Predictors of adverse events after neck dissection: An analysis of the 2006-2011 National Surgical Quality Improvement Program (NSQIP) Database.

While neck dissection is an important primary and adjunctive procedure in the treatment of head and neck cancer, there is a paucity of studies evaluating outcomes. A retrospective review of the National Surgical Quality Improvement Program (NSQIP) database was performed to identify factors associated with adverse events (AEs) in patients undergoing neck dissection. A total of 619 patients were identified, using CPT codes specific to neck dissection. Of the 619 patients undergoing neck dissection, 142 (22.9%) experienced an AE within 30 days of the surgical procedure. Risk factors on multivariate regression analysis associated with increased AEs included dyspnea (odds ratio [OR] 2.57; 95% confidence interval [CI] 1.06 to 6.22; p = 0.037), previous cardiac surgery (OR 3.38; 95% CI 1.08 to 10.52; p = 0.036), increasing anesthesia time (OR 1.005; 95% CI 1 to 1.009; p = 0.036), and increasing total work relative value units (OR 1.09; CI 1.04 to 1.13; p < 0.001). The current study is the largest, most robust analysis to identify specific risk factors associated with AEs after neck dissection. This information will assist with preoperative optimization, patient counseling, and appropriate risk stratification, and it can serve as benchmarking for institutions comparing surgical outcomes.

Preoperative Albumin Alone is Not a Predictor of 30-Day Outcomes in Pressure Ulcer Patients: A Matched Propensity-Score Analysis of the 2006-2011 NSQIP Datasets.

BACKGROUND: While there has been a great deal of literature describing the relationship between nutritional status and development of pressure ulcers, statistically rigorous studies analyzing the relationship between hypoalbuminemia and outcomes are lacking. METHODS: The American College of Surgeons' multicenter, prospective, National Surgical Quality Improvement Program database was used to identify patients who underwent surgery for treatment of pressure ulcers between 2006 and 2011. Matched propensity-score analysis was performed to match experimental groups with regard to preoperative comorbidities. Outcomes of interest included overall/surgical/medical complications and 30-day mortality. Multivariable logistic regression models were used to assess the independent association between hypoalbuminemia and outcomes. RESULTS: Over the 6-year study period, 551 patients met criteria for study inclusion. Median albumin level was 2.8 g/dL. Before propensity matching, multiple adverse outcomes were significantly elevated in patients with albumin levels below the median value (very-low albumin, or VLA), compared to control patients. However, after matching preoperative comorbidities, the differences in 30-day outcomes were eliminated. In both analyses, there was no significant difference in 30-day surgical complications. CONCLUSIONS: It is generally understood that hypoalbuminemic patients have elevated risks for surgical procedures. In pressure ulcer patients, it appears that these risks are not due to hypoalbuminemia alone, but rather a long list of attendant comorbidities. Consequently, hypoalbuminemia alone should not be used to determine the timing of a procedure for pressure ulcer surgery. Knowledge of these risks is necessary for patient counseling and surgical planning in this population.

Reconstruction of Desmoid Tumors: Case Series and Systematic Review.

BACKGROUND: Desmoid tumors (DT) represent a group of rare, distinct lesions. There are few published studies examining outcomes and safety of complex reconstruction after DT resection. METHODS: A retrospective review identified 39 patients who underwent surgical treatment of DT at St. Jude Children's Research Hospital over a 12-year period. A systematic review of the literature identified 17 further studies for inclusion. Treatment characteristics were analyzed. RESULT: Thirty-nine patients were treated during the study period, with a total number of 67 resections. Median age was 12.2 years; 49% of patients were male, and 51% were female. Median tumor size was 9.8 cm. DT most commonly arose in the extremities (40%), thorax (23%), head and neck (21%), and trunk (16%). One- and 5-year recurrence-free survival were 97.1% and 73.1%, respectively. The majority of defects were closed primarily, with the exception of head and neck defects. Long-term outcomes were good for chest, abdomen, and upper extremity defects, but were problematic for head and neck, breast, and lower extremity defects. There were no recurrences at the site of flap harvest in either the study population or in reviewed studies. CONCLUSION: For patients with DT, surgical extirpation should not come at the expense of functional preservation, as overall survival is excellent. However, specific defects, including those of the lower extremity, breast, and head and neck, will benefit from improved techniques for resection and reconstruction.

Oropharyngeal Contamination Predisposes to Complications after Neck Dissection: An Analysis of 9462 Patients.

