COSMETIC Frequency and Risk Factors of Blood Transfusion in Abdominoplasty in Post–Bariatric Surgery Patients: Data from the Nationwide Inpatient Sample Hossein Masoomi, M.D. Jonathan Rimler, M.D. Garrett A. Wirth, M.D., M.S. Christine Lee, B.S. Keyianoosh Z. Paydar, M.D. Gregory R. D. Evans, M.D. Orange, Calif.
Background: There are limited data regarding blood transfusion following abdominoplasty, especially in post–bariatric surgery patients. The purpose of this study was to evaluate (1) the frequency and outcomes of blood transfusion in post–bariatric surgery patients undergoing abdominoplasty and (2) the predictive risk factors of blood transfusion in this patient population. Methods: Using the Nationwide Inpatient Sample database, the authors examined the clinical data of patients with a history of bariatric surgery who underwent abdominoplasty from 2007 to 2011 in the United States. Results: A total of 20,130 post–bariatric surgery patients underwent abdominoplasty during this period. Overall, 1871 patients (9.3 percent) received blood transfusion. Chronic anemia patients had the highest rate of blood transfusion (25.6 percent). Post–bariatric surgery patients who received blood transfusion experienced a significantly higher complication rate (10.1 percent versus 4.8 percent; p < 0.01), longer mean hospital stay (4.0 days versus 2.4 days; p < 0.01), and higher mean total hospital charges ($49,116 versus $33,927; p < 0.01). Multivariate regression analysis showed that deficiency anemia (adjusted OR, 3.8), congestive heart failure (adjusted OR, 2.4), concurrent breast reduction (adjusted OR, 1.5), diabetes mellitus (adjusted OR, 1.4), coronary artery disease (adjusted OR, 1.4), African American race (adjusted OR, 1.4), Hispanic race (adjusted OR, 1.4), and female sex (adjusted OR, 1.3) were all independent risk factors for blood transfusion. Conclusions: The blood transfusion rate in post–bariatric surgery abdominoplasty patients is not insignificant. Chronic anemia and congestive heart failure are the two major predictors of transfusion. Modifying risk factors such as anemia before abdominoplasty might significantly decrease the possibility of blood transfusion. (Plast. Reconstr. Surg. 135: 861e, 2015.) CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.
W
ith the rise in obesity rates during the past decade, bariatric surgery has grown increasingly prevalent, as it is the only option for sustained weight loss in the morbidly obese individuals.1,2 These procedures allow From the Department of Surgery and Department of Plastic Surgery Institute, University of California, Irvine Medical Center. Received for publication August 6, 2014; accepted S eptember 30, 2014. Presented at Plastic Surgery The Meeting 2014: Annual Meeting of the American Society of Plastic Surgeons, in Chicago, Illinois, October 11 through 14, 2014. Copyright © 2015 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000001161
patients to achieve massive weight loss and have been proven to produce marked improvement in various comorbid conditions.3–7 However, many patients will seek subsequent body contouring to address the excess skin folds that remain.8 This desire to complete one’s transformation after bariatric surgery explains the parallel increase in the number of abdominoplasties, which has escalated by 79 percent from 2000 to 2013.9 Despite the psychological and functional benefits of abdominoplasty,10,11 these operations are not without complications, especially in the Disclosure: The authors have no financial interest to declare in relation to the content of this article.
www.PRSJournal.com
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Plastic and Reconstructive Surgery • May 2015 post–bariatric surgery population.12,13 One significant complication is the need for blood transfusions resulting from excessive bleeding that may occur during the intraoperative state. Reported transfusion rates vary widely, ranging from 6 to 20 percent.13,14 Furthermore, although many studies identify blood transfusion as a potential complication, there are no studies that specifically examine risk factors of blood transfusion requirement, which can potentially minimize exposure to allogenic blood if identified preoperatively. The purpose of this study was to evaluate the frequency of blood transfusions in post–bariatric surgery patients who underwent abdominoplasty using the Nationwide Inpatient Sample database. In addition, we examined the effects of blood transfusion on surgical outcomes and the predictive risk factors of blood transfusions in this patient population.
