Perioperative variables associated with surgical site infection in breast cancer surgery

The effect of neoadjuvant chemotherapy on surgical site wound infection after immediate breast reconstruction in patients with breast cancer: A meta-analysis

Using a meta-analysis approach, we conducted a comprehensive evaluation of the effect of neoadjuvant chemotherapy (NACT) on the incidence of surgical site wound infection during immediate breast reconstruction (IBR) following breast cancer. The aim was to provide evidence-based support for the prevention of wound surgical site infection during IBR after breast cancer surgery. Relevant literature on the effects of NACT on IBR in patients with breast cancer published up until May 2023, was retrieved from various databases, including PubMed, Cochrane Library, EMBASE, China National Knowledge Infrastructure (CNKI), Wanfang databases, and China Biology Medicine Database. Two researchers performed the literature screening, data collection, and quality assessment of the included studies independently. The meta-analysis was conducted using Stata version 17.0. Fourteen studies involving 3401 patients (599 in the intervention group and 2802 in the control group) were included in the analysis. The incidence of surgical site infection in the NACT group was higher than that in the control group, but the difference between the two groups was not statistically significant (7.17% vs. 4.85%, odds ratio: 1.02, 95% confidence interval: 0.70-1.50, p = 0.902). These findings suggest that NACT does not increase the risk of surgical site infection during IBR. However, owing to the variation in sample size and literature quality among the included studies, randomised controlled trials are needed to confirm the safety of IBR in patients receiving neoadjuvant chemotherapy.

Ultrasonic scissors decrease postoperative bleeding complications in mastectomy: A retrospective multicenter cohort study on 728 patients

INTRODUCTION

The aim of this study was to evaluate the rate of postoperative bleeding complications (primary outcome) and any other surgical complications (secondary outcome) in mastectomy between two surgical instruments, ultrasonic SonoSurg® scissors (US) and traditional electrocautery (EC).

MATERIALS AND METHODS

In total 728 patients undergoing mastectomy in two adjacent university hospitals were retrospectively evaluated in terms of postoperative bleeding episodes, surgical site infections, skin flap necrosis, and any reoperations for 30 postoperative days. A propensity score matching was performed to acquire balanced groups. Patients consuming medications affecting hemostasis were excluded from the study. A multivariable logistic regression analysis was conducted to define the odds ratio (OR) for each complication separately. A cost analysis was performed.

RESULTS

The rate of postoperative bleeding complications was significantly lower in patients operated with US (0.3% vs 11.5%, OR 0.020, 95% CI 0.034-0.14) when compared to EC. The rate of surgical site infections (OR 0.65, 95% CI 0.35-1.23) was similar with both instruments, but there were less skin flap necroses (OR 0.35, 95% CI 0.13-0.98) in US group. For any reoperation, the OR for US was 0.13 (95% CI 0.046-0.39), mainly due to the lower number of acute bleeding complications. Even though the US instrument is more expensive than EC, the total cost of the treatment is lower in patients operated with US (3419 vs. 3475 euro).

CONCLUSIONS

US seems to be associated with a lower risk of bleeding complications in mastectomy.

Preoperative antibiotic prophylaxis in mastectomy: A retrospective comparative analysis of 1413 patients with breast cancer

BACKGROUND AND OBJECTIVE

The reported rate of surgical site infections (SSIs) in breast cancer surgery varies widely in previous literature. The use of antibiotic prophylaxis is controversial but recommended by several guidelines. The aim of this study was to evaluate the efficacy of routine antibiotic prophylaxis in patients with breast cancer undergoing mastectomy.

METHODS

In this retrospective single-institution study, we reviewed 1413 consecutive female breast cancer patients who underwent mastectomy and/or axillary lymph node surgery between years 2012 and 2019. Prophylactic antibiotics for all patients undergoing mastectomy was introduced in our hospital in 2016 and before that the prophylaxis was prescribed individually on surgeons' preference. All patient records for 30 postoperative days were evaluated in detail and all SSIs were recorded. The rate of SSIs was compared between patients who received antibiotic prophylaxis and those who did not. A multivariate logistic regression model was used to define the odds ratio (OR) for the efficacy of antibiotic prophylaxis.

RESULTS

A total of 335 patients underwent mastectomy without antibiotic prophylaxis and 1078 with prophylaxis. The rate of SSIs was 6.9% in patients who received prophylaxis and 6.3% in patients without prophylaxis (p = 0.70). The rate of SSIs was similar before and after the introduction of regular antibiotic prophylaxis and there was no difference in any of the patient subgroups investigated. In multivariable logistic regression analysis, the OR for antibiotic prophylaxis was 1.04 (95% CI: 0.62-1.73, p = 0.88).

CONCLUSIONS

Routine use of antibiotic prophylaxis did not reduce the rate of SSIs in mastectomy. Unselective antibiotic prophylaxis for all patients does not seem mandatory in mastectomy.

Impact of diabetes on outcomes in breast reconstruction: A systematic review and meta-analysis

BACKGROUND

As rates of breast cancer and type II diabetes increase, so does the number of women with diabetes undergoing breast reconstruction (BR). Patients with diabetes are at increased risk of postoperative complications. This meta-analysis seeks to evaluate the post-operative outcomes of women with diabetes who underwent BR following mastectomy.