OBJECTIVE: While neck dissection is important in the treatment of head and neck cancer, there is a paucity of studies evaluating outcomes. We sought to compare preoperative variables and outcomes between clean and contaminated neck dissections, using the 2006-2011 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data sets. STUDY DESIGN: Retrospective review of prospectively maintained database. SETTING: Multicenter (university hospitals; tertiary referral centers). SUBJECTS AND METHODS: A retrospective review was performed of the NSQIP database to identify patients undergoing neck dissection in clean vs oropharyngeal contaminated cases. Clinical factors, comorbidities, epidemiologic factors, and procedural characteristics were analyzed to identify factors associated with 30-day postoperative adverse events, including medical and surgical complications, unplanned reoperation, and mortality. Bivariate and multivariable analyses were performed for the outcome of one or more adverse events. RESULTS: In total, 8890 patients had clean neck dissections, while 572 patients had neck wound contamination with oropharyngeal flora. On multivariable regression analysis, oropharyngeal contamination was a significant risk factor for surgical complications (odds ratio [OR], 3.42; 95% confidence interval [CI], 1.96-5.96; P < .001). However, medical complications and mortality were not significantly different between the 2 cohorts. This finding persisted after subgroup analysis, with removal of all thyroidectomy patients from analysis (OR, 2.33; 95% CI, 1.25-4.36; P = .008). CONCLUSION: Using the ACS-NSQIP data set, this study found an increased risk of surgical complications in the setting of contaminated neck dissections. These data should be used for patient risk stratification, informed consent, and to guide further research.

Increased anaesthesia duration increases venous thromboembolism risk in plastic surgery: A 6-year analysis of over 19,000 cases using the NSQIP dataset.

BACKGROUND: Venous thromboembolism (VTE) is a significant cause of morbidity and mortality, particularly in the postoperative setting. Various risk stratification schema exist in the plastic surgery literature, but do not take into account variations in procedure length. The putative risk of VTE conferred by increased length of time under anaesthesia has never been rigorously explored. AIM: The goal of this study is to assess this relationship and to benchmark VTE rates in plastic surgery. METHODS: A large, multi-institutional quality-improvement database was queried for plastic and reconstructive surgery procedures performed under general anaesthesia between 2005-2011. In total, 19,276 cases were abstracted from the database. Z-scores were calculated based on procedure-specific mean surgical durations, to assess each case's length in comparison to the mean for that procedure. A total of 70 patients (0.36%) experienced a post-operative VTE. Patients with and without post-operative VTE were compared with respect to a variety of demographics, comorbidities, and intraoperative characteristics. Potential confounders for VTE were included in a regression model, along with the Z-scores. RESULTS: VTE occurred in both cosmetic and reconstructive procedures. Longer surgery time, relative to procedural means, was associated with increased VTE rates. Further, regression analysis showed increase in Z-score to be an independent risk factor for post-operative VTE (Odds Ratio of 1.772 per unit, p-value < 0.001). Subgroup analyses corroborated these findings. CONCLUSIONS: This study validates the long-held view that increased surgical duration confers risk of VTE, as well as benchmarks VTE rates in plastic surgery procedures. While this in itself does not suggest an intervention, surgical time under general anaesthesia would be a useful addition to existing risk models in plastic surgery.

Assessing safety and outcomes in outpatient versus inpatient thyroidectomy using the NSQIP: a propensity score matched analysis of 16,370 patients.

BACKGROUND: With increasing economic healthcare constraints and an evolving understanding of patient selection criteria and patient safety, outpatient thyroidectomy is now more frequently employed. However, robust statistical analyses evaluating outcomes and safety after outpatient thyroidectomy with matched comparisons to inpatient cohorts are lacking. METHODS: The 2011-2012 NSQIP datasets were queried to identify all patients undergoing thyroidectomy. Inpatient and outpatient procedures cohorts were matched 1:1 using propensity score analysis to assess outcomes. Outcomes of interest included surgical and medical complications, reoperation, mortality, and readmission. Univariate and multivariate analyses were utilized to identify predictors of these events. Relative risk ratios were calculated for adverse events between inpatient and outpatient cohorts. RESULTS: In total, 21,508 patients were identified to have undergone a thyroidectomy in 2011-2012. Inpatients and outpatients were matched 1:1 with respect to preoperative and operative characteristics, leaving 8,185 patients in each treatment arm. After matching, overall 30-day morbidity was rare with only 250 patients (1.53 %) experiencing any perioperative morbidity. 476 patients (2.91 %) were readmitted within 30-days of the operation. Both pre- and post-matching, inpatient thyroidectomy was associated with increased risks of readmission, reoperation, and any complication. CONCLUSIONS: Based on this comprehensive population-based study, outpatient thyroidectomy appears to be at least as safe as inpatient thyroidectomy. However, there are still differences in outcomes between inpatient and outpatient cohorts, despite statistical matching of preoperative and intraoperative variables. Future research needs to be spent identifying these as-of-yet unknown risk factors to resolve this discrepancy.

