Anesthesia Duration as an Independent Risk Factor for Postoperative Complications in Free Flap Surgery: A Review of 1,305 Surgical Cases

 

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Abstract

Surgical dogma and objective data support the relationship between increased operative times and perioperative complications. However, there has been no large-scale, multi-institutional study that evaluates the impact of increased anesthesia duration on microvascular free tissue transfer. The National Surgical Quality Improvement Program (NSQIP) database was retrospectively reviewed to identify all free-flap patients between 2006 and 2011. Included patients were subdivided into quintiles of anesthesia time. Univariate and multivariate analyses were performed to assess its impact on 30-day postoperative complications. The mean anesthesia duration for all patients was 603 ± 222 minutes. In univariate analysis, 30-day overall/medical complications, reoperation, and free flap loss demonstrated statistically significant increases as anesthesia duration increased (p < 0.05). However, in multivariate analyses, these trends and significances were abolished, with exception of the utilization of postoperative transfusions. Of interest, increasing anesthesia duration did not predict flap failure on multivariate analysis. We found that increased anesthesia time correlates with increased postoperative transfusions in free flap patients. As a result, limiting blood loss and avoiding prolonged anesthesia times should be goals for the microvascular surgeon. This is the largest multidisciplinary study to investigate the ongoing debate that longer anesthesia times impart greater risk.