METHOD

This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The EMBASE, PUBMED, and MEDLINE electronic databases were searched from inception to November 1, 2020 for studies published in English. Outcomes evaluated were overall complications, surgical complications, and longer hospital stay. Subgroup analysis investigated outcomes, such as implant/flap failure, infection, and necrosis.

RESULTS

Sixty-five studies met our inclusion criteria and 38 provided data to be included in the meta-analysis. A total of 151,585 patients were included, of which 9299 had diabetes. Women with diabetes were more likely to experience overall complications (11.6% vs 5.6%; p<0.0001) and surgical complications (7.7% vs 3.3%; p<0.0001), and were more likely to have a prolonged hospital stay (p = 0.04) than women without diabetes. Subgroup analysis showed that implant loss (2.5% vs 1.6%; p = 0.0003), infection (6.8% vs 2.5%; p<0.0001) and necrosis (23.8% vs 6.5; p = 0.001) were significantly higher in women with diabetes.

CONCLUSIONS

This study provides evidence that diabetes mellitus increases the risk of complications in patients with breast cancer undergoing BR after mastectomy. Prospective studies are required to establish whether diabetes that is well-controlled prior to reconstruction, including diabetes that is paired with adjuvant radiation therapy, reduces the perioperative risks.

Do Preoperative Prophylactic Antibiotics Reduce Surgical Site Infection Following Wire-Localized Lumpectomy? A Single-Blind Randomized Clinical Trial

BACKGROUND

Data on the benefits of preoperative prophylactic antibiotics for breast surgery are conflicting, and there is no specific guideline for their use in wire-localized lumpectomy.

PATIENTS AND METHODS

This is a proof-of-concept, single-blind randomized controlled trial carried out from April 2018 to June 2019 at the Centre des Maladies du Sein du CHU de Québec - Université Laval. The objectives were to determine whether a single dose of preoperative antibiotics reduces surgical site infection (SSI) after wire-localized lumpectomy and to identify the risk factors for SSI. The patients were randomized to receive preoperative prophylactic antibiotics or not. SSI was defined by positive breast wound cultures, abscess drainage, and/or antibiotics given for clinical signs of breast infection within 30 days of the operation. This study was registered with ClinicalTrials.gov, NCT04818931.

RESULTS

A total of 330 patients were enrolled. Eighteen patients were excluded. The SSI rate was 3.1% (5/160) in the antibiotic group versus 5.9% (9/152) in the control group (p = 0.28). Only obesity was a significant risk factor for SSI. All cases of SSI were treated routinely with antibiotics; one patient required wound re-opening. None of the SSIs delayed the adjuvant treatment.

CONCLUSION

Preoperative antibiotic prophylaxis does not significantly decrease the occurrence of breast SSI. It is safe to omit prophylactic antibiotics for a wire-localized lumpectomy. This could also decrease the treatment costs and avoid unnecessary side effects.

Impact of duration of antibiotic prophylaxis on rates of surgical site infection (SSI) in patients undergoing mastectomy without immediate reconstruction, comparing a single prophylactic dose versus continued antibiotic prophylaxis postoperatively: a multicentre, double-blinded randomised control trial protocol

INTRODUCTION

In breast surgeries, prophylactic antibiotics given before the surgical incision as per Joint Commission Surgical Care Improvement Project guidelines have been shown to decrease the rate of postoperative infections. There is, however, no clear consensus on postoperative antibiotic prophylaxis in patients undergoing mastectomy with indwelling drains. This trial protocol proposes to study the difference in rates of surgical site infection (SSI) with or without continuation of postoperative antibiotics in patients undergoing mastectomy without immediate reconstruction and with indwelling drains.

METHODS AND ANALYSIS

In this multicentre, double-blinded clinical trial, all patients undergoing mastectomy (without immediate reconstruction) will receive a single prophylactic dose of preoperative antibiotics at induction of anaesthesia and will then get randomised to either continue antibiotic prophylaxis or a placebo postoperatively, for the duration of indwelling drains. The primary and secondary outcomes will be development of an SSI and antibiotic-associated adverse effects, respectively. Data will be collected through a standard questionnaire by wound assessors. Intention-to-treat analysis will be carried out using STATA V.12. For categorical variables, frequencies and percentages will be assessed by χ2 test/Fisher's exact test as appropriate. The quantitative variables will be computed by their mean±SD or median (IQR) and will be assessed by independent t-test/Mann-Whitney test as appropriate. Unadjusted and adjusted relative risk with their 95% CI will be reported using Cox proportional regression. A p value of <0.05 will be considered statistically significant.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from each site's Ethical Review Board. The study background and procedure will be explained to the study participants and informed consent will be obtained. Participation in the study is voluntary. All data will be deidentified and kept confidential. The study findings will be published in scientific media and authorship guidelines of International Committee of Medical Journal Editors will be followed.

TRIAL REGISTRATION NUMBER

NCT04577846. (patient recruitment).

