Immediate Unilateral Breast Reconstruction using Abdominally Based Flaps: Analysis of 3,310 Cases

2018 ◽  
Vol 35 (01) ◽  
pp. 074-082 ◽  
Author(s):  
Andrew Simpson ◽  
Xiangyang Ye ◽  
Eric Tatro ◽  
Jayant Agarwal ◽  
Alvin Kwok
Keyword(s):  
Breast Reconstruction ◽  
Hospital Charges ◽  
Vascular Anastomosis ◽  
Lengths Of Stay ◽  
Epigastric Artery ◽  
Nationwide Inpatient Sample Database ◽  
Aesthetic Results ◽  
Siea Flap ◽  
The Mean ◽  
Total Charges

Background The abdomen is the most common area from which tissue is harvested for autologous breast reconstruction. We sought to examine national data to determine the differences in total hospital charges, length of stay (LOS), and early postoperative complications following pedicled transverse rectus abdominis myocutaneous flap (pTRAM), free TRAM (fTRAM), deep-inferior epigastric perforator (DIEP), and superficial inferior epigastric artery perforator (SIEA) flaps. Methods The 2009–2013 Nationwide Inpatient Sample Database was used to identify patients who underwent a unilateral mastectomy and only one type of abdominally based autologous flap (pTRAM, fTRAM, DIEP, and SIEA) during the same hospital admission. Outcomes of interest included total charges, LOS, and complications including revision of vascular anastomosis and hematoma. Results A total of 3,310 cases were identified, corresponding to 15,991 abdominally based unilateral immediate breast reconstructions after standard weighting was applied; 5,079 (31.8%) were pTRAM flaps, 4,461 (27.9%) were fTRAM flaps, 6,206 (38.8%) were DIEP flaps, and 245 (1.5%) were SIEA flaps. The mean total charges for pTRAM, fTRAM, DIEP, and SIEA flaps were $17,765.5, $22,637.6, $25,814.6, and $26,605.2, respectively (p < 0.0001). The mean LOS for pTRAM, fTRAM, DIEP, and SIEA flaps were 96.5, 106.5, 106.7, and 108.9 hours, respectively (p = 0.002). The rates for return to the OR for the revision of a vascular anastomosis for pTRAM, fTRAM, DIEP, and SIEA were 0.0%, 1.72%, 2.66%, and 5.64%, respectively (p < 0.0001). Conclusions There is variation in the total charges, LOS, and early complications between pTRAM, fTRAM, DIEP, and SIEA flap-based breast reconstruction. fTRAM, DIEP, and SIEA flaps incur higher hospital total charges, have longer lengths of stay, and experience more immediate complications compared with pTRAM. Well-designed prospective trials are required to better understand the findings from this study with the inclusion of other critical outcomes such as patient satisfaction, aesthetic results, and long-term outcomes such as abdominal wall morbidity.

scholarly journals Early Clinical and Economic Outcomes of Prophylactic and Acute Pathologic Fracture Treatment

2019 ◽  
Vol 15 (2) ◽  
pp. e132-e140 ◽  
Author(s):  
Zachary A. Mosher ◽  
Harshadkumar Patel ◽  
Michael A. Ewing ◽  
Thomas E. Niemeier ◽  
Matthew C. Hess ◽  
...  
Keyword(s):  
Lower Extremity ◽  
Hospital Costs ◽  
Pathologic Fracture ◽  
Hospital Charges ◽  
Nationwide Inpatient Sample Database ◽  
Pathologic Fractures ◽  
Fixation Techniques ◽  
Prevalence Of Obesity ◽  
Student’S T ◽  
Total Charges

