A Nationwide Analysis of Outcomes

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Author Affiliations: Department of Surgery, University of Miami Leonard M. diastasis recti (728.84) or umbilical/ventral hernia without ob- Miller School of Medicine, Miami, Florida. struction (553.1-553.29). Patients with concurrent autoim- Corresponding Author: Rishi Rattan, MD, Department of Surgery, University of mune CTD diagnoses were also identified, including rheuma- Miami Leonard M. Miller School of Medicine, 1800 NW 10th Ave, Building T215, toid arthritis, systemic lupus erythematosus, Raynaud Room D-40, Miami, FL 33136 ([email protected]). phenomenon, scleroderma, Sjögren syndrome, psoriatic ar- Accepted for Publication: June 25, 2017. thritis, and mixed CTD. Demographic characteristics, comor- Published Online: October 18, 2017. doi:10.1001/jamasurg.2017.3116 bidities, and in-hospital postoperative complications were com- Author Contributions: Dr Parreco had full access to all the data in the study and pared among groups. Outcomes included in-hospital wound takes responsibility for the integrity of the data and the accuracy of the data analysis. complications, venous thromboembolism (VTE), blood trans- Study concept and design: Both authors. fusion, medical adverse events (myocardial infarction, stroke, Acquisition, analysis, or interpretation of data: Both authors. pulmonary, and/or renal complications), and length of stay. Drafting of the manuscript: Both authors. Critical revision of the manuscript for important intellectual content: Both Multivariable logistic regression models for each outcome in- authors. cluded primary predictor group (CTD status, with non-CTD as Statistical analysis: Parreco. reference), in addition to cofactors including age, sex, race, in- Administrative, technical, or material support: Rattan. surance type, and medical comorbidities. This study using pub- Study supervision: Rattan. licly available deidentified patient data was exempt from full Conflict of Interest Disclosures: None reported. review by the institutional review board at the University of Additional Contributions: Antonio Hidalgo, MS, provided technical assistance, for which he was not compensated. Miami Miller School of Medicine. P values of less than .05 were 1. Kaufman E, Rising K, Wiebe DJ, Ebler DJ, Crandall ML, Delgado MK. Recurrent considered statistically significant. violent injury: magnitude, risk factors, and opportunities for intervention from a statewide analysis. Am J Emerg Med. 2016;34(9):1823-1830. Results | Overall, 41 030 patients were identified. Of these, 537 2. Teo AR, Holley SR, Leary M, McNiel DE. The relationship between level of (1.3%) had autoimmune CTD. The most common autoim- training and accuracy of violence risk assessment. Psychiatr Serv. 2012;63(11): mune CTDs were rheumatoid arthritis (n = 315 [58.7%]) and 1089-1094. systemic lupus erythematosus (n = 124 [23.1%]), followed by 3. Oermann EK, Rubinsteyn A, Ding D, et al. Using a machine learning approach to predict outcomes after radiosurgery for cerebral arteriovenous Raynaud phenomenon (n = 44 [8.2%]), psoriatic arthritis malformations. Sci Rep. 2016;6:21161. (n = 30 [5.6%]), Sjögren syndrome (n = 14 [2.6%]), and sclero- 4. Walsh CG, Ribeiro JD, Franklin JC. Predicting risk of suicide attempts over derma (n = 10 [1.9%]). Mean (SD) age of patients with CTD was time through machine learning [published online April 7, 2017]. Clin Psychol Sci. 54.1 (11.6) years compared with 49.7 (12.0) years in patients doi:10.1177/2167702617691560 without CTD (Table 1). As expected, the CTD group had higher 5. Kiankhooy A, Crookes B, Privette A, Osler T, Sartorelli K. Fait accompli: rates of medical comorbidities than the non-CTD group. Post- suicide in a rural trauma setting. J Trauma. 