsi flap
were assessed. Chi-squared and multivariate analyses were performed to identify inde-
Pedicled TRAM flap
pendent risk factors of resource utilization and postoperative complications.
Cost utilization
Results: A total of 29,074 cases were identified; 17,670 (61%) LD and 11,405 (39%) pTRAM. 74%
Length of stay
percent were Caucasian, 94% insured, and 66% were treated in teaching hospitals. There
Postoperative complications
were 24 mortalities (15 LD, 9 pTRAM). LD patients were more likely to be obese (odds ratio [OR] ¼ 1.3), suffer from flap loss (OR ¼ 1.4), wound infection (OR ¼ 1.6), wound dehiscence (OR ¼ 2.2), and hematoma (OR ¼ 1.3), P < 0.05. Patients undergoing pTRAM were more likely to undergo surgical revision (OR ¼ 6.9), suffer from systemic infection (OR ¼ 1.8), pneumonia (OR ¼ 5.0), or pulmonary embolism (OR ¼ 29.2), P < 0.05. Risk-adjusted multivariate analysis demonstrated LD was an independent risk factor for postoperative complication (OR ¼ 1.4) and increased TC (OR ¼ 1.3), P < 0.001. Conversely, undergoing pTRAM was an independent risk factor for increased LOS (OR ¼ 6.3), P < 0.001. Conclusions: Analysis of a national database found LD breast reconstruction to have higher TC and increased risk for surgical site complications. Patients undergoing pTRAM had increased risk for pulmonary complications and LOS. Procedure selection may be refined as additional characteristics are discovered using outcomes-based research. ª 2015 Elsevier Inc. All rights reserved.
* Corresponding author. Division of Plastic, Aesthetic & Reconstructive Surgery, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, 1120 N.W. 14th Street, 4th Floor, Miami, FL 33136. Tel.: þ1 305 243 4500; fax: þ1 305 243 4535. E-mail address: [email protected] (S.R. Thaller). 0022-4804/$ e see front matter ª 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2015.04.011
j o u r n a l o f s u r g i c a l r e s e a r c h 1 9 9 ( 2 0 1 5 ) 2 7 4 e2 7 9
1.
Introduction
Autologous breast reconstruction offers patients the option of having their own tissue, avoiding the need for prosthesis placement and associated complications [1]. Although autologous reconstruction includes the drawback of an additional donor site and donor-site morbidity, it still carries the advantage of increased patient satisfaction while eliminating prosthesis complications [1,2]. Latissimus dorsi (LD) flap has been used as both a pedicled and free flap in many types of reconstructive surgery and its ideal location adjacent to the chest wall allows for reliable reconstruction postmastectomy with minimal functional deficit [3,4]. Because reconstruction using the LD pedicled flap has been limited by inadequate tissue volume, its use has been combined with implant placement and modified with the development of the extended latissimus flap [5,6]. Pedicled transverse rectus abdominis myocutaneous (pTRAM) flap, initially popularized by Hartrampf [7], has also gained interest by many plastic surgeons for reconstruction of the breast. In fact, the use of the pTRAM for autologous breast reconstruction has been favored over the free transverse rectus abdominis myocutaneous (fTRAM) flap by most surgeons [8]. Although it has the disadvantage of causing potential fat necrosis and/or abdominal wall hernia, this reconstructive method has been successful in creating aesthetic breast mounds [8,9]. Although these reconstructive techniques differ in terms of their indications, there is considerable overlap in the types of defect they can help reconstruct. Furthermore, there are differences in the complications and costs that each flap can incur. Therefore, our goal in this study was to determine the impact flap selection, using either the LD flap or pTRAM, had on postoperative outcomes and resource utilization.
2.
Methods
We reviewed the Nationwide Inpatient Sample (NIS) database (2010e2011) for cases of latissimus dorsi (LD; International Classification of Diseases, Ninth Revision, Clinical Modification, 85.71) and pTRAM; 85.72 breast reconstruction. The NIS data set samples up to 1051 hospitals for approximately 8 million unweighted cases per annual release. Thus, weighted national estimates represent approximately 40 million cases. Males were excluded from the analysis. Demographic, socioeconomic, and clinical factors were assessed, along with postoperative complications, including reoperation, hemorrhage, hematoma, seroma, pulmonary embolus, wound infection, and flap loss. Clinical end points also included total charges (TC) and length of stay (LOS). Chi-squared and multivariate analyses were performed to identify independent risk factors of higher resource utilization and postoperative complications after reconstructive surgery. Cases were weighted to represent national estimates. P < 0.05 was considered statistically significant.