PATIENTS AND METHODS Database The Nationwide Inpatient Sample15 is the largest inpatient care database in the United States. The Nationwide Inpatient Sample contains clinical and resource use information included in a typical discharge abstract, with safeguards to protect the privacy of individual patients, physicians, and hospitals as required by data sources. The Nationwide Inpatient Sample database is composed of nationally represented data from over 1000 hospitals in the United States, which is a stratified sample of approximately 20 percent of all U.S. hospitals, through 46 states. The Nationwide Inpatient Sample can be weighted to produce national estimates. Data elements within the Nationwide Inpatient Sample allow determination of all procedures performed during a given hospital admission. It also contains discharge information on inpatient hospital stay, including patient characteristics, length of stay, specific in-hospital postoperative complications, total hospital charges, and observed in-hospital mortality. The Nationwide Inpatient Sample includes charge information for all patients, regardless of payer, including persons covered by Medicare, Medicaid, private insurance, and the uninsured. The Nationwide Inpatient Sample database has no information available on complications occurring after discharge. Approval for use of the Nationwide Inpatient Sample patient-level data in this study was obtained from the Human Research Protections of the University of California, Irvine
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Medical Center and the Nationwide Inpatient Sample. Using the Nationwide Inpatient Sample database, we analyzed discharge data for patients with a history of bariatric surgery who underwent abdominoplasty from 2007 to 2011 in the United States. There was no age limitation in this study. We used the International Classification of Diseases, Ninth Revision, Clinical Modification16 to identify our patient population. International Classification of Diseases, Ninth Revision, Clinical Modification codes of blood transfusion were used to identify patients who received blood transfusion. We evaluated (1) the overall rate of blood transfusion and (2) risk factors of blood transfusion in this patient population. Also, we compared the outcomes of patients who received blood transfusion with patients who did not. Deficiency anemia has been defined as iron deficiency anemia or vitamin deficiency anemia (B12 or folic acid) or protein deficiency anemia or anemia of chronic disease (e.g., chronic kidney disease). With regard to hemoglobin/hematocrit level, anemia is defined as values that are more than 2 SD below the mean; then, by using these ranges, a hemoglobin level less than 13.5 g/dl or a hematocrit level less than 41.0 percent represents anemia in men, and a hemoglobin level less than 12.0 g/dl or a hematocrit level less than 36.0 percent represents anemia in women.17 Statistical Analysis Univariate and multivariate regression analyses were performed to identify independent predictors of blood transfusion following abdominoplasty in post–bariatric surgery patients. The adjusted odds ratio was calculated to determine the combined effect of various preoperative factors including patient characteristics (e.g., age, sex, and race), patient comorbidities, teaching status of hospitals, and concurrent operations (e.g., abdominal wall hernia repair, breast augmentation, and reduction mammaplasty) on blood transfusion. Patient age younger than 65 years, male sex, Caucasian, no comorbidity, nonteaching hospital, and no concurrent operations were set as reference values in the univariate and multivariate regression analyses. All statistical analyses for the Nationwide Inpatient Sample database were conducted using SAS version 9.3 (SAS Institute, Inc., Cary, N.C.). As the Nationwide Inpatient Sample database is a stratified sample of 20 percent of all U.S. hospitals, discharge weight was used to create national estimates for all analyses. Statistical significance was set at p < 0.05 and odds ratio, with the 95 percent confidence interval not
Volume 135, Number 5 • Post–Bariatric Surgery Blood Transfusion including the value of 1. An adjusted odds ratio greater than 1 was considered a risk factor for blood transfusion.