2009;67(2):366-371. operatively,the overall in-hospital complication rate was 14.9%, 6. Whitlock J, Eckenrode J, Silverman D. Self-injurious behaviors in a college which was not significantly different among groups. How- population. Pediatrics. 2006;117(6):1939-1948. ever, the CTD group experienced higher rates of hematoma (4.5% vs 3.0%; P < .05), VTE (1.9% vs 0.9%; P < .05), and need for blood transfusion (13.0% vs 7.7%; P < .01) than the non- ASSOCIATION OF VA SURGEONS CTD group, respectively. Median (interquartile range [IQR]) Association of Autoimmune Connective Tissue length of stay was longer for the CTD group compared with the Disease With Abdominoplasty Outcomes: non-CTD group (4 [2-6] vs 3 [2-5] days; P < .001). On risk- A Nationwide Analysis of Outcomes adjusted multivariate analysis, CTD status was associated with Abdominoplasty is generally associated with favorable out- increased risk of VTE (adjusted odds ratio, 2.12; 95% CI, 1.11- comes and high levels of patient satisfaction. Nonetheless, 4.05) and perioperative blood transfusion (adjusted odds ra- abdominoplasties have one of the highest complication tio 1.75; 95% CI, 1.32-2.31) (Table 2). rates among aesthetic procedures.1 Patient selection and risk stratification is paramount to preventing postop- Discussion | Autoimmune CTDs can be associated with several erative complications. Patients with autoimmune connec- features that may increase risk of postoperative adverse events. tive tissue diseases (CTDs) may have associated systemic These include chronic anemia, hypercoagulable states, soft tis- and soft tissue manifestations that increase their risk of sue inflammation, chronic immunosuppressive therapy, as well complications.2 To date, the association of CTDs with as cardiac, pulmonary, and renal disease.2-4 abdominoplasty outcomes has not been reported. The pur- In this study, patients with autoimmune CTDs experi- pose of this study was to evaluate whether patients with enced similar overall in-hospital complication rates follow- autoimmune CTDs undergoing abdominoplasties are at an ing abdominoplasty compared with patients without CTD. increased risk of complications. However, results highlight an increased risk of VTE events and need for blood transfusions in these patients. Incidence of these Methods | Patients who underwent abdominoplasty as a pri- complications are also higher than have been reported in large mary procedure from January 2006 to December 2011 were cohorts of patients who have undergone abdominoplasty.1,5 identified in the Nationwide Inpatient Sample by Interna- Plastic surgeons should be aware of these elevated risks for ap- tional Classification of Diseases, 9th Revision, Clinical Modifi- propriate patient counseling and informed consent. We rec- cation code 86.83 in combination with a primary diagnoses of ommend plastic surgeons work in a multidisciplinary fash-