INTRODUCTION: Pathologic fractures often contribute to adverse events in metastatic bone disease, and prophylactic fixation offers to mitigate their effects. This study aims to analyze patient selection, complications, and in-hospital costs that are associated with prophylactic fixation compared with traditional acute fixation after completed fracture. MATERIALS AND METHODS: The Nationwide Inpatient Sample database was queried from 2002 to 2014 for patients with major extremity pathologic fractures. Patients were divided by fixation technique (prophylactic or acute) and fracture location (upper or lower extremity). Patient demographics, comorbidities, complications, hospitalization length, and hospital charges were compared between cohorts. Preoperative variables were analyzed for potential confounding, and χ2 tests and Student’s t tests were used to compare fixation techniques. RESULTS: Cumulatively, 43,920 patients were identified, with 14,318 and 28,602 undergoing prophylactic and acute fixation, respectively. Lower extremity fractures occurred in 33,582 patients, and 10,333 patients had upper extremity fractures. A higher proportion of prophylactic fixation patients were white ( P = .043), male ( P = .046), age 74 years or younger ( P < .001), and privately insured ( P < .001), with decreased prevalence of obesity ( P = .003) and/or preoperative renal disease ( P = .008). Prophylactic fixation was also associated with decreased peri- and postoperative blood transfusions ( P < .001), anemia ( P < .001), acute renal failure ( P = .010), and in-hospital mortality ( P = .031). Finally, prophylactic fixation had decreased total charges (−$3,405; P = .001), hospitalization length ( P = .004), and extended length of stay (greater than 75th percentile; P = .012). CONCLUSION: Prophylactic fixation of impending pathologic fractures is associated with decreased complications, hospitalization length, and total charges, and should be considered in appropriate patients.

scholarly journals Orienting the superficial inferior epigastric artery (SIEA) pedicle in a stacked SIEA-deep inferior epigastric perforator free flap configuration for unilateral tertiary breast reconstruction

2020 ◽  
Vol 47 (5) ◽  
pp. 473-482
Author(s):  
Ya-han Yu ◽  
Dina Ghorra ◽  
Christine Bojanic ◽  
Oti N. Aria ◽  
Louise MacLennan ◽  
...  
Keyword(s):  
Breast Reconstruction ◽  
Free Flaps ◽  
Inferior Epigastric Artery ◽  
Skin Paddle ◽  
Epigastric Artery ◽  
Internal Mammary ◽  
Siea Flap ◽  
Deep Inferior Epigastric Perforator ◽  
Nipple Sparing Mastectomy ◽  
Nipple Sparing

Superficial inferior epigastric artery (SIEA) flaps represent a useful option in autologous breast reconstruction. However, the short-fixed pedicle can limit flap inset options. We present a challenging flap inset successfully addressed by de-epithelialization, turnover, and counterintuitive rotation. A 47-year-old woman underwent left tertiary breast reconstruction with stacked free flaps using right deep inferior epigastric perforator and left SIEA vessels. Antegrade and retrograde anastomoses to the internal mammary (IM) vessels were preferred; additionally, the thoracodorsal vessels were unavailable due to previous latissimus dorsi breast reconstruction. Optimal shaping required repositioning of the lateral ends of the flaps superiorly, which would position the ipsilateral SIEA hemi-flap pedicle lateral to and out of reach of the IM vessels. This problem was overcome by turning the SIEA flap on its long axis, allowing the pedicle to sit medially with the lateral end of the flap positioned superiorly. The de-epithelialized SIEA flap dermis was in direct contact with the chest wall, enabling its fixation. This method of flap inset provides a valuable solution for medializing the SIEA pedicle while maintaining an aesthetically satisfactory orientation. This technique could be used in ipsilateral SIEA flap breast reconstructions that do not require a skin paddle, as with stacked flaps or following nipple-sparing mastectomy.

Immediate Bilateral Breast Reconstruction Using Abdominally Based Flaps: An Analysis of the Nationwide Inpatient Sample Database

2019 ◽  
Vol 35 (08) ◽  
pp. 594-601 ◽  
Author(s):  
Kathleen A. Holoyda ◽  
Andrew M. Simpson ◽  
Xiangyang Ye ◽  
Jayant P. Agarwal ◽  
Alvin C. Kwok
Keyword(s):  
Postoperative Complications ◽  
Breast Reconstruction ◽  
Nationwide Inpatient Sample ◽  
Free Flaps ◽  
Hospital Charges ◽  
Single Type ◽  
Bilateral Mastectomy ◽  
Complication Rates ◽  
Total Cost ◽  
Nationwide Inpatient Sample Database

