Overlapping Surgery in Plastic Surgery

An Analysis of Patient Safety and Clinical Outcomes

Rajiv P. Parikh, M.D., M.P.H.S.; Ketan Sharma, M.D., M.P.H.; Melissa Thornton, B.S.; Gabriella Brown, B.S.; Terence M. Myckatyn, M.D.

Disclosures

Plast Reconstr Surg. 2019;143(6):1787-1796. 

In This Article

Results

A total of 866 cases, performed between January of 2016 and January of 2018, constituted the study population. Patients were separated into two cohorts: those undergoing overlapping surgery and those undergoing nonoverlapping surgery. There were 311 patients (35.9 percent) in the overlapping surgery cohort and 555 patients (64.1 percent) in the nonoverlapping surgery cohort. Demographic and clinical characteristics were analyzed and compared, with results are listed in Table 1. There was no significant difference (p > 0.05) with regard to age, sex, body mass index, tobacco use, and American Society of Anesthesiologists rating between the two cohorts. In addition, there was no significant difference in Charlson Comorbidity Index scores for the overlapping and nonoverlapping surgery cohorts.

A comparison of the primary perioperative outcomes is presented in Table 2 for patients undergoing nonoverlapping surgery versus patients undergoing overlapping surgery. There was no significant difference in postoperative complications for patients undergoing nonoverlapping surgery (12.1 percent) versus overlapping surgery (11.9 percent) (p = 0.939). In addition, there were no significant differences in the clinical outcomes of unplanned reoperations (6.1 percent versus 6.8 percent; p = 0.717), unplanned readmissions (3.6 percent versus 3.5 percent; p = 0.960), and emergency room visits (4.7 percent versus 4.8 percent; p = 0.927) between the nonoverlapping surgery cohort and the overlapping surgery cohort, respectively. On further evaluation, there were no significant differences in the types of complications that occurred in the two cohorts (Table 3). Overall adverse events following surgery, as measured by the aforementioned Agency for Healthcare Research and Quality Patient Safety Indicators, were very rare. There were no adverse events for Patient Safety Indicator 04 (mortality), Patient Safety Indicator 05 (retained surgical items), Patient Safety Indicator 10 (physiologic and metabolic derangement), Patient Safety Indicator 12 (pulmonary embolism or deep venous thrombosis), or Patient Safety Indicator 13 (sepsis) in either study group. In the nonoverlapping cohort, one patient (0.18 percent) had postoperative respiratory failure (Patient Safety Indicator 11), whereas there were no Patient Safety Indicator 11 events in the overlapping cohort.

Based on subspecialty procedure category, breast reconstruction operations were most commonly performed [n = 587 (67.8 percent)], compared with aesthetic surgery operations [n = 159 (18.4 percent)] and general reconstructive operations [n = 120 (13.9 percent)]. There was no significant difference (p = 0.324) in cases performed based on subspecialty procedure category between the cohorts (Table 1). The following specific types of procedures were performed in the study population (Table 4): prosthetic breast reconstruction [n = 318 (36.7 percent)], secondary breast reconstruction [n = 134 (15.5 percent)], symmetry breast procedures [n = 32 (3.7 percent)], microvascular breast reconstruction [n = 60 (6.9 percent)], nonmicrovascular autologous breast reconstruction [n = 46 (5.3 percent)], breast reduction [n= 36 (4.2 percent)], male breast procedures [n = 18 (2.1 percent)], breast augmentation [n = 56 (6.5 percent)], body contouring [n = 67 (7.7 percent)], wound débridement [n = 27 (3.1 percent)], facial aesthetic procedures [n = 16 (1.8 percent)], cutaneous oncologic reconstruction [n = 23 (2.7 percent)], and reconstructive flaps [n = 33 (3.8 percent)]. Stratification based on procedure type (Table 4) showed no differences in 90-day postoperative complication rates, including for the most commonly performed procedures primary prosthetic breast reconstruction (10.2 percent nonoverlapping versus 13.2 percent overlapping; p = 0.401) and secondary breast reconstruction (4.3 percent nonoverlapping versus 4.8 percent overlapping; p = 0.914).

Median operative duration was significantly longer for overlapping operations (105 minutes; interquartile range, 58 to 166 minutes) compared with nonoverlapping operations (83 minutes; interquartile range, 51 to 142 minutes) (p = 0.004) (Table 2). A graphic comparison is presented in Figure 1. The distribution of operative time among overlapping operations was broader, with an increased frequency of cases taking between 2 and 4 hours, as compared to the nonoverlapping group, where an increased frequency of cases took between 0 and 2 hours; however, both groups had similar tails with respect to long cases (>4 hours). Similar to median operative time, median anesthesia duration was also significantly longer for overlapping operations (150 minutes; interquartile range, 98 to 219 minutes) compared to nonoverlapping operations (124 minutes; interquartile range, 89 to 184 minutes) (p = 0.001). In evaluation of overlapping cases, the median amount of overlap between procedures was 34 minutes (interquartile range, 17 to 61 minutes), and 73.6 percent (n = 229) of cases had less than 1 hour of overlap. The complication rate did not vary as a function of the duration of overlap (p = 0.317) (Figure 2).

Figure 1.

Kernel density plots demonstrating operative duration (in hours) of nonoverlapping surgery versus overlapping surgery.

Figure 2.

Complication rate by duration (in minutes) of operative overlap. The complication rate did not vary as a function of the duration of overlap (p = 0.317).

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