Risk Factors Associated With Complications After Unilateral Immediate Breast Reconstruction: A French Prospective Multicenter Study

BACKGROUND/AIM

For women who have undergone a mastectomy, breast reconstruction provides psychological as well as aesthetic benefits. Thus, many patients ask for an immediate breast reconstruction (IBR). The present study focuses on risk factors assiociated with complications after IBR.

PATIENTS AND METHODS

A national prospective study (2007-2009) was conducted on 404 patients who underwent an unilateral IBR: 205 implants alone (IA) including 46 tissue expanders, 91 latissimus dorsi musculocutaneous flaps with implant (LDI), 78 autologous latissimus dorsi musculocutaneous flaps (LD), and 30 autologous transverse rectus abdominis musculocutaneous flaps (TRAM). Outcomes concerned major and minor complications, as well as early and late complications.

RESULTS

Related risks of complications were different according to the IBR technique. Major complications rate remained moderate and concerned 15% of patients. Obesity and diabetes significantly increased the incidence of major complications.

CONCLUSION

To reduce complication rate, the risk factors associated with each type of IBR should be taken into account.

The Use of Oral Antibiotics to Prevent Surgical Site Infection on Postoperative Modified Radical Mastectomy Patients in Dr. Soetomo General Hospital, Surabaya

Surgical operations on modified radical mastectomy are considered clean procedures by the Centers for Disease Control and Prevention (CDC) wound classification system. Despite this, higher than expected Surgical Site Infection (SSI) rates are reported, varying from 1 % to 26 % across the literature. Some surgeons also prescribe postoperative prophylaxis for postoperative modified radical mastectomy patients to prevent infection despite its lack of proven efficacy. The aim of this study is to analyze the use of oral antibiotics to prevent Surgical Site Infection (SSI) on postoperative modified radical mastectomy patients in Dr. Soetomo General Hospital. This study was double-blinded randomized control trial of 60 postoperative modified radical mastectomy patients (2 groups) during the period of December 2017 to March 2018. Samples were prospectively divided into two groups (random sampling), in group A (n=30) patients received single dose prophylactic antibiotics and continued with oral antibiotics postoperative (Cefadroxil 2 x 500 mg) during 7 days and in group B (n=30) patients received single dose prophylactic antibiotics and continued without postoperative antibiotics (placebo). Both groups were evaluated clinically for surgical site infection up to 30 days. There was no statistically significant difference in both groups {p=1 (p>0.05)}. There was no incidence of surgical site infection in both groups during the 30-day follow-up period (days 3, 7, 14 and 30). There was no difference in the surgical site infection rate among those who received oral postoperative antibiotics prophylactic and without antibiotics (placebo) on postoperative modified radical mastectomy patients in Dr. Soetomo General Hospital. Because of the potential adverse events associated with antibiotic use, further evaluation of this practice is required.

The Impact of Postoperative Wound Complications on Oncological Outcomes Following Immediate Breast Reconstruction for Breast Cancer: A Meta-analysis

The association between immediate breast reconstruction (IBR)-related wound complications and breast cancer recurrence (BCR) remains uncertain. This study aimed to investigate the oncological outcomes in patients with wound complications following mastectomy and IBR. A comprehensive search was undertaken for all studies describing complications in patients with breast cancer following IBR. Studies were included if they reported on complications and investigated their relationship with BCR. A meta-analysis was performed using a random-effects model, with data presented as odds ratios and 95% confidence intervals. A total of 1418 patients from five studies were included in the final analysis. The mean age of patients included was 47.2 years. A total of 382 (26.9%) patients had postoperative complications following a majority of implant-based IBR (929/1418). A total of 158 (11.1%) recurrences, which included 63 locoregional and 106 distant recurrences, was noted at a mean follow-up of 66 months. Although there was an increase in recurrence rates in the complication group (n = 66/382; 17.3% vs. n = 92/1036; 8.9%), there was no significant association between complications and BCR (17.3% vs. 8.9%; P = .18) or mortality (3.6% vs. 2.3%; P = .15). Time to adjuvant therapy was significantly increased in patients with complications (mean difference, 8.69 days; range, 1.18-16.21 days; P = .02; I² = 0.02). This meta-analysis demonstrated a higher incidence of wound complications following IBR and a statistically significant increased time to adjuvant therapy. However, this did not translate into adverse oncological outcomes in patients with breast cancer undergoing IBR.

The relationship between post-surgery infection and breast cancer recurrence

Breast cancer is the second most prevalent form of cancer in women worldwide, with surgery remaining the standard treatment. The adverse impact of the surgery remains controversial. It has been suggested that systemic factors during the postoperative period may increase the risk of recurrence, specifically surgical site infection (SSI). The aim of this review was to critically appraise current published literature regarding the influence of SSIs, after primary breast cancer surgery, on breast cancer recurrence, and to delve into potential links between these. This systematic review adopted two approaches: to identify the incidence rates and risk factors related to SSI after primary breast cancer surgery; and, secondly, to examine breast cancer recurrence following SSI occurrence. Ninety-nine studies with 484,605 patients were eligible in the SSI-focused searches, and 53 studies with 17,569 patients for recurrence-focused. There was a 13.07% mean incidence of SSI. Six-hundred and thirty-eight Gram-positive and 442 Gram-negative isolates were identified, with methicillin-susceptible Staphylococcus aureus and Escherichia coli most commonly identified. There were 2077 cases of recurrence (11.8%), with 563 cases of local recurrence, 1186 cases of distant and 25 cases which recurred both locally and distantly. Five studies investigated the association between SSI and breast cancer recurrence with three concluding that an association did exist. In conclusion, there is association between SSI and adverse cancer outcomes, but the cellular link between them remains elusive. Confounding factors of retrospective study design, surgery type and SSI definition make results challenging to compare and interpret. A standardized prospective study with appropriate statistical power is justified.