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Table 1. Perioperative Details of Patients Who Underwent Abdominoplastya

No. (%) Total Non-CTD CTD (N = 41 030 (n = 40 493 (n = 537 Characteristics [100%]) [98.7%]) [1.3%]) P Value Age, mean (SD), y 49.7 (12.0) 49.6 (12.0) 54.1 (11.6) <.001 Sex <.001 Male 4994 (12.00) 4976 (12.10) 18 (3.40) Female 36 036 (88.00) 35 517 (87.90) 519 (96.60) Race <.001 White 26 885 (77.80) 25 730 (77.70) 347 (81.60) Black 3172 (9.20) 3149 (9.20) 23 (5.40) Hispanic 3005 (8.70) 2955 (8.70) 50 (11.80) Other 1505 (4.30) 1500 (4.40) <10 (1.20) Insurance <.001 Medicare 8109 (19.90) 7886 (19.60) 223 (41.60) Medicaid 2852 (7.00) 2827 (7.00) 25 (4.70) Private insurance 22 340 (54.70) 22 096 (54.80) 244 (45.50) Uninsured/other 7545 (14.70) 7501 (14.80) 10 (6.30) Combined with breast reduction 1158 (2.80) 1143 (2.80) 15 (2.80) .97 Comorbidities Diabetes mellitus 7496 (18.30) 7362 (18.20) 134 (25.00) <.001 Hypertension 13 832 (33.70) 13 619 (33.60) 213 (39.70) <.001 Congestive heart failure 1020 (2.50) 994 (2.50) 26 (4.80) <.001 Chronic lung disease 5873 (14.30) 5749 (14.20) 124 (23.10) <.001 Renal failure 852 (2.10) 838 (2.10) 14 (2.60) .38 Liver disease 499 (1.20) 478 (1.20) 21 (3.90) <.001 Peripheral artery disease 329 (0.80) 324 (0.80) <10 (0.90) .74 Obesity 8627 (21.00) 8462 (20.90) 165 (30.80) <.001 Coagulopathy 432 (1.10) 427 (1.10) <10 (0.90) .78 APR-DRG severity of illness subclass <.001 1, Mild 22 895 (55.80) 22 757 (56.20) 139 (25.90) 2, Moderate 13 253 (32.30) 12 958 (32.00) 283 (52.70) 3, Major 3487 (8.50) 3401 (8.40) 96 (17.90) 4, Extreme 1395 (3.40) 1377 (3.40) 19 (3.50) APR-DRG mortality subclass <.001 1, Mild 35 901 (87.50) 35 446 (87.60) 437 (81.40) 2, Moderate 3036 (7.40) 2956 (7.30) 66 (12.30) 3, Major 1354 (3.30) 1336 (3.30) 29 (5.40) 4, Extreme 739 (1.80) 729 (1.80) <10 (0.90) Outcomes (in-hospital) Mortality 203 (0.50) 203 (0.50) 0 (0.00) .10 Wound complications 2706 (6.60) 2668 (6.60) 38 (7.10) .65 Venous thromboembolism 385 (0.90) 375 (0.90) 10 (1.90) .03 Blood transfusions 3205 (7.80) 3135 (7.70) 70 (13.00) <.001 Medical complication 3885 (9.50) 3837 (9.50) 48 (9.00) .68 Abbreviations: APR-DRG; All Patient Myocardial infarction 113 (0.30) 113 (0.30) 0 (0.00) .22 Refined Disease Related Group; Stroke 15 (0.00) 15 (0.00) 0 (0.00) .66 CTD, autoimmune connective tissue Pulmonary complication 3046 (7.40) 3007 (7.40) 39 (7.30) .89 disease; IQR, interquartile range; NIS, Nationwide Inpatient Sample. Acute kidney injury 1171 (2.90) 1157 (2.90) 14 (2.60) .74 a According to the NIS Database from Length of stay, median (IQR), d 3 (2-5) 3 (2-5) 4 (2-6) <.001 2006 to 2011.

ion to optimize perioperative management. Strategies for VTE rates may be underestimated. Furthermore, this study was not prophylaxis should be implemented.6 able to evaluate the relationship between individual CTD di- Limitations of the Nationwide Inpatient Sample database agnoses, disease severity, immunosuppressive regimen, and include lack of postdischarge data; therefore, complication VTE prophylaxis on postoperative complication rates. Future

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Table 2. Risk-Adjusted Multivariate Logistic Regression Models for Outcomes Following Abdominoplasty Based on Autoimmune Connective Tissue Disease Statusa

CTD (vs No CTD) Outcomes AOR (95% CI) P Value AUC (95% CI) Wound complication 0.70 (0.46-1.09) .11 0.69 (0.67-0.72) Venous thromboembolism 2.12 (1.11-4.05) .02 0.74 (0.68-0.80) Medical complications 0.98 (0.71-1.35) .90 0.75 (0.74-0.77) Blood transfusion 1.75 (1.32-2.31) <.001 0.70 (0.68-0.73) Abbreviations: AOR, adjusted odds ratio; AUC, area under the curve; (white, black, Hispanic, other), insurance (Medicare, Medicaid, private, CTD, connective tissue disease. uninsured, and/or other), and medical comorbidities (congestive heart failure, a Each row represents a multivariable logistic regression model with CTD status chronic lung disease, hypertension, obesity, liver disease, renal failure, as the main predictor variable. Models also include age (years), sex, race peripheral artery disease, and diabetes mellitus).