Predictors of adverse events after parotidectomy: a review of 2919 cases.

OBJECTIVE: There is a current paucity of large-scale, multi-institutional studies that explore the risk factors for major complications following parotidectomy. METHODS: The American College of Surgeons National Surgical Quality Improvement Program participant use file was reviewed to identify all patients who had undergone parotidectomy between 2006 and 2011. Risk factors that predicted adverse events were estimated by using multivariate logistic regression. RESULTS: Of 2919 included patients, 202 patients experienced adverse outcomes within the first 30 days of surgery. These included surgical complications in 76 (2.6%) patients; medical complications in 90 (3.1%) patients; death in 7 (0.2%) patients; and reoperation in 77 (2.6%) patients. Predictors of any complication included disseminated cancer (odds ratio [OR] = 2.28; 95% confidence interval [CI], 1.05-4.95; P = .036) and increasing total relative value units (OR = 1.01; 95% CI, 1.00-1.02; P = .027). Active smoking was a major risk factor for surgical complications (OR = 1.81; 95% CI, 1.08-3.05; P = .025). Dyspnea (OR = 2.93; 95% CI, 1.37-6.27; P = .006) significantly predicted medical complications. CONCLUSION: Although complication rates after parotidectomy are generally low, avoidance of specific and nonspecific postoperative complications still remains an area for improvement. Future outcomes databases should include procedure-specific complications, including facial nerve injury.

Predictors of 61 unplanned readmission cases in microvascular free tissue transfer patients: multi-institutional analysis of 774 patients.

BACKGROUND: Unplanned readmissions serve as a marker for health care quality. Risk factors associated with unplanned readmission after microvascular free tissue transfer have never been examined. In this study, we sought to identify perioperative predictors of 30-day unplanned readmission in free flap patients. METHODS: The National Surgical Quality Improvement Program (NSQIP) database was retrospectively reviewed to identify all patients who underwent microvascular free tissue transfer in 2011. Multivariate logistic regression models were used to estimate independent predictors of unplanned readmission. RESULTS: Among free flap patients, unplanned readmission rate was 7.9%. In multivariate analysis, the only factor that significantly predicted unplanned readmission (P < 0.05) was open wound/wound infection (odds ratio [OR] 2.71). Postoperative variables significantly associated with unplanned readmission included surgical complications (OR 5.43), medical complications (OR 5.62), and unplanned reoperation (OR 3.94). Flap failure was not associated with unplanned readmission. CONCLUSIONS: In our study, the presence of either open wound/wound infection, development of surgical complications, medical complications, and unplanned reoperations were associated with unplanned readmissions. Further research in predictive factors is suggested to avoid costly, unnecessary, and preventable readmissions.

Catastrophic Outcomes in Free Tissue Transfer: A Six-Year Review of the NSQIP Database.

Background. No studies report robust data on the national incidence and risk factors associated with catastrophic medical outcomes following free tissue transfer. Methods. The American College of Surgeons (ACS) multicenter, prospective National Surgical Quality Improvement Program (NSQIP) database was used to identify patients who underwent free tissue transfer between 2006 and 2011. Multivariable logistic regression was used for statistical analysis. Results. Over the 6-year study period 2,349 patients in the NSQIP database underwent a free tissue transfer procedure. One hundred and twenty-two patients had at least one catastrophic medical outcome (5.2%). These 122 patients had 151 catastrophic medical outcomes, including 93 postoperative respiratory failure events (4.0%), 14 pulmonary emboli (0.6%), 13 septic shock events (0.5%), 12 myocardial infarctions (0.5%), 6 cardiac arrests (0.3%), 4 strokes (0.2%), 1 coma (0.0%), and 8 deaths (0.3%). Total length of hospital stay was on average 14.7 days longer for patients who suffered a catastrophic medical complication (P < 0.001). Independent risk factors were identified. Conclusions. Free tissue transfer is a proven and safe technique. Catastrophic medical complications were infrequent but added significantly to length of hospital stay and patient morbidity.