Peri-Operative Antibiotic Prophylaxis Does Not Reduce Surgical Site Infection in Breast Cancer

Background: The reported rate of surgical site infection (SSI) in breast surgery is often higher than expected. Using antibiotic prophylaxis to reduce SSI is debatable because of the risk of developing bacteria resistance and the cost burden. In this study, we evaluated the effectiveness of antibiotic prophylaxis in breast surgery and the factors predisposing patients to SSI. Methods: A retrospective-prospective (ambispective) study was conducted in the Department of Breast Surgery, Qilu Hospital, P.R. China. The retrospective antibiotic-using group was composed of patients found to have breast cancer between January 2008 and October 2010. The prospective non-antibiotic-using group was composed of patients identified between November 2010 and November 2013. Pre-operative, peri-operative, and post-operative clinical data were analyzed. Results: The SSI rate of the non-prophylaxis and prophylaxis groups was 1.1% (11/1,022) and 1.2% (12/1,034), respectively. Neoadjuvant chemotherapy was related to SSI in the non-prophylaxis group (p = 0.026). Staphylococcus aureus was the predominant microorganism responsible for SSI, without obvious resistance to a widely used first-generation cephalosporin. Conclusions: Peri-operative antibiotic prophylaxis is of no significant value in preventing SSI in breast cancer surgery. Our results indicated that neoadjuvant chemotherapy might be a risk factor doe SSI, but further research is needed because of the sample size disparity between infected and uninfected groups.

Randomized Controlled Trial to Reduce Bacterial Colonization of Surgical Drains with the Use of Chlorhexidine-Coated Dressings After Breast Cancer Surgery

BACKGROUND

Breast surgery is considered a clean surgery. However, surgical-site infection (SSI) rates are currently higher than predicted. Postoperative drains remain in situ for several days, with inevitable bacterial colonization and increased SSI risk.

METHODS

This randomized controlled trial from October 2016 to January 2018 analyzed patients undergoing breast cancer surgery. The patients were randomized to either the standard drain care group or the antiseptic dressing group (3M® Tegaderm® CHG). Drain samples taken on postoperative days (PODs) 7 and 14 were cultured as standardized in the laboratory. Colonization rates and SSI were compared between the two groups.

RESULTS

The study enrolled 104 patients with 167 surgical drains. The patients' clinical characteristics were similar in the two groups, with no statistically significant differences. Bulb fluid cultures at postoperative week (POW) 1 were positive for 42.9% of the control group and 28.9% of the antiseptic group (p = 0.06). Cultures from the POW 2 assessment were positive for 79.7% of the control group versus 54.9% of the antiseptic group (p = 0.001). Cultures from drain tubes were positive for 79.8% of the control group and 50.7% of the antiseptic group (p = < 0.001). In 11 patients, an SSI developed, 3 (5.8%) from the intervention and 8 (15.4%) from the control procedure (p = 0.11).

CONCLUSION

The study findings demonstrated that the use of antiseptics at the drain exit site significantly reduced bacterial colonization of the closed drainage system in breast cancer surgery. Semi-permeable occlusive chlorhexidine-impregnated dressings provide an opportunity to test simple, safe, and low-cost interventions that may reduce drain bacterial colonization and SSI after breast surgery.

Preoperative Hypoglycemia and Hyperglycemia Are Related to Postoperative Infection Rates in Implant-Based Breast Reconstruction

OBJECTIVES

Diabetic patients undergoing surgery are known to have a higher risk for infection. However, current literature does not adequately investigate the effects of preoperative hypoglycemia or hyperglycemia on postoperative infection risk.

METHODS

A retrospective review of a national private payer database within the PearlDiver Supercomputer application (Warsaw, IN) for patients undergoing breast reconstruction with implant/expander (BR) was conducted. These patients were identified by Current Procedural Terminology (CPT) and International Classification of Disease (ICD-9) ninth revision codes. Glucose ranges were identified by filtering for Logical Observation Identifiers Names and Codes ranging from 25 to 219 mg/dL, in 15 mg/mL increments. Patients with preexisting diabetes diagnoses were excluded. These patients were longitudinally tracked for infection at the 90 d and 1-y postoperative period using ICD-9 codes.