Table 1. Characteristics of Post–Bariatric Surgery Patients Who Underwent Abdominoplasty in the United States from 2007 to 2011 Characteristics
RESULTS From 2007 to 2011, a total of 93,227 patients underwent abdominoplasty in the United States, of which 20,130 of these patients had a history of bariatric surgery. We included only post–bariatric surgery abdominoplasty patients in this study. Examining patient characteristics, the mean age was 48 ± 11 years, and 5.2 percent of patients were older than 65 years. The majority of the patients were Caucasian (76.8 percent). The most common comorbidities were hypertension (25.1 percent), diabetes mellitus (16.3 percent), smoking (13.2 percent), and chronic lung disease (13.1 percent). The majority of the operations were performed at teaching hospitals (60.5 percent). The most common payer type was private payer (56.1 percent), and the highest rate of post–bariatric surgery abdominoplasty was performed in the Northeast U.S. region (28.2 percent) (Table 1). Of these patients, 36.5 percent underwent abdominal hernia repair, 7.3 percent underwent mastopexy, 4 percent underwent breast reduction mammaplasty, and 3.8 percent underwent breast augmentation. The overall rate of blood transfusion was 9.3 percent (1871 patients). The highest rate of blood transfusion was seen in chronic anemia patients (25.6 percent). Post–bariatric surgery abdominoplasty patients who received blood transfusion experienced a significantly higher complication rate (10.1 versus 4.8 percent; p < 0.01), a longer mean hospital stay (4.0 days versus 2.4 days; p
Background: There are limited data regarding blood transfusion following abdominoplasty, especially in post–bariatric surgery patients. The purpose of this study was to evaluate (1) the frequency and outcomes of blood transfusion in post–bariatric surgery patients undergoing abdominoplasty and (2) the predictive risk factors of blood transfusion in this patient population. Methods: Using the Nationwide Inpatient Sample database, the authors examined the clinical data of patients with a history of bariatric surgery who underwent abdominoplasty from 2007 to 2011 in the United States. Results: A total of 20,130 post–bariatric surgery patients underwent abdominoplasty during this period. Overall, 1871 patients (9.3 percent) received blood transfusion. Chronic anemia patients had the highest rate of blood transfusion (25.6 percent). Post–bariatric surgery patients who received blood transfusion experienced a significantly higher complication rate (10.1 percent versus 4.8 percent; p < 0.01), longer mean hospital stay (4.0 days versus 2.4 days; p < 0.01), and higher mean total hospital charges ($49,116 versus $33,927; p < 0.01). Multivariate regression analysis showed that deficiency anemia (adjusted OR, 3.8), congestive heart failure (adjusted OR, 2.4), concurrent breast reduction (adjusted OR, 1.5), diabetes mellitus (adjusted OR, 1.4), coronary artery disease (adjusted OR, 1.4), African American race (adjusted OR, 1.4), Hispanic race (adjusted OR, 1.4), and female sex (adjusted OR, 1.3) were all independent risk factors for blood transfusion. Conclusions: The blood transfusion rate in post–bariatric surgery abdominoplasty patients is not insignificant. Chronic anemia and congestive heart failure are the two major predictors of transfusion. Modifying risk factors such as anemia before abdominoplasty might significantly decrease the possibility of blood transfusion. (Plast. Reconstr. Surg. 135: 861e, 2015.) CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.
W
ith the rise in obesity rates during the past decade, bariatric surgery has grown increasingly prevalent, as it is the only option for sustained weight loss in the morbidly obese individuals.1,2 These procedures allow From the Department of Surgery and Department of Plastic Surgery Institute, University of California, Irvine Medical Center. Received for publication August 6, 2014; accepted S eptember 30, 2014. Presented at Plastic Surgery The Meeting 2014: Annual Meeting of the American Society of Plastic Surgeons, in Chicago, Illinois, October 11 through 14, 2014. Copyright © 2015 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000001161
patients to achieve massive weight loss and have been proven to produce marked improvement in various comorbid conditions.3–7 However, many patients will seek subsequent body contouring to address the excess skin folds that remain.8 This desire to complete one’s transformation after bariatric surgery explains the parallel increase in the number of abdominoplasties, which has escalated by 79 percent from 2000 to 2013.9 Despite the psychological and functional benefits of abdominoplasty,10,11 these operations are not without complications, especially in the Disclosure: The authors have no financial interest to declare in relation to the content of this article.
www.PRSJournal.com
861e
Plastic and Reconstructive Surgery • May 2015 post–bariatric surgery population.12,13 One significant complication is the need for blood transfusions resulting from excessive bleeding that may occur during the intraoperative state. Reported transfusion rates vary widely, ranging from 6 to 20 percent.13,14 Furthermore, although many studies identify blood transfusion as a potential complication, there are no studies that specifically examine risk factors of blood transfusion requirement, which can potentially minimize exposure to allogenic blood if identified preoperatively. The purpose of this study was to evaluate the frequency of blood transfusions in post–bariatric surgery patients who underwent abdominoplasty using the Nationwide Inpatient Sample database. In addition, we examined the effects of blood transfusion on surgical outcomes and the predictive risk factors of blood transfusions in this patient population.