Pediatric mandibular reconstruction following resection of oral squamous cell carcinoma: a case report.

PURPOSE: Squamous cell carcinoma is a common entity among adult head and neck cancer patients, with many requiring reconstruction post resection. Conversely, this entity is rare among children with major reconstruction even more unique. This case and the concomitant review of literature highlight the intricacies of pediatric facial reconstruction. METHODS: The case described is of a 6-year-old African-American boy with poor dentition and a painful, 1.5 cm epiphytic lesion on the alveolar ridge of the left mandible. Incisional biopsy and computerized tomography were employed to obtain diagnosis and extent of disease. Surgical resection and reconstruction followed. RESULTS: Incisional biopsy confirmed the diagnosis of squamous cell carcinoma. Maxillofacial computerized tomography confirmed the extent of the mandibular lesion. After interdisciplinary discussion and weighing options with the family, a segmental mandibulectomy, neck dissection, and right fibula free flap reconstruction with titanium 2.0 mm metal plate fixation was performed. Re-examination post-operatively showed complete coverage of the defect and the ability to restore excised dentition. CONCLUSION: Squamous cell carcinoma within the pediatric population occurs less often than sarcomas, but may necessitate major reconstruction. Without rigid reconstruction, contracture may result. The current consensus favors microvascular bone reconstruction. However, a lack of consensus exists regarding the timing of dental rehabilitation.

Young Plastic Surgeons Forum member survey: Part I. Investing in the future: attitudes toward the Plastic Surgery Foundation.

BACKGROUND: Professional and social changes have resulted in decreased involvement in organizations. Little is currently known about young plastic surgeons' attitudes toward the Plastic Surgery Foundation and its sponsored activities. The authors gathered opinions of young plastic surgeons to determine factors related to participation. METHODS: A 21-question online survey was e-mailed to all 2155 members of the Young Plastic Surgeons Forum. Questions were related to demographics, current involvement, and initiatives in education, research, funding, and health policy. RESULTS: Of 2155 forum members, 397 responded (19 percent response rate). Most had not contributed to the Plastic Surgery Foundation. The primary reason cited was financial hardship, and respondents noted this would change with increased practice revenue. Involvement in American Society of Plastic Surgeons committees correlated with contribution to Plastic Surgery Foundation. The main educational initiatives favored by Young Plastic Surgeons included critical analysis of literature/evidence-based medicine, statistical analysis, and compensation issues. According to respondents, primary areas for organizational focus should be clinical research, increased representation of young surgeons, and leadership development. Respondents would be more willing to donate if they could earmark their contributions for specific purposes, including leadership training, clinical research, and medical missions. CONCLUSIONS: Methods to recruit and retain young surgeons into the American Society of Plastic Surgeons and in contributing to the Plastic Surgery Foundation should include opportunities to participate at a decreased cost, focus on compensation issues, clinical research, leadership development, and increased young surgeon representation. These data should be used to guide efforts to increase young member involvement.

Young Plastic Surgeons Forum member survey: Part II. Advocacy in plastic surgery: opinions toward the ASPS and PlastyPAC.

BACKGROUND: Given the continued evolution of the American health system, the authors explored young plastic surgeons' attitudes on challenges affecting the specialty and the future role of organized plastic surgery and its advocacy mission. METHODS: A 21-question online survey was distributed to all members of the Young Plastic Surgeons Forum. Questions were related to demographics, attitudes toward policy issues, participation in the American Society of Plastic Surgeons, and its advocacy efforts. RESULTS: The survey was e-mailed to 2155 Forum members, of which 397 responded (19% response rate). Young plastic surgeons appear to be interested in American Society of Plastic Surgeons and PlastyPAC, as evidenced by a higher than normal response rate to this survey and rate of contribution. However, a lack of awareness about the details of the organizations and mechanisms for involvement remains. Scope-of-practice issues and encroachment on the specialty by noncore providers remain the top concern of young plastic surgeons. Other top concerns were financial barriers to participation in advocacy efforts and concerns with return on investment on PlastyPAC contributions. A majority received minimal or no public policy education on issues affecting plastic surgery during training. A minority currently participate in American Society of Plastic Surgeons advocacy efforts. CONCLUSIONS: These data represent the first such collection of opinions from Young Plastic Surgeons members regarding goals and directions of the American Society of Plastic Surgeons and PlastyPAC. These organizations are in a uniquely strong position to enlist participation from and provide for the future success of the profession's younger members.