Abstract Background Bilateral mastectomy rates are increasing in the United States. The abdomen is the most common harvest site for autologous reconstruction. Nationwide data were examined to determine differences in hospital charges, length of stay (LOS), and early postoperative complications following immediate bilateral pedicled transverse rectus abdominis myocutaneous (pTRAM), free TRAM (fTRAM), deep inferior epigastric perforator (DIEP), and superficial inferior epigastric artery (SIEA) perforator flaps and were compared with unilateral reconstruction. Methods Patients who underwent immediate bilateral breast reconstruction using a single method of abdominally based reconstruction were identified using the 2009 to 2014 Nationwide Inpatient Sample Database. Outcomes included total hospital charges, LOS, and immediate postoperative complications. Results We identified 13,348 cases of bilateral mastectomy with a single type of immediate bilateral autologous flap reconstruction. The majority were bilateral DIEP flaps. Mean total cost for bilateral pTRAM, fTRAM, DIEP, and SIEA flaps was US $21,886.80, US $28,839.40, US $30,051.30, and US $33,784.90, respectively (p < 0.0001). Mean LOS for bilateral pTRAM, fTRAM, DIEP, and SIEA was 4.3, 4.9, 4.5, and 5.4 days, respectively (p = 0.0002), and hematoma rates were 1.93, 2.61, 3.68, and 16.59%, respectively, (p = 0.0001), whereas return to the operating room for vascular anastomosis revision was 0, 1.63, 1.99, and 19.07%, respectively (p < 0.0001). Cost is less for unilateral pTRAM, fTRAM, and DIEP flaps (p < 0.0001). LOS is shorter for unilateral fTRAM versus bilateral (p < 0.0001). No differences were appreciated between unilateral and bilateral hematoma and reoperation rates for any reconstruction (p > 0.1). Conclusion Immediate complication rates were higher in bilateral free flaps compared with bilateral pedicled flaps. pTRAM and fTRAM flap reconstructions are still performed frequently with acceptable immediate results without considering long-term morbidity, aesthetics, and abdominal muscle function. Bilateral SIEA free flaps were associated with significantly higher total cost, LOS, and complication rates compared with other groups. Complications were similar between unilateral and bilateral reconstruction procedures. While cost is significantly greater for bilateral procedures compared with unilateral pTRAM, fTRAM, and DIEP flaps, it is not doubled.

scholarly journals The Deep Circumflex Iliac Artery Perforator Flap for Breast Reconstruction: Un lambeau perforateur de l’artère iliaque circonflexe profonde pour la reconstruction mammaire

2018 ◽  
Vol 26 (4) ◽  
pp. 229-237 ◽  
Author(s):  
Kate Elzinga ◽  
Edward Buchel
Keyword(s):  
Breast Reconstruction ◽  
Iliac Artery ◽  
Donor Site ◽  
Perforator Flap ◽  
Donor Site Morbidity ◽  
Diep Flap ◽  
Deep Circumflex Iliac Artery ◽  
Epigastric Artery ◽  
Early Results ◽  
Aesthetic Results

Autologous breast reconstruction using abdominal-based perforator flaps produces excellent aesthetic results with minimal donor site morbidity. The superficial inferior epigastric artery and deep inferior epigastric perforator (DIEP) flaps reliably perfuse a hemi-abdomen, up to the anterior axillary line. Beyond this line laterally, the flank or “love handle” tissue is primarily perfused by the deep circumflex iliac artery (DCIA) or secondarily by the superficial circumflex iliac artery. The flank tissue is a valuable addition to increase flap size when harvested with a DIEP flap or to provide vascularized tissue when the abdomen has been previously harvested. Harvesting the flank tissue in combination with the anterior abdominal tissue improves the contour of the trunk, accentuates the waist, and minimizes secondary revisions to excise prominent “dogears.” The DCIA flap is a novel technique for breast reconstruction. In this article, we describe our technique, pearls and pitfalls, and early results.

Resource Utilization Among Patients With Sepsis Syndrome

2003 ◽  
Vol 24 (1) ◽  
pp. 62-70 ◽  
Author(s):  
David W. Bates ◽  
D. Tony Yu ◽  
Edgar Black ◽  
Kenneth E. Sands ◽  
J. Sanford Schwartz ◽  
...  
Keyword(s):  
Resource Utilization ◽  
Tertiary Care ◽  
Sepsis Syndrome ◽  
Hospital Charges ◽  
Linear Regression Models ◽  
Academic Medical ◽  
The Mean ◽  
Tertiary Care Centers ◽  
Post Onset ◽  
Total Charges

