Individualized Risk of Surgical Complications

Abstract

Background:Risk discussion is a central tenet of the dialogue between surgeon and patient. Risk calculators have recently offered a new way to integrate evidence-based practice into the discussion of individualized patient risk and expectation management. Focusing on the comprehensive Tracking Operations and Outcomes for Plastic Surgeons (TOPS) database, we endeavored to add plastic surgical outcomes to the previously developed Breast Reconstruction Risk Assessment (BRA) score.Methods:The TOPS database from 2008 to 2011 was queried for patients undergoing breast reconstruction. Regression models were constructed for the following complications: seroma, dehiscence, surgical site infection (SSI), explantation, flap failure, reoperation, and overall complications.Results:Of 11,992 cases, 4439 met inclusion criteria. Overall complication rate was 15.9%, with rates of 3.4% for seroma, 4.0% for SSI, 6.1% for dehiscence, 3.7% for explantation, 7.0% for flap loss, and 6.4% for reoperation. Individualized risk models were developed with acceptable goodness of fit, accuracy, and internal validity. Distribution of overall complication risk was broad and asymmetric, meaning that the average risk was often a poor estimate of the risk for any given patient. These models were added to the previously developed open-access version of the risk calculator, available at http://www.BRAscore.org.Conclusions:Population-based measures of risk may not accurately reflect risk for many individual patients. In this era of increasing emphasis on evidence-based medicine, we have developed a breast reconstruction risk assessment calculator from the robust TOPS database. The BRA Score tool can aid in individualizing—and quantifying—risk to better inform surgical decision making and better manage patient expectations.

Development of a Risk Prediction Model to Individualize Risk Factors for Surgical Site Infection After Mastectomy

“…14 Kim subsequently used plastic surgeon self-reported data from the Tracking Operations and Outcomes for Plastic Surgeons database to develop a SSI risk prediction model for immediate breast reconstruction. 43 This model contained 9 variables available preoperatively (age, BMI, former or current smoker, diabetes, higher ASA score, and type of reconstruction) and had a c-statistic of 0.637. Neither model has been validated with additional internal or external datasets.…”

Surveillance and Prevention of Surgical Site Infections in Breast Oncologic Surgery with Immediate Reconstruction

“…[55] Most recently the SSI rate after mastectomy with immediate tissue expander reconstruction reported using the NSQIP database was 3.4%. [56, 57] The SSI rates after immediate autologous reconstruction in the NSQIP database vary depending on the type of flap reconstruction, ranging from 2.8% after pedicled latissimus dorsi (with or without concurrent implant), to 5.5% after microvascular free flap, and 6.0% after pedicled transverse rectus abdominis myocutaneous (TRAM) flap. [57] Silva and colleagues compared the SSI rates after immediate unilateral and bilateral implant versus autologous reconstruction using the 2005–2013 database, and found higher rates after bilateral versus unilateral surgery for both implant (3.6% versus 3.3%, respectively) and autologous reconstruction (5.2% versus 4.3%, respectively).…”

“…Risk factors identified repeatedly in multivariate analyses using institutional data or the most recent NSQIP data include obesity or increased body mass index (BMI),[38, 61–72] larger breast size,[21, 47, 66] diabetes[32, 61, 68, 69, 72, 73] or hyperglycemia,[74] smoking, [16, 42, 61, 67–69, 72, 73, 75–78] heavy alcohol use,[61, 79] older age,[16, 62, 74, 78], higher ASA score,[57, 69, 79] history of radiotherapy,[21, 42, 64, 77], duration of operation (mastectomy-only),[16, 62, 69], bilateral operation,[21, 68] and drain duration. [47, 80].…”

“…This model contained a smaller set of variables available preoperatively, including age, BMI, former or current smoker, diabetes, higher ASA score, and type of reconstruction, and had a c-statistic of 0.637. [57] Kato reported a risk score for SSI after immediate or delayed tissue expander or implant reconstruction with 7 variables, including age ≥ 50 years, diabetes, repeated expander insertion, large expander size, neoadjuvant chemotherapy, nipple-sparing mastectomy, and postoperative hormone use, with a c-statistic of 0.734. The risk score was used to categorize risk into three strata, with progressively higher cumulative incidence rates of SSI.…”

Beyond 30 Days: A Risk Calculator for Longer Term Outcomes of Prosthetic Breast Reconstruction

“…Our group introduced the first iteration of the Breast Reconstruction Assessment (BRA) Score in 2014 to predict risk of 30-day complications for women undergoing immediate autologous or prosthetic breast reconstruction. 17–19 Available to surgeons and patients through an open-source, patient-centric, online platform at www.brascore.org, its flexible underlying design permits additions and adjustments to the core risk calculator as new data become available for analysis. BRA Score has since been externally validated against a large intrainstitutional cohort for 30-day complications occurring after prosthetic reconstruction.…”