RESULTS

The search query yielded 13,237 BR procedures with preoperative glycemic levels ranging from 25 to 219 mg/mL. Most procedures (34.6%) were performed on patients with preoperative glycemic levels ranging from 70 to 99 mg/dL. Of the total procedures performed (n = 13,237), 19.4% (n = 2564) resulted in infections documented at the 90-d interval, and 24.8% (n = 3285) resulted in infections documented at the 1-y interval. BR patients within the 40-54 mg/dL range had the highest rate of infection (90 d: 30.1%; 1 y: 53.4%). There was a statistically higher incidence of infection among patients with preoperative hypoglycemia (<70 mg/dL).

CONCLUSIONS

The incidence of infection remains high in preoperatively hyperglycemic patients undergoing breast reconstruction procedures. However, our results show that preoperatively hypoglycemic patients also have an increased incidence of infection.

Factors influencing the decision to pursue immediate breast reconstruction after mastectomy for breast cancer

BACKGROUND

Immediate breast reconstruction (IBR) after mastectomy has shown to be oncologically safe and to improve quality of life in breast cancer patients. However, most women undergoing mastectomy do not undergo IBR. In this study, we aim to identify breast surgeon-related factors in considering IBR and factors affecting patients' decision to choose for IBR.

METHODS

Retrospective analysis of the records of breast cancer patients who underwent mastectomy with or without IBR between 2010 and 2013. We documented all information whether or not a patient underwent IBR after mastectomy.

RESULTS

Of 437 patients, 97 (22.2%) underwent IBR, 89.8% of which received tissue expanders. Patient who did not undergo IBR had a higher age (62.2 versus 51.9 years, P<0.001) and higher body mass index (BMI) (27.0 versus 24.3, P<0.001). Hundred three patients declined IBR, mainly because considering reconstruction as too much trouble. In 128 cases the breast surgeon did not offer IBR, mostly because of the predicted need for post mastectomy radiation. Approximately 11% of the patients were not informed about IBR.

CONCLUSIONS

Anticipated radiation therapy, higher age and higher BMI were important breast surgeon-related factors in refraining from IBR. Almost one third of all patients declined IBR. In almost 10% of all patients, IBR was not discussed.

Surgical Site Infections in Breast Surgery: The Use of Preoperative Antibiotics for Elective, Nonreconstructive Procedures

Background. Antibiotic prophylaxis for surgical site infections (SSIs) for breast surgery is widespread, but the benefit in clean surgical cases is not well defined. Methods. A retrospective analysis of 855 patients undergoing elective, nonreconstructive breast operations was performed, with 401 patients receiving no antibiotics and 454 patients receiving a single dose of preoperative antibiotic. Results. Administration of a preoperative antibiotic did not decrease the SSI rate. In this community-based study, antibiotic use practices varied considerably by surgeon. In univariate analyses, SSI rates appeared to increase with prophylactic antibiotic use (12% SSI with antibiotics versus 4% without, p < 0.0001), likely because the use of underdosed antibiotics was associated with higher rates of SSI (13.2% SSI with cefazolin 1 gram, p < 0.0001, and 15.4% SSI with clindamycin 300 mg or less, p = 0.0269). Methicillin-resistant Staphylococcus aureus was the most common isolate from SSI cultures, 31.8% (7 of 22). In multivariable analyses, increased risk of SSI was associated with BMI > 25 kg/m² (OR: 1.08, 95% CI: 1.04-1.11, p < 0.0001). Conclusion. The administration of a single dose of preoperative antibiotic did not decrease the rate of SSI in this large series of patients undergoing clean breast operations. BMI >25 kg/m² and the use of an inadequate dose of antibiotics for prophylaxis may increase risk of SSI.

[Systematizing support in cessation smoking to improve care for cancer patients]

Approximately 20% of cancer patients smoke at diagnosis (all localizations included), and over two thirds continue despite the therapeutic management of their cancer, especially when cancer is not associated with tobacco. The impact of smoking on quality of care for patients is actually not enough considered. A literature review conducted by the French National Cancer Institute emphasizes the importance of tobacco cessation to improve the prognosis (decreased mortality from all causes and specific); to reduce the risk of second primary cancers; to reduce per- and post-surgical risks as long as some toxicities related to treatments and to improve the quality of physical and mental life of patients. It is important that a communication with the patient takes place at the beginning of the treatment to impact the smoking behavior. All oncology health professionals should deliver a clearly and personalized cessation advice in the light of scientific data and ensure that smoking cessation help will be offered to the patient.

Preoperative chemotherapy and corticosteroids: independent predictors of cranial surgical-site infections