AbstractObjective:To assess the resource utilization associated with sepsis syndrome in academic medical centers.Design:Prospective cohort study.Setting:Eight academic, tertiary-care centers.Patients:Stratified random sample of 1,028 adult admissions with sepsis syndrome and all 248,761 other adult admissions between January 1993 and April 1994. The main outcome measures were length of stay (LOS) in total and after onset of sepsis syndrome (post-onset LOS) and total hospital charges.Results:The mean LOS for patients with sepsis was 27.7 ± 0.9 days (median, 20 days), with sepsis onset occurring after a mean of 8.1 ± 0.4 days (median, 3 days). For all patients without sepsis, the LOS was 7.2 ± 0.03 days (median, 4 days). In multiple linear regression models, the mean for patients with sepsis syndrome was 18.2 days, which was 11.0 days longer than the mean for all other patients (P < .0001), whereas the mean difference in total charges was $43,000 (both P < .0001). These differences were greater for patients with nosocomial as compared with community-acquired sepsis, although the groups were similar after adjusting for pre-onset LOS. Eight independent correlates of increased post-onset LOS and 12 correlates of total charges were identified.Conclusions:These data quantify the resource utilization associated with sepsis syndrome, and demonstrate that resource utilization is high in this group. Additional investigation is required to determine how much of the excess post-onset LOS and charges are attributable to sepsis syndrome rather than the underlying medical conditions.

Breast reconstruction using the free superficial inferior epigastric artery (SIEA) flap

1999 ◽  
Vol 52 (4) ◽  
pp. 276-279 ◽  
Author(s):  
Z.M. Arnez ◽  
U. Khan ◽  
D. Pogorelec ◽  
F. Planinsek
Keyword(s):  
Breast Reconstruction ◽  
Inferior Epigastric Artery ◽  
Epigastric Artery ◽  
Siea Flap

scholarly journals 948. The Changing Dynamics of Hospitalizations Among People Living with HIV Over Time

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S506-S507
Author(s):  
Shruti Gujaran ◽  
Kristen A Stafford ◽  
David J Riedel
Keyword(s):  
Primary Diagnosis ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
People Living With Hiv ◽  
Lengths Of Stay ◽  
The Mean ◽  
Living With Hiv ◽  
Total Charges ◽  
Over Time ◽  
Hiv Negative

Abstract Background As antiretroviral therapy for HIV has become more successful, people living with HIV (PLWH) are aging. Nearly half (48%) of all PLWH in the U.S. are now ≥ 50 years old, and this proportion is expected to continue to grow. The aging population of PLWH offers new challenges to the healthcare system beyond HIV management, with increased risks for chronic comorbidities and other complications of aging. Few studies have examined the causes and outcomes of hospitalizations among PLWH or how these diagnoses have changed over time. Methods Using U.S. hospitalization data from 1993 to 2014 from the National Inpatient Sample, we compared the primary diagnosis at admission among PLWH to HIV-negative hospitalizations and how this changed over time. We also compared the mean age at admission, hospital length of stay, total charges, and hospital disposition. Results There were 654,783,064 hospitalizations recorded from 1993 - 2014, with 5,370,749 among PLWH (0.8%) and 649,412,315 among HIV-negative patients (99.2%). The mean age of PLWH on admission increased from 37.4 years in 1993 to 48.1 years in 2014 and was lower than HIV-negative patients every year (Figure 1). There was a significant decrease in the proportion of admissions with HIV as the primary diagnosis for PLWH between 1993 - 2014 (53.1% to 24.2%) with a corresponding increase in non-HIV diagnoses over that time (Figure 2). The proportions of primary admission diagnoses for HIV-Negative patients were largely unchanged over the period. Although mean hospital lengths of stay for PLWH decreased over time, they were consistently longer than HIV-negative patients (Figure 3). Similarly, mean total charges for PLWH increased over time but were consistently higher than those for HIV-negative patients (Figure 3). The proportion of PLWH who died during hospitalization declined from a peak of 8.8% in 1993 to 2.4% in 2014 while inpatient mortality among HIV-negative patients declined from 3.2% to 2.2% over the same time. Figure 1. Trends of Mean Age for PLWH and HIV-Negative Admissions from 1993 – 2014 Figure 2. Trends of HIV vs. non-HIV as the Primary Admission Diagnoses for PLWH from 1993 – 2014 Figure 3. Trends of Length of Hospital Admission and Total Charges for PLWH and HIV-Negative Patients from 1993 – 2014 Conclusion The primary admission diagnoses for PLWH has shifted from HIV to non-communicable causes as PLWH are living longer. PLWH are typically younger on admission and have longer and more expensive hospitalizations than HIV-negative patients. Disclosures All Authors: No reported disclosures

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