• References

• 1 Procter LD, Davenport DL, Bernard AC, Zwischenberger JB. General surgical operative duration is associated with increased risk-adjusted infectious complication rates and length of hospital stay. J Am Coll Surg 2010; 210 (1) 60-65 , e1–e2
  CrossrefPubMedGoogle Scholar
• 2 Kim JY, Mioton LM, Rambachan A, Krejcie TC, Mahvi DM, Wang CE. Surgical duration as an independent risk factor for postoperative complications: A review of 1,615,471 surgical cases. Unpublished study
  PubMedGoogle Scholar
• 3 Siemionow M, Arslan E. Ischemia/reperfusion injury: a review in relation to free tissue transfers. Microsurgery 2004; 24 (6) 468-475
  CrossrefPubMedGoogle Scholar
• 4 Wang WZ, Baynosa RC, Zamboni WA. Update on ischemia-reperfusion injury for the plastic surgeon: 2011. Plast Reconstr Surg 2011; 128 (6) 685e-692e
  CrossrefPubMedGoogle Scholar
• 5 Fogarty BJ, Khan K, Ashall G, Leonard AG. Complications of long operations: a prospective study of morbidity associated with prolonged operative time (> 6 h). Br J Plast Surg 1999; 52 (1) 33-36
  CrossrefPubMedGoogle Scholar
• 6 Malhotra A, Chhaya N, Nsiah-Sarbeng P, Mosahebi A. CT-guided deep inferior epigastric perforator (DIEP) flap localization — better for the patient, the surgeon, and the hospital. Clin Radiol 2013; 68 (2) 131-138
  CrossrefPubMedGoogle Scholar
• 7 Baumann DP, Crosby MA, Selber JC , et al. Optimal timing of delayed free lower abdominal flap breast reconstruction after postmastectomy radiation therapy. Plast Reconstr Surg 2011; 127 (3) 1100-1106
  CrossrefPubMedGoogle Scholar
• 8 Balasubramanian D, Thankappan K, Kuriakose MA , et al. Reconstructive indications of simultaneous double free flaps in the head and neck: a case series and literature review. Microsurgery 2012; 32 (6) 423-430
  CrossrefPubMedGoogle Scholar
• 9 Carty MJ, Hivelin M, Dumontier C , et al. Lessons learned from simultaneous face and bilateral hand allotransplantation. Plast Reconstr Surg 2013; 132 (2) 423-432
  CrossrefPubMedGoogle Scholar
• 10 Khuri SF, Daley J, Henderson W , et al. Risk adjustment of the postoperative mortality rate for the comparative assessment of the quality of surgical care: results of the National Veterans Affairs Surgical Risk Study. J Am Coll Surg 1997; 185 (4) 315-327
  CrossrefPubMedGoogle Scholar
• 11 Khuri SF, Henderson WG, Daley J , et al; Principal Investigators of the Patient Safety in Surgery Study. Successful implementation of the department of Veteran Affair's National Surgical Quality Improvement Program in the private sector: The patient safety in surgery study. Ann Surg 2008; 248 (2) 329-336
  CrossrefPubMedGoogle Scholar
• 12 Birkmeyer JD, Shahian DM, Dimick JB , et al. Blueprint for a new American College of Surgeons: National Surgical Quality Improvement Program. J Am Coll Surg 2008; 207 (5) 777-782
  CrossrefPubMedGoogle Scholar
• 13 Shiloach M, Frencher Jr SK, Steeger JE , et al. Toward robust information: data quality and inter-rater reliability in the American College of Surgeons National Surgical Quality Improvement Program. J Am Coll Surg 2010; 210 (1) 6-16
  CrossrefPubMedGoogle Scholar
• 14 Flegal KM, Carroll MD, Kuczmarski RJ, Johnson CL. Overweight and obesity in the United States: prevalence and trends, 1960-1994. Int J Obes Relat Metab Disord 1998; 22 (1) 39-47
  CrossrefPubMedGoogle Scholar
• 15 Kuczmarski RJ, Flegal KM. Criteria for definition of overweight in transition: background and recommendations for the United States. Am J Clin Nutr 2000; 72 (5) 1074-1081
  PubMedGoogle Scholar
• 16 Bui DT, Cordeiro PG, Hu QY, Disa JJ, Pusic A, Mehrara BJ. Free flap reexploration: indications, treatment, and outcomes in 1193 free flaps. Plast Reconstr Surg 2007; 119 (7) 2092-2100
  CrossrefPubMedGoogle Scholar
• 17 Frederick JW, Sweeny L, Carroll WR, Peters GE, Rosenthal EL. Outcomes in head and neck reconstruction by surgical site and donor site. Laryngoscope 2013; 123 (7) 1612-1617
  CrossrefPubMedGoogle Scholar
• 18 Andree C, Langer S, Seidenstuecker K , et al. A single center prospective study of bilateral breast reconstruction with free abdominal flaps: a critical analyses of 144 patients. Med Sci Monit 2013; 19: 467-474
  CrossrefPubMedGoogle Scholar
• 19 Dowthwaite SA, Theurer J, Belzile M , et al. Comparison of fibular and scapular osseous free flaps for oromandibular reconstruction: a patient-centered approach to flap selection. JAMA Otolaryngol Head Neck Surg 2013; 139 (3) 285-292
  CrossrefPubMedGoogle Scholar
• 20 Green III JM, Thomas S, Sabino J , et al. Use of intraoperative fluorescent angiography to assess and optimize free tissue transfer in head and neck reconstruction. J Oral Maxillofac Surg 2013; 71 (8) 1439-1449
  CrossrefPubMedGoogle Scholar
• 21 Fischer JP, Sieber B, Nelson JA , et al. A 15-year experience of complex scalp reconstruction using free tissue transfer-analysis of risk factors for complications. J Reconstr Microsurg 2013; 29 (2) 89-97
  PubMedGoogle Scholar
• 22 Peersman G, Laskin R, Davis J, Peterson MG, Richart T. Prolonged operative time correlates with increased infection rate after total knee arthroplasty. HSS J 2006; 2 (1) 70-72
  CrossrefPubMedGoogle Scholar
• 23 Allen F. Respiratory complications in relation to the administration of anesthetics. N Engl J Med 1931; 204: 1288-1293
  CrossrefPubMedGoogle Scholar
• 24 Johnson AS, Lombard HL. The estimation of operative risk in patients with cancer. N Engl J Med 1941; 224: 759-762
  CrossrefPubMedGoogle Scholar
• 25 Welch CE. Abdominal surgery. N Engl J Med 1966; 275 (23) 1291-1301
  CrossrefPubMedGoogle Scholar
• 26 Waldvogel FA, Medoff G, Swartz MN. Osteomyelitis: a review of clinical features, therapeutic considerations and unusual aspects (second of three parts). N Engl J Med 1970; 282 (5) 260-266
  CrossrefPubMedGoogle Scholar
• 27 Nichols RL. Postoperative wound infection. N Engl J Med 1982; 307 (27) 1701-1702
  CrossrefPubMedGoogle Scholar
• 28 Selim M. Perioperative stroke. N Engl J Med 2007; 356 (7) 706-713
  CrossrefPubMedGoogle Scholar
• 29 Dexter SP, Martin IG, Marton J, McMahon MJ. Long operation and the risk of complications from laparoscopic cholecystectomy. Br J Surg 1997; 84 (4) 464-466
  CrossrefPubMedGoogle Scholar
• 30 Ball CG, Pitt HA, Kilbane ME, Dixon E, Sutherland FR, Lillemoe KD. Peri-operative blood transfusion and operative time are quality indicators for pancreatoduodenectomy. HPB (Oxford) 2010; 12 (7) 465-471
  CrossrefPubMedGoogle Scholar
• 31 Aloia TA, Fahy BN, Fischer CP , et al. Predicting poor outcome following hepatectomy: analysis of 2313 hepatectomies in the NSQIP database. HPB (Oxford) 2009; 11 (6) 510-515
  CrossrefPubMedGoogle Scholar
• 32 Pattani KM, Byrne P, Boahene K, Richmon J. What makes a good flap go bad? A critical analysis of the literature of intraoperative factors related to free flap failure. Laryngoscope 2010; 120 (4) 717-723
  CrossrefPubMedGoogle Scholar
• 33 Rosenberg AJ, Van Cann EM, van der Bilt A, Koole R, van Es RJ. A prospective study on prognostic factors for free-flap reconstructions of head and neck defects. Int J Oral Maxillofac Surg 2009; 38 (6) 666-670
  CrossrefPubMedGoogle Scholar
• 34 Tan TW, Kalish JA, Hamburg NM