3.
275
Results
A total of 29,074 patients who underwent either pTRAM or LD breast reconstruction were identified during the study period. Of these cases, 17,670 (61%) were LD patients and 11,404 (39%) were pTRAM patients. Patient demographics and clinical data are summarized in Table 1. Seventy-four percent of the cohort was composed of Caucasian patients. Majority of patients in the cohort (94%) were insured. Seventy-one percent were insured by private insurance/health maintenance organization. Medicare and Medicaid patients comprised 21% of the cohort. Eighteen percent were in the first quartile for household income and 31% were in the fourth quartile for household income. Most of the cases (66%) in the study cohort were treated at a large, urbanteaching hospital setting with a predominant distribution in the southern United States. There were 24 inhospital mortalities (15 LD, 9 pTRAM). LD patients were more likely to be obese (odds ratio [OR] ¼ 1.3), suffer from flap loss (OR ¼ 1.4), wound infection (OR ¼ 1.6), wound dehiscence (OR ¼ 2.2), and hematoma (OR ¼ 1.3), P < 0.05. Patients undergoing pTRAM were more likely to undergo surgical revision (OR ¼ 6.9), suffer from systemic infection (OR ¼ 1.8), pneumonia (OR ¼ 5.0), or pulmonary embolism (OR ¼ 29.2), P < 0.05. There was no difference in rates of postoperative hemorrhage. We examined independent predictors of increased postsurgical complications via risk-adjusted analysis (Table 2). Race (P < 0.001) and self-paying patients (P ¼ 0.003) were independent risk factors for higher postoperative complications. When compared to the fourth quartile of income, being in the first, second, or third quartile were all independent risk factors for increased postsurgical complications (OR, 1.41, [95% confidence interval, 1.18e1.67; P < 0.001], OR, 1.44 [1.22e1.69; P < 0.001], and OR, 1.68 [1.45e1.94; P < 0.001], respectively). Obesity was also an independent risk factor for postsurgical complications (OR, 1.57 [1.32e1.88; P < 0.001]). LD breast reconstruction was a risk factor for postsurgical complications when compared with pTRAM (OR, 1.39 [1.24e1.57; P < 0.001]). Risk-adjusted multivariate analysis of LOS (Fig. 1) demonstrated that pTRAM was an independent predictor for increased LOS (OR, 0.16 [0.15e0.17; P < 0.001]). In this analysis, flap loss (OR, 3.30 [2.61e4.17; P < 0.001]), hematoma (OR, 4.50 [3.61e5.62; P < 0.001]), seroma (OR, 1.42 [1.13e1.78; P ¼ 0.003]), wound infection (OR, 16.86 [12.48e22.78; P < 0.001]), and wound dehiscence (OR, 1.42 [1.09e1.85; P < 0.001]) were all independent predictors for increased LOS. On a risk-adjusted multivariate analysis for TCs (Fig. 2), independent predictors for increased TC included LD breast reconstruction (OR, 1.28 [1.21e1.34; P < 0.001]) and hematoma (OR, 1.40 [1.13e1.73; P ¼ 0.002]).
4.
