Combining Breast and Ovarian Operations Increases Complications

Dominic Henn, M.D.; Janos A. Barrera, M.D.; Dharshan Sivaraj, B.S.; John Q. Lin, B.S.; Nada M. Rizk, M.S.; Irene Ma, M.D.; Geoffrey C. Gurtner, M.D.; Gordon K. Lee, M.D.; Rahim S. Nazerali, M.D., M.H.S.

Disclosures

Plast Reconstr Surg. 2022;149(5):1050-1059. 

In This Article

Results

Baseline Characteristics

The patients' demographic characteristics and comorbidities were comparable between the groups without statistically significant differences. There was a higher rate of Hispanic patients in the separate surgical procedures group (Table 1).

The majority of patients in both groups had a diagnosis of breast cancer, 88 percent of patients with separate procedures and 90 percent of patients with combined procedures. The remaining 16 patients had undergone prophylactic risk-reducing breast operations. Nine patients with separate procedures had a diagnosis of gynecologic malignancy, whereas only one patient in the combined group had a gynecologic cancer diagnosis (Table 2).

Mutations or variants of unknown significance in BRCA1, BRCA2, or other breast cancer susceptibility genes, were present in 53 percent of patients with separate procedures and 60 percent of patients with combined operations (Table 2). Indications for breast and gynecologic operations in patients without genetic mutations were breast cancer with a strong family history for familial breast and ovarian cancer and hormone receptor-positive breast cancer requiring ovarian ablation.

Both patient groups were comparable in the types of breast operations they had undergone (Table 3). The most commonly performed breast operation was mastectomy with tissue expander placement in 27.6 percent of patients with separate procedures and 29.0 percent of patients with combined operations, followed by immediate autologous breast reconstruction with free muscle-sparing transverse rectus abdominis muscle flaps (24 percent in both groups). All patients had undergone salpingo-oophorectomy either alone or in combination with hysterectomy. The majority of gynecologic operations were performed laparoscopically (Table 3).

Cumulative operative times for breast and gynecologic procedures were analyzed separately for autologous breast reconstructions and all other breast procedures. Operative times were longer for patients undergoing breast and gynecologic procedures separately compared to patients undergoing combined operations (Table 3).

All patients underwent surgery under general anesthesia. Among patients undergoing autologous breast reconstruction with abdominal free tissue transfer, 24 percent of patients in the combined surgery group and 25 percent of patients in the separate surgery group underwent transverse abdominis plane blocks for regional anesthesia (Table 3).

Postoperative Outcomes

With regard to postoperative complications after breast surgery, patients with combined operations had a significantly higher rate of overall complications (46.5 percent versus 19.0 percent; p < 0.001), delayed wound healing (13.2 percent versus 0 percent; p < 0.05), and infections (22.2 percent versus 8.6 percent; p < 0.05) compared to patients with separate procedures. A three-times higher odds for developing infection was found among patients with a diagnosis of diabetes or obesity (OR, 3.0; 95 percent CI, 1.28 to 7.33), confirming the findings from previous studies.[15,16]

There was a trend toward a higher rate of postoperative fat necrosis of the reconstructed breast after combined operations compared to separate operations (9.3 percent versus 1.7 percent; p = 0.09) (Figure 1). For postoperative complications related to gynecologic procedures, there was a trend toward a higher overall complication rate for patients with combined operations (12.8 percent versus 3.4 percent; p = 0.08); however, statistical significance was not reached (Table 4).

Figure 1.

Postoperative complications of breast procedures in patients with combined breast and ovarian operations and patients with separate operations. **p < 0.01; *p < 0.05.

We further compared postoperative complications between combined and separate breast and gynecologic procedures in subgroups of patients who had undergone mastectomy and tissue expander placement or autologous breast reconstruction with abdominal free flaps. Among patients with mastectomy and tissue expander placement, a significantly higher rate of delayed wound healing and wound dehiscence was found in patients with combined procedures compared to patients who had undergone separate operations (28.0 percent versus 0 percent; p < 0.05 for both comparisons) (Table 5 and Table 6). Moreover, there was a trend toward a higher overall complication rate for patients with combined operations compared to patients with separate procedures (56.0 percent versus 12.5 percent; p = 0.08) (Table 5 and Table 6).

A trend toward higher complication rates in patients with combined procedures was also found among patients who had undergone combined oophorectomy and immediate autologous breast reconstructions with an abdominal free flap compared to patients who had undergone these procedures separately (48.1 percent versus 23.5 percent; p = 0.18) (Table 5 and Table 6).

Multivariate logistic regression analysis confirmed a significant association between combined surgery and overall postoperative complications (OR, 5.87; 95 percent CI, 2.03 to 16.91; adjusted p = 0.02; area under the curve, 0.75), although no significant associations were found for other independent variables in the regression model (Table 7). (See Figure, Supplemental Digital Content 1, which shows the receiver operating characteristic curve for the multiple logistic regression model for overall complications. AUC, area under the curve; blue area, 95 percent confidence intervals, https://links.lww.com/PRS/F4.) An association was also identified between combined surgery and overall complications related to the breast surgery, whereas statistical significance was marginally missed after p value adjustment, presumably because of a low sample size (OR, 5.56; 95 percent CI, 2.30 to 14.90; p < 0.01; adjusted p = 0.05; area under the curve, 0.71) (Table 8). (See Figure, Supplemental Digital Content 2, which shows the receiver operating characteristic curve for the multiple logistic regression model for overall complications. AUC, area under the curve; blue area, 95 percent confidence intervals, https://links.lww.com/PRS/F5.) No significant associations were identified between the predictor variables and complications related to the gynecologic operations.

Overall, patients who underwent combined operations had a significantly longer hospital stay compared to the total number of days in the hospital for patients with separate operations [median, 3.0 days (interquartile range, 2.0 to 4.3 days) versus 1.8 days (interquartile range, 1.0 to 3.7 days); p < 0.0001] (Table 4). Subgroup comparisons revealed that these differences were only related to patients who had undergone mastectomy and tissue expander placement for combined surgery (median, 4.0 days; interquartile range, 2.2 to 5.0 days) versus separate surgery (median, 1.0 day; interquartile range, 1.0 to 2.0 days; p = 0.0002) (Table 5 and Table 6), whereas no differences in the length of hospital stay were found for patients who had undergone breast reconstruction with autologous flaps (Table 5 and Table 6). Moreover, we compared the time between the initial surgery and the initiation of adjuvant chemotherapy (combined surgery group, n = 14; separate surgery group, n = 18) or radiation therapy (combined surgery group, n = 15; separate surgery group, n = 16) between patients who had undergone combined or separate breast and gynecologic operations and did not find significant differences between the groups (Table 4).

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