Differential impact of non-insulin-dependent diabetes mellitus and insulin-dependent diabetes mellitus on breast reconstruction outcomes.

While the comparative safety of breast reconstruction in diabetic patients has been previously studied, we examine the differential effects of insulin and non-insulin-dependence on surgical/medical outcomes. Patients undergoing implant/expander or autologous breast reconstruction were extracted from the National Surgical Quality Improvement Program 2005-2012 database. Preoperative and postoperative variables were analyzed using chi-square and Student's t test as appropriate. Multivariate regression modeling was used to evaluate whether non-insulin-dependent diabetes mellitus (NIDDM) or insulin-dependent diabetes mellitus (IDDM) is independently associated with adverse 30-day events following breast reconstruction. Of 29,736 patients meeting inclusion criteria, 23,042 (77.5 %) underwent implant/expander reconstructions, of which 815 had NIDDM and 283 had IDDM. Of the 6,694 (22.5 %) patients who underwent autologous reconstructions, 286 had NIDDM and 94 had IDDM. Rates of overall and surgical complications significantly differed among non-diabetic, NIDDM and IDDM patients in both the implant/expander and autologous cohorts on univariate analysis. After multivariate analysis, NIDDM was significantly associated with surgical complications (OR 1.511); IDDM was significantly associated with medical (OR 1.815) and overall complications (OR 1.852); and any type of diabetes was significantly associated with surgical (OR 1.58) and overall (OR 1.361) complications after autologous reconstruction. Diabetes of any type was not associated with any type of complication after implant/expander reconstruction. In this large, multi-institutional study, diabetes mellitus was significantly associated with adverse outcomes after autologous, but not implant-based breast reconstruction. The multivariate analysis in this study adds granularity to the differential effects of NIDDM and IDDM on complication risk.

Individualized risk of surgical-site infection: an application of the breast reconstruction risk assessment score.

BACKGROUND: Risk factors for surgical-site infection following beast reconstruction have been thoroughly investigated at a population level. However, traditional population-based measures may not always capture the nuances of individual patients. The authors aimed to develop a validated breast reconstruction risk assessment calculator for surgical-site infection that informs risk at an individual level. METHODS: Mastectomies with immediate reconstruction (n = 16,069) from 2005 to 2011 were identified from the National Surgical Quality Improvement Program database. A multiple logistic regression model was created for postoperative surgical-site infection. Hosmer-Lemeshow, C statistic, and Brier score were computed to assess model performance. Bootstrap analysis validated the model. RESULTS: A robust, validated risk model for surgical-site infection was developed using 11 covariates. The model Hosmer-Lemeshow p value was 0.371, the Brier score was 0.0357, and the C statistic was 0.682 (optimism-corrected C statistic, 0.678). The distribution of individual risks demonstrated a positive skew. Population-derived risk underestimated or overestimated individual risk by at least 1.5-fold in nearly one-fifth of all patients. CONCLUSIONS: The breast reconstruction risk assessment score risk calculator for surgical-site infection mitigates the potentially inaccurate interpolation of population-based risk to individual patients. The authors concomitantly developed an online interface-accessible by patients and surgeons alike-to quantify a patient's risk for surgical-site infection, better informing evidence-based decisions and managing patient expectations. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Predictors of 30-day readmission after outpatient thyroidectomy: an analysis of the 2011 NSQIP data set.

PURPOSE: With enhancements in patient safety and improvements in anesthesia administration, outpatient thyroidectomy is now frequently undertaken as an outpatient procedure, with several peer-reviewed reports of safe implementation totaling over 4500 procedures since 2006. However, robust statistical analyses of predictors for readmission are lacking. METHODS: The 2011 NSQIP data set was queried to identify all patients undergoing thyroidectomy on an outpatient basis. Outcomes of interest included surgical and medical complications, reoperation, mortality, and readmission. Univariate and multivariate analyses were utilized to identify the predictors of these events. RESULTS: In total 5121 patients were identified to have undergone an outpatient thyroidectomy in 2011. Overall 30-day morbidity was rare with only 47 patients (0.92%) experiencing any perioperative morbidity. One hundred eleven (2.17%) patients were readmitted within 30 days of the operation. A history of COPD was the only preoperative comorbid medical condition that significantly increased a patient's risk for readmission (OR 3.73 95% CI 1.57-8.85, p=0.003). Patients with a surgical complication were more than 7 times as likely to be readmitted (OR 2.08-25.28, p=0.002), and those with a medical complication were over 19 times as likely to be readmitted (OR 7.32-50.78, p<0.001). CONCLUSIONS: Readmission after outpatient thyroidectomy is infrequent, and compares well with other outpatient procedures. The main identified risks include preoperative COPD and any of the generic postoperative complications tracked in NSQIP. As procedures continue to transition into outpatient settings and financial penalties associated with readmission become a reality, these findings will serve to optimize outpatient surgery utilization.

