Operative Time Predicts Postoperative Outcomes in Bilateral DIEP Flap Reconstruction: Multivariate 1000 Flap Analysis

Abstract

Background: Skin-to-skin operative time (OT) as a risk factor for adverse postoperative outcomes in microvascular breast reconstruction has not been thoroughly investigated. This study evaluates OT’s impact on length of stay (LOS), overall morbidity, individual complications, and unplanned reoperation (UR) in deep inferior epigastric artery perforator (DIEP) flaps, with a primary objective of identifying a clinically relevant time of decreased odds. Methods: Patients who underwent bilateral DIEP flaps from 2010 to 2021 by two senior surgeons (N.T.H. and S.S.T.) with standardized surgical and postoperative protocols were retrospectively reviewed. One thousand flaps (500 patients) were analyzed with extensive multivariate regression equations to adjust for potential confounders, including intraoperative complexity. The odds of postoperative complication, extended LOS (eLOS, defined as ≥5 days) were compared across OT per hour and OT intervals. Results: After risk-adjustment, each hour of OT increased morbidity by 19%, UR by 8.7%, and LOS by 6.5 hours (all P < 0.001). For eLOS, procedures ≤5 hours had 9.5 times lower odds than ≥5 hours (P = 0.050), 5–7 hours had comparable odds (P = 0.540), and 7–9 hours had 5.5 times lower odds than procedures ≥ 9 hours (P < 0.001). Last, a multivariate linear regression showed that LOS can be calculated from OT: LOS (days) =1.527 + 0.272 × OT (hours) (R2 = 0.308; P < 0.001). Conclusions: OT (per hour) independently predicts morbidity, UR and LOS in DIEP flaps. Furthermore, 5 and 9 hours are critical cutoffs for eLOS. These findings emphasize the benefits of decreasing OT through efficiency models, such as process analysis, team-based intraoperative protocols, and co-surgery model.

Operative Time Predicts Long-Term Abdominal Morbidity and Complication Requiring Treatment after DIEP Flap Breast Reconstruction

“…readmission treatment (8-10% hourly) compared with the occurrence of any overall postoperative complications (19% hourly) in bilateral DIEP flap breast reconstructions. 4 The risk for overall (25%) and breast flap-site (26%) complications requiring extended hospital stay for treatment was substantially higher per hour of operative time compared with the occurrence of any overall (19%) and breast flap-site (19%) complications in bilateral DIEP flap breast reconstructions, 4 as well as those requiring outpatient or readmission treatment. Increased operative time's disproportionate effect on more severe perioperative complications may be explained by the treatment required to address microvascular issues.…”

“…Furthermore, these findings demonstrate that operative time may have a lower impact on the odds of developing less morbid complications only requiring outpatient treatment (9-11% hourly) compared to the occurrence of any overall postoperative complications (19% hourly) in bilateral DIEP flap breast reconstructions. 4 The odds of breast flap-site complications requiring readmission treatment increased by 25% per hour of operative time, while overall and medical complications requiring readmission treatment increased by 8-10% per hour of operative time. In a multicenter study, Mlodinow et al showed that operative time is a predictor of autologous breast reconstruction readmission rates.…”

“…2 Operative time demonstrated a greater impact on developing a breast flap-site complication requiring readmission treatment (25% hourly) than any breast flap-site complication (19% hourly). 4 However, operative time may have a lesser impact on other complications requiring readmission treatment (8-10% hourly) compared to the occurrence of any overall postoperative complications (19% hourly) in bilateral DIEP flap breast reconstructions. 4 The risk for overall (25%) and breast flap-site (26%) complications requiring extended hospital stay for treatment was substantially higher per hour of operative time compared to the occurrence of any overall (19%) and breast flap-site (19%) complications in bilateral DIEP flap breast reconstructions, 4 as well as those requiring outpatient or readmission treatment.…”

“…3,24 The occurrence of more serious perioperative complications may reflect the importance of microsurgical efficiency in a patient's hospital course and length of stay. 4,18 This article is protected by copyright. All rights reserved.…”

A Single-center Comparison of Unipedicled and Bipedicled Diep Flap Early Outcomes in 98 Patients

“…A unilateral DIEP within 8 hours is an acceptable time limit as found by Shammas et al 24 However, with dual consultant operations, operative time can be reduced by nearly an hour and confer increased patient safety. 25 With operative time increasing postoperative complications, 26 surgeons should consider performing more dual consultant operations. Including bilateral cases in our study could be seen to be a counfounding factor for assessing the effect of operative time on odds of donor site morbidity; however, we felt it necessary to include these cases in our analyses to increase the study power.…”