Discussion
Main findings of the study demonstrated that the LD flap was associated with higher cost utilization and an increased risk for surgical site complications. In contrast, patients
276
j o u r n a l o f s u r g i c a l r e s e a r c h 1 9 9 ( 2 0 1 5 ) 2 7 4 e2 7 9
Table 1 e Demographics of cohort. Category Age, y LOS, d TCs, $ Vital status, n (%) Survivor Mortality Race, n (%) Caucasian African American Hispanic Asian/Pacific Islander Native American Other Primary payer, n (%) Medicare Medicaid Private insurance/health maintenance organization Self-pay No charge Other Median household income, n (%) First quartile Second quartile Third quartile Fourth quartile Hospital bed size, n (%) Small Medium Large Hospital location/teaching status, n (%) Rural Urban nonteaching Urban teaching Hospital region, n (%) Northeast Midwest South West
Lat. Dorsi Flap n ¼ 17,670
Pedicled TRAM n ¼ 11,404
Overall n ¼ 29,074
52 (15) 2 (1) 40,127 (32,168)
52 (14) 4 (2) 44,579 (37,224)
52 (14) 3 (2) 41,771 (33,565)
17,654 (99.9) 15 (0.1)
11,396 (99.9) 9 (0.1)
29,050 (99.9) 24 (0.1)
2343 (76) 380 (12) 239 (8) 55 (2) 9 (0) 68 (2)
1520 281 201 64 9 61
584 (16) 330 (9) 2490 (70)
257 (11) 223 (10) 1719 (74)
841 (14) 553 (9) 4209 (71)
41 (1) 15 (0) 106 (3)
46 (2) 3 (0) 76 (3)
87 (1) 18 (0) 182 (3)
667 (19) 763 (22) 982 (28) 1092 (31)
390 519 657 709
(71) (13) (9) (3) (0) (3)
(17) (23) (29) (31)
3863 661 440 119 18 129
1057 1282 1639 1801
(74) (13) (8) (2) (0) (2)
(18) (22) (28) (31)
535 (15) 686 (19) 2297 (65)
324 (14) 425 (18) 1555 (67)
859 (15) 1111 (19) 3852 (66)
70 (2) 1189 (34) 2259 (64)
65 (3) 652 (28) 1587 (69)
135 (2) 1841 (32) 3846 (66)
559 (16) 825 (23) 1479 (41) 709 (20)
undergoing pTRAM had an increased risk for pulmonary complications and longer LOS. Postoperative seroma has been found to occur in 70%e95% of cases after LD breast reconstruction [10e12] and 2%e13.5% of cases after pTRAM [13e16]. Furthermore, wound infection, flap loss, and wound dehiscence are all known complications of LD breast reconstruction [17e19]. This is supportive of our finding that LD breast reconstruction is associated with higher surgical site complications. Of note, pTRAM procedures often prove difficult because of the risk of vascular compromise leading to poor perfusion of the flap [20]. Our study, however, showed that pTRAM procedures had a lower rate of flap loss in comparison with LD breast reconstruction. Management of surgical site complications status post-LD breast reconstruction could be a causative factor of increased costly hospitalizations. Israeli et al. [21] found that patients sought more care for treatment of complications after TRAM, but it did not translate into higher cost of medical care in comparison with LD breast reconstruction. This study was consistent with our findings that LD breast reconstruction was associated with higher rates of surgical
653 436 857 381
(28) (19) (37) (16)
1212 1261 2336 1090
(21) (21) (40) (18)
site complications but their total cost analysis was not. However, this study examined the entire 18-mo period of follow-up when considering cost. Interestingly, their complication-related TC was lower for LD breast reconstruction than those for TRAM [21]. This discordance with our findings may have a few possible explanations. First, we looked at admissions retrospectively, without a longitudinal follow-up period. Second, their study cohort does not specifically look at pTRAM, as does ours. In contrast to surgical site complications, patients undergoing pTRAM had a significantly higher risk of developing pulmonary complications, including both thromboembolism and infection. Incidence of asymptomatic and symptomatic pulmonary thromboembolism postoperatively in pTRAM patients has been reported to vary from 0.7%e20.4% [22e25]. This is consistent with our rate of pulmonary thromboembolism after pTRAM (0.7%). Unfortunately, however, this reported number is most likely an underestimate of the true value because asymptomatic events may not have been identified and part of this data set. Both, LD and pTRAM, are associated with risk factors for
j o u r n a l o f s u r g i c a l r e s e a r c h 1 9 9 ( 2 0 1 5 ) 2 7 4 e2 7 9
277
Table 2 e Independent predictors of postsurgical complications. Indicator Alive (versus died) Year (versus 2011) 2008 2009 2010 Race (versus Caucasian) Black Hispanic Asian/Pacific Islander Native American Other Primary payer (versus private insurance/health maintenance organization) Medicare Medicaid Self-pay No charge Other Median income quartile (versus fourth) First Second Third Hospital location/teaching (versus urban teaching) Rural Urban nonteaching Hospital region (versus West) Northeast Midwest South Transferred (versus not transferred) Obesity (versus no obesity) Latissimus dorsi flap (versus pedicled TRAM)
Significance
OR (95% CI)
0.024 0.039 N.S. N.S. 0.006