studies should focus on further evaluating these relation- COMMENT & RESPONSE ships in order establish evidence-based recommendations. Association Between Appendectomy Outcomes Gustavo A. Rubio, MD and Surgeons’ Seniority Leela S. Mundra, BA To the Editor We read with great interest the article by Siam et al.1 Seth R. Thaller, MD, DMD This study showed no significant difference in postoperative outcomes after appendectomy between senior general surgeons Author Affiliations: DeWitt Daughtry Family Department of Surgery, University (SGSs) and general surgery residents (GSRs); the authors proposed of Miami Leonard M. Miller School of Medicine, Miami, Florida (Rubio); that under standard conditions, more experienced surgical resi- University of Miami Leonard M. Miller School of Medicine, Miami, Florida (Mundra); Division of Plastic, Aesthetic, and Reconstructive Surgery, DeWitt dents can be allowed to perform appendectomy alone. Herein, Daughtry Family Department of Surgery, University of Miami Leonard M. Miller we would like to raise the following comments. School of Medicine, Miami, Florida (Thaller). As shown in Table 1,1 there were some differences in some Corresponding Author: Seth R. Thaller, MD, DMD, Division of Plastic, Aesthetic, aspects of preoperative presentation and operative course be- and Reconstructive Surgery, DeWitt Daughtry Family Department of Surgery, tween the SGS and GSR groups, including patients’ mean age, University of Miami Leonard M. Miller School of Medicine, 1120 NW 14th St, Clinical Research Bldg, Room 410, Miami, FL 33136 ([email protected]). percentage of surgeons performing laparoscopic surgeries, and Accepted for Publication: July 2, 2017. use of laparoscopic staplers (all P < .001), suggesting an un- Published Online: November 1, 2017. doi:10.1001/jamasurg.2017.3796 balanced enrollment between these 2 groups. In fact, propen- Author Contributions: Drs Rubio and Thaller had full access to all the data in sity score matching analysis has been generally used in obser- the study and take responsibility for the integrity of the data and the accuracy vational studies, which enables better balance between groups of the data analysis. across all putative risk factors and evaluates the extent of bal- Study concept and design: All authors. anced match in a measurable approach.2,3 Therefore, we sug- Acquisition, analysis, or interpretation of data: All authors. Drafting of the manuscript: Rubio, Mundra. gest that this method be used here. In fact, a 2012 study by Critical revision of the manuscript for important intellectual content: Mundra, Graatetal4 investigated the same topic using this method, and Thaller. their conclusion was the same. We prefer the study using pro- Statistical analysis: Rubio, Mundra. pensity score matching analysis, as it is more statistically Study supervision: Thaller. convictive. Conflict of Interest Disclosures: None reported. In addition, in this study, length of surgery was signifi- Previous Presentation: This paper was presented at the Association of Veterans Affairs Surgeons Annual Meeting; May 8, 2017; Houston, Texas. cantly shorter in the SGS group than in the GSR group by uni- 1 1. Winocour J, Gupta V, Ramirez JR, Shack RB, Grotting JC, Higdon KK. variate analysis (mean length, 39.9 vs 48.6 minutes; P < .001). Abdominoplasty: risk factors, complication rates, and safety of combined However, a higher proportion of patients in the SGS group un- procedures. Plast Reconstr Surg. 2015;136(5):597e-606e. derwent laparoscopic surgeries compared with the GSR group 2. Tsai DM, Borah GL. Implications of rheumatic disease and biological (95.8% vs 90.0%; P < .001), which, in our opinion, might be response-modifying agents in plastic surgery. Plast Reconstr Surg. 2015;136(6): the main reason for the difference of length of surgery be- 1327-1336. tween these 2 groups. Therefore, we suggest that multivari- 3. Zöller B, Li X, Sundquist J, Sundquist K. Risk of pulmonary embolism in patients with autoimmune disorders: a nationwide follow-up study from ate logistic regression analysis be used here to reveal which fac- Sweden. Lancet. 2012;379(9812):244-249. tors were significantly associated with length of surgery for 4. Wong LE, Bass AR. Postoperative risk of venous thromboembolism in appendectomy. rheumatic disease patients. Curr Rheumatol Rep. 2015;17(2):11. In summary, clarification regarding the above-mentioned 5. Familusi OT, Doscher M, Manrique OJ, Shin J, Benacquista T. Abdominal omissions would greatly solidify the conclusions of the study contouring: can the American Society of Anesthesiologists classification system by Siam et al.1 help determine when to say no? Plast Reconstr Surg. 2016;138(6):1211-1220.

6. Pannucci CJ, Swistun L, MacDonald JK, Henke PK, Brooke BS. Individualized Jiong-Jie Yu, BA venous thromboembolism risk stratification using the 2005 caprini score to identify the benefits and harms of chemoprophylaxis in surgical patients: Xin-Fei Xu, BA a meta-analysis. Ann Surg. 2017;265(6):1094-1103. Tian Yang, MD

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