PATIENTS AND METHODS Database The Nationwide Inpatient Sample15 is the largest inpatient care database in the United States. The Nationwide Inpatient Sample contains clinical and resource use information included in a typical discharge abstract, with safeguards to protect the privacy of individual patients, physicians, and hospitals as required by data sources. The Nationwide Inpatient Sample database is composed of nationally represented data from over 1000 hospitals in the United States, which is a stratified sample of approximately 20 percent of all U.S. hospitals, through 46 states. The Nationwide Inpatient Sample can be weighted to produce national estimates. Data elements within the Nationwide Inpatient Sample allow determination of all procedures performed during a given hospital admission. It also contains discharge information on inpatient hospital stay, including patient characteristics, length of stay, specific in-hospital postoperative complications, total hospital charges, and observed in-hospital mortality. The Nationwide Inpatient Sample includes charge information for all patients, regardless of payer, including persons covered by Medicare, Medicaid, private insurance, and the uninsured. The Nationwide Inpatient Sample database has no information available on complications occurring after discharge. Approval for use of the Nationwide Inpatient Sample patient-level data in this study was obtained from the Human Research Protections of the University of California, Irvine
862e
Medical Center and the Nationwide Inpatient Sample. Using the Nationwide Inpatient Sample database, we analyzed discharge data for patients with a history of bariatric surgery who underwent abdominoplasty from 2007 to 2011 in the United States. There was no age limitation in this study. We used the International Classification of Diseases, Ninth Revision, Clinical Modification16 to identify our patient population. International Classification of Diseases, Ninth Revision, Clinical Modification codes of blood transfusion were used to identify patients who received blood transfusion. We evaluated (1) the overall rate of blood transfusion and (2) risk factors of blood transfusion in this patient population. Also, we compared the outcomes of patients who received blood transfusion with patients who did not. Deficiency anemia has been defined as iron deficiency anemia or vitamin deficiency anemia (B12 or folic acid) or protein deficiency anemia or anemia of chronic disease (e.g., chronic kidney disease). With regard to hemoglobin/hematocrit level, anemia is defined as values that are more than 2 SD below the mean; then, by using these ranges, a hemoglobin level less than 13.5 g/dl or a hematocrit level less than 41.0 percent represents anemia in men, and a hemoglobin level less than 12.0 g/dl or a hematocrit level less than 36.0 percent represents anemia in women.17 Statistical Analysis Univariate and multivariate regression analyses were performed to identify independent predictors of blood transfusion following abdominoplasty in post–bariatric surgery patients. The adjusted odds ratio was calculated to determine the combined effect of various preoperative factors including patient characteristics (e.g., age, sex, and race), patient comorbidities, teaching status of hospitals, and concurrent operations (e.g., abdominal wall hernia repair, breast augmentation, and reduction mammaplasty) on blood transfusion. Patient age younger than 65 years, male sex, Caucasian, no comorbidity, nonteaching hospital, and no concurrent operations were set as reference values in the univariate and multivariate regression analyses. All statistical analyses for the Nationwide Inpatient Sample database were conducted using SAS version 9.3 (SAS Institute, Inc., Cary, N.C.). As the Nationwide Inpatient Sample database is a stratified sample of 20 percent of all U.S. hospitals, discharge weight was used to create national estimates for all analyses. Statistical significance was set at p < 0.05 and odds ratio, with the 95 percent confidence interval not
Volume 135, Number 5 • Post–Bariatric Surgery Blood Transfusion including the value of 1. An adjusted odds ratio greater than 1 was considered a risk factor for blood transfusion.
Table 1. Characteristics of Post–Bariatric Surgery Patients Who Underwent Abdominoplasty in the United States from 2007 to 2011 Characteristics
RESULTS From 2007 to 2011, a total of 93,227 patients underwent abdominoplasty in the United States, of which 20,130 of these patients had a history of bariatric surgery. We included only post–bariatric surgery abdominoplasty patients in this study. Examining patient characteristics, the mean age was 48 ± 11 years, and 5.2 percent of patients were older than 65 years. The majority of the patients were Caucasian (76.8 percent). The most common comorbidities were hypertension (25.1 percent), diabetes mellitus (16.3 percent), smoking (13.2 percent), and chronic lung disease (13.1 percent). The majority of the operations were performed at teaching hospitals (60.5 percent). The most common payer type was private payer (56.1 percent), and the highest rate of post–bariatric surgery abdominoplasty was performed in the Northeast U.S. region (28.2 percent) (Table 1). Of these patients, 36.5 percent underwent abdominal hernia repair, 7.3 percent underwent mastopexy, 4 percent underwent breast reduction mammaplasty, and 3.8 percent underwent breast augmentation. The overall rate of blood transfusion was 9.3 percent (1871 patients). The highest rate of blood transfusion was seen in chronic anemia patients (25.6 percent). Post–bariatric surgery abdominoplasty patients who received blood transfusion experienced a significantly higher complication rate (10.1 versus 4.8 percent; p < 0.01), a longer mean hospital stay (4.0 days versus 2.4 days; p