OBJECT Preoperative corticosteroids and chemotherapy are frequently prescribed for patients undergoing cranial neurosurgery but may pose a risk of postoperative infection. Postoperative surgical-site infections (SSIs) have significant morbidity and mortality, dramatically increase the length and cost of hospitalization, and are a major cause of 30-day readmission. In patients undergoing cranial neurosurgery, there is a lack of data on the role of patient-specific risk factors in the development of SSIs. The authors of this study sought to determine whether chemotherapy and prolonged steroid use before surgery increase the risk of an SSI at postoperative Day 30. METHODS Using the national prospectively collected American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database for 2006-2012, the authors calculated the rates of superficial, deep-incisional, and organ-space SSIs at postoperative Day 30 for neurosurgery patients who had undergone chemotherapy or had significant steroid use within 30 days before undergoing cranial surgery. Trauma patients, patients younger than 18 years, and patients with a preoperative infection were excluded. Univariate analysis was performed for 25 variables considered risk factors for superficial and organ-space SSIs. To identify independent predictors of SSIs, the authors then conducted a multivariate analysis in which they controlled for duration of operation, wound class, white blood cell count, and other potential confounders that were significant on the univariate analysis. RESULTS A total of 8215 patients who had undergone cranial surgery were identified. There were 158 SSIs at 30 days (frequency 1.92%), of which 52 were superficial, 27 were deep-incisional, and 79 were organ-space infections. Preoperative chemotherapy was an independent predictor of organ-space SSIs in the multivariate model (OR 5.20, 95% CI 2.33-11.62, p < 0.0001), as was corticosteroid use (OR 1.86, 95% CI 1.03-3.37, p = 0.04), but neither was a predictor of superficial or deep-incisional SSIs. Other independent predictors of organ-space SSIs were longer duration of operation (OR 1.16), wound class of ≥ 2 (clean-contaminated and further contaminated) (OR 3.17), and morbid obesity (body mass index ≥ 40 kg/m(2)) (OR 3.05). Among superficial SSIs, wound class of 3 (contaminated) (OR 6.89), operative duration (OR 1.13), and infratentorial surgical approach (OR 2.20) were predictors. CONCLUSIONS Preoperative chemotherapy and corticosteroid use are independent predictors of organ-space SSIs, even when data are controlled for leukopenia. This indicates that the disease process in organ-space SSIs may differ from that in superficial SSIs. In effect, this study provides one of the largest analyses of risk factors for SSIs after cranial surgery. The results suggest that, in certain circumstances, modulation of preoperative chemotherapy or steroid regimens may reduce the risk of organ-space SSIs and should be considered in the preoperative care of this population. Future studies are needed to determine optimal timing and dosing of these medications.

Perspectives of Cosmesis following Breast Conservation for Multifocal and Multicentric Breast Cancers

Background. Contemporary data suggest that breast conservation treatment (BCT) for multifocal and multicentric breast cancer (MFMCBC) may be appropriate with noninferior local control rates. However, there is a paucity of data to evaluate patient's satisfaction with cosmetic outcomes after BCT for MFMCBC. This study was performed to bridge this information gap. Methods. All patients treated at the authors' healthcare facility were included in the study. Patients with MFMCBC who were assessed to be eligible for BCT underwent tumour resection using standard surgical techniques with direct parenchymal closure through a single incision. After at least three years of follow-up, they were invited to participate in a survey regarding their cosmetic outcomes. Results. Of a total of 160 patients, 40 had MFMCBC, of whom 34 (85%) underwent successful BCT. Five-year cancer-specific survival and disease-free survival were 95.7%. Twenty of the 34 patients responded to the survey. No patient rated her cosmetic outcome as "poor." Analysis indicated low agreement between patients' self-assessment and clinician-directed evaluation of aesthetic results. Conclusion. BCT for MFMCBC is feasible with acceptable survival and cosmetic outcomes. However, there appears to be a disparity between patient and clinician-directed evaluation of cosmetic results which warrant further research.

Impact of intra-operative intraperitoneal chemotherapy on organ/space surgical site infection in patients with gastric cancer

BACKGROUND

Various risk factors for surgical site infection (SSI) have been identified such as age, overweight, duration of surgery, blood loss, etc. Intraperitoneal chemotherapy during surgery is a common procedure in patients with gastric cancer, yet its impact on SSI has not been evaluated.

AIM

To evaluate whether intra-operative intraperitoneal chemotherapy is a key risk factor for organ/space SSI in patients with gastric cancer.

METHODS

All patients with gastric cancer who underwent surgery at the Department of Gastrointestinal Surgery between January 2008 and December 2013 were studied. The organ/space SSI rates were compared between patients who received intra-operative intraperitoneal chemotherapy and patients who did not receive intra-operative intraperitoneal chemotherapy, and the risk factors for organ/space SSI were analysed by univariate and multi-variate regression analyses. The microbial causes of organ/space SSI were also identified.

FINDINGS

Of the eligible 845 patients, 356 received intra-operative intraperitoneal chemotherapy, and the organ/space SSI rate was higher in these patients compared with patients who did not receive intra-operative intraperitoneal chemotherapy (9.01% vs 3.88%; P = 0.002). Univariate analysis confirmed the significance of this finding (odds ratio 2.443; P = 0.003). As a result, hospital stay was increased in patients who received intra-operative intraperitoneal chemotherapy {mean 20.91 days [95% confidence interval (CI) 19.76-22.06] vs 29.72 days (95% CI 25.46-33.99); P = 0.000}. The results also suggested that intra-operative intraperitoneal chemotherapy may be associated with more Gram-negative bacterial infections.

CONCLUSION

Intra-operative intraperitoneal chemotherapy is a significant risk factor for organ/space SSI in patients with gastric cancer.