Lower extremity reconstruction after limb-sparing sarcoma resection of the proximal tibia in the pediatric population: case series, with algorithm.

Limb salvage surgery (LSS) is the current treatment of choice for bone sarcomas in children. These procedures require composite resection and reconstruction, and are subject to high functional demands. Proximal tibia tumours, in particular, pose a significant challenge to treatment and reconstruction. A retrospective review was performed of all patients undergoing resection of proximal tibia bone sarcomas at a single centre over a 12-year period. Twenty-one patients (14 male, seven female) with an average age of 14.4 years (range = 8.3-19.2 years) underwent resection of a proximal tibial sarcoma. Pathology included osteosarcoma (OS) in 16, and Ewing's sarcoma family of tumours (ESFT) in five. Seventeen patients had bone tumour reconstruction with modular endoprsothesis, one patient with allograft, and three patients with an expandable endoprosthesis. One patient had primary closure; 20 patients had combined gastrocnemius and soleus flap reconstruction; three patients required subsequent bipedicled flap reconstruction, and two patients required subsequent sural artery flap reconstruction. No patients required free flap reconstruction. The average length of tibial osteotomy was 15 cm (range = 12.7-22.5 cm). Median soft tissue mass volume resected was 293 cm(3) (range = 211-1141 cm(3)). Median follow-up was 2.8 years (range = 0.5-6.8 years). Two patients died from metastatic disease. Two patients ultimately required amputation. Nineteen patients were ambulatory at last follow-up. This study presents an algorithm for soft-tissue reconstruction after resection of bone sarcomas of the proximal tibia. These techniques minimise complications, and maximise function in the paediatric population.

Intraoperative transfusion of packed red blood cells in microvascular free tissue transfer patients: assessment of 30-day morbidity using the NSQIP dataset.

Although often a life-saving therapeutic maneuver, there is minimal data available that details the effects of intraoperative packed red blood cell transfusion (IOT) after microvascular free tissue transfer. The National Surgical Quality Improvement Program database was queried to identify all patients who underwent microvascular free tissue transfer between 2006 and 2010. Multivariate logistic regression models were used to determine the association between intraoperative transfusion and outcomes. Upon bivariate and multivariate analyses, IOT was significantly associated with higher rates of overall complications (odds ratio [OR], 2.02; 95% confidence interval [CI], 1.12-3.63), medical complications (OR, 3.35; 95% CI, 1.75-6.42), postoperative transfusion (OR, 6.02; 95% CI, 2.02-17.97), and reoperation (OR, 2.24; 95% CI, 1.24-4.04). IOT was not associated with either surgical complications or free flap loss. IOT significantly increases risk for adverse overall and medical complications. However, IOT was not associated with surgical complications or free flap loss. Transfusion practices in the operating room should be reevaluated to improve overall outcomes.

Anesthesia duration as an independent risk factor for postoperative complications in free flap surgery: a review of 1,305 surgical cases.

Surgical dogma and objective data support the relationship between increased operative times and perioperative complications. However, there has been no large-scale, multi-institutional study that evaluates the impact of increased anesthesia duration on microvascular free tissue transfer. The National Surgical Quality Improvement Program (NSQIP) database was retrospectively reviewed to identify all free-flap patients between 2006 and 2011. Included patients were subdivided into quintiles of anesthesia time. Univariate and multivariate analyses were performed to assess its impact on 30-day postoperative complications. The mean anesthesia duration for all patients was 603 ± 222 minutes. In univariate analysis, 30-day overall/medical complications, reoperation, and free flap loss demonstrated statistically significant increases as anesthesia duration increased (p<0.05). However, in multivariate analyses, these trends and significances were abolished, with exception of the utilization of postoperative transfusions. Of interest, increasing anesthesia duration did not predict flap failure on multivariate analysis. We found that increased anesthesia time correlates with increased postoperative transfusions in free flap patients. As a result, limiting blood loss and avoiding prolonged anesthesia times should be goals for the microvascular surgeon. This is the largest multidisciplinary study to investigate the ongoing debate that longer anesthesia times impart greater risk.