Advanced age is a predictor of 30-day complications after autologous but not implant-based postmastectomy breast reconstruction

BACKGROUND

Older breast cancer patients undergo postmastectomy breast reconstruction infrequently, in part because of a perception of increased surgical risk. This study sought to investigate the effects of age on perioperative complications after postmastectomy breast reconstruction.

METHODS

The American College of Surgeons National Surgery Quality Improvement Program Participant Use Files from 2005 to 2012 were used to identify women with breast cancer who underwent unilateral mastectomy alone or with immediate reconstruction. Thirty-day complication rates were compared between younger (<65 years) and older (≥65 years) women after implant-based reconstruction, autologous reconstruction, or mastectomy alone. Linear and logistic regression models were used to control for differences in comorbidities and age.

RESULTS

A total of 40,769 patients were studied, of whom 15,093 (37 percent) were aged 65 years or older. Breast reconstruction was performed in 39.5 percent of younger and 10.7 percent of older women. The attributable risks of breast reconstruction, manifested by longer hospital stays (p < 0.001), more frequent complications (p < 0.001), and more reoperations (p < 0.001), were similar in older and younger women. There were no differences in the adjusted complication rates between older and younger patients undergoing implant-based reconstruction. However, older women undergoing autologous reconstruction were more likely to suffer venous thromboembolism (OR, 3.67; p = 0.02).

CONCLUSIONS

The perioperative risks attributable to breast reconstruction are similar in older and younger women. Older patients should be counseled that their age does not confer an increased risk of complications after implant-based breast reconstruction. However, age is an independent risk factor for venous thromboembolism after autologous reconstruction. Special attention should be paid to venous thromboembolism prophylaxis in this group.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Identification of complications in mastectomy with immediate reconstruction using tissue expanders and permanent implants for breast cancer patients

BACKGROUND

Since complications of postmastectomy breast reconstruction may reduce patient satisfaction, we investigated complications of reconstruction with tissue expanders (TEs), particularly surgical site infections requiring TE/permanent implant (PI) removal.

PATIENTS AND METHODS

A retrospective review was performed of 234 primary breast cancer patients undergoing 239 postmastectomy breast reconstructions with TEs/PIs from 1997 to 2009. Clinicopathological findings and postoperative complications, particularly infections, were analyzed. Data were analyzed by the Chi-square test and a multivariate logistic regression model. TE infection risk factors considered for model inclusion were excisional biopsy, (neo) adjuvant chemotherapy, lymph node resection, body mass index (BMI), simultaneous bilateral reconstructions, and seroma aspiration.

RESULTS

Removal of TEs/PIs was observed in 15.5% (37/239) of reconstructions, and 18/37 underwent re-reconstructions. Of the 19/37 reconstructions that were not achieved completely, the most frequent reason was TE infection (11 reconstructions). The completion rate was 92% (220/239 reconstructions) and it was significantly higher in reconstructions without TE infection than with infection (96 vs. 54%, p < 0.0001). Patients with BMI ≥ 25 kg/m² and seroma aspiration were more likely to develop TE infections (p = 0.0019, p < 0.001, respectively). By multivariate logistic regression analysis, seroma aspiration was a significant independent risk factor for TE infection (odds ratio 28.75, 95% confidence interval 5.71-40.03, p < 0.0001).

CONCLUSION

To improve completion rates of breast reconstruction, prevention of TE infection plays a key role. We should reduce unnecessary seroma aspirations and delay elevation/exercise of the ipsilateral arm.

Increased Risk of Surgical Site Infection Among Breast-Conserving Surgery Re-excisions

PURPOSE

The aim of this study was to determine the risk of surgical site infection (SSI) after primary breast-conserving surgery (BCS) versus re-excision among women with carcinoma in situ or invasive breast cancer.

METHODS

We established a retrospective cohort of women aged 18-64 years with International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) procedure or Current Procedural Terminology, 4th edition (CPT-4) codes for BCS from 29 June 2004 to 31 December 2010. Prior insurance plan enrollment of at least 180 days was required to establish the index BCS; subsequent re-excisions within 180 days were identified. SSIs occurring 2-90 days after BCS were identified by ICD-9-CM diagnosis codes. The attributable surgery was defined based on SSI onset compared with the BCS date(s). A χ (2) test and generalized estimating equations model were used to compare the incidence of SSI after index and re-excision BCS procedures.

RESULTS

Overall, 23,001 women with 28,827 BCSs were identified; 23.2 % of women had more than one BCS. The incidence of SSI was 1.82 % (418/23,001) for the index BCS and 2.44 % (142/5,826) for re-excision BCS (p = 0.002). The risk of SSI after re-excision remained significantly higher after accounting for multiple procedures within a woman (odds ratio 1.34, 95 % confidence interval 1.07-1.68).

CONCLUSIONS

Surgeons need to be aware of the increased risk of SSI after re-excision BCS compared with the initial procedure. Our results suggest that risk adjustment of SSI rates for re-excision would allow for better comparison of BCS SSI rates between institutions.

Use of prophylactic postoperative antibiotics during surgical drain presence following mastectomy

BACKGROUND

National guidelines recommend one dose of perioperative antibiotics for breast surgery and discourage postoperative continuation. However, reported skin and soft tissue infection (SSI) rates after mastectomy range from 1-26 %, higher than expected for clean cases. Utility of routine or selective postoperative antibiotic use for duration of drain presence following mastectomy remains uncertain.

METHODS

This study included all female patients who underwent mastectomy without reconstruction at our institution between 2005 and 2012. SSI was defined using CDC criteria or clinical diagnosis of cellulitis. Information on risk factors for infection (age, body mass index [BMI], smoking status, diabetes, steroid use), prior breast cancer treatment, drain duration, and antibiotic use was abstracted from medical records. Multivariable logistic regression was used to assess the association between postoperative antibiotic use and the occurrence of SSI, adjusting for concurrent risk factors.

RESULTS

Among 480 patients undergoing mastectomy without reconstruction, 425 had sufficient documentation for analysis. Of these, 268 were prescribed antibiotics (63 %) at hospital discharge. An overall SSI rate of 7.3 % was observed, with 14 % of patients without postoperative antibiotics developing SSI compared with 3.4 % with antibiotics (p < 0.0001). Factors independently associated with SSI were smoking and advancing age. Diabetes, steroid use, BMI, prior breast surgery, neoadjuvant chemotherapy, prior radiation, concomitant axillary surgery, and drain duration were not associated with increased SSI rates.

CONCLUSIONS

SSI rates among patients who did and did not receive postoperative antibiotics after mastectomy were significantly different, particularly among smokers and women of advanced age. These patient subgroups may warrant special consideration for postoperative antibiotics.

[Operative risk related to tobacco in gynecology]

If tobacco has been recognized for many years as a major risk factor for cardiovascular, lung diseases and cancer in the general population, women are insufficiently aware of the consequences and the specific gynecological operative risks related to this intoxication. Thus, a regular tobacco consumption increases the risk for many gynecological conditions may require surgical treatment with in addition a significant negative impact on the healing process and the risk of postoperative complications. The operative risk must be explained by surgeons in daily practice gynecological, pelvic surgery or breast screening. The issue of smoking cessation should precede surgery has been established by a consensus conference of experts on perioperative smoking held in 2005. The implementation of these recommendations during the preoperative period requires improvement of staff training and better practices to allow smoking cessation effective and sustainable. It is lawful in this context to delay scheduled surgery of 6 to 8 weeks to allow an optimal smoking cessation and to continue smoking cessation for the time necessary for healing to reduce the excess operative risk associated with smoking.

Outbreak of infections caused by Group A Streptococcus after modified radical mastectomy

BACKGROUND

Eight infections occurred after modified radical mastectomies in a tertiary-care hospital. Group A streptococci (GAS) were isolated from three of the eight patients.

METHODS

To control the outbreak, an epidemiologic investigation was conducted, and healthcare workers were screened for pathogens. Strains isolated from healthcare workers were compared with patient strains by emm typing.

RESULTS

One surgeon attended one of the eight operations and observed the other seven. Streptococcus strains from the hands of this surgeon were identical to the patient strains. After the surgeon was suspended from duty and underwent eradication treatment, the outbreak was controlled.

CONCLUSIONS

This outbreak of GAS infection is believed to have occurred by airborne transmission. Suspending patient care by healthcare workers who carry the causative GAS in a site(s) other than the respiratory tract for only the first 24 h they are receiving chemoprophylaxis may not be long enough. Sampling of the hands of healthcare workers during an investigation of nosocomial GAS infection is valuable.

Do clinicopathological features of the cancer patient relate with nipple areolar complex necrosis in nipple-sparing mastectomy?

BACKGROUND

The selections of nipple-sparing mastectomy (NSM) are principally depending on oncologic indication and oncologic safety. The main complication of NSM is nipple areolar complex (NAC) necrosis, and it is usually related to surgical technique. However, the patients' clinicopathological factors should be also considered.

METHOD

We retrospectively reviewed 934 consecutive NSM patients during 2002-2007 at the European Institute of Oncology, Milan, Italy. We identified a group of patient who had NAC excision because of NAC necrosis and compared this group with those who had successful NAC conservation. We analyzed the association between the risk of NAC necrosis and the clinicopathological features of the patients.

RESULTS

Among 934 NSM, 772 were invasive cancers and 162 were in situ cancers. Of the 934, 40 NAC (4.2%) were removed during the postoperative period because of necrosis. When we considered age, BMI, menopausal status, smoking status, tumor size, axillary lymph node status, in situ or invasive cancer histology, presence of extensive situ component, grading, estrogen receptor, progesterone receptor, HER2/neu overexpression, Ki-67 proliferative index, and peritumoral vascular invasion, no association was observed between patients' clinicopathological features and NAC necrosis incidence.

CONCLUSIONS

In our study, clinicopathological features have no significant impact on necrosis complication in therapeutic NSMs. Positive retroareolar margin is the risk of necrosis. Further studies are required to avoid bias due to the different cancer treatments such as different reconstruction techniques and intraoperative radiation protocols. The correlation between breast morphology and NAC necrosis should also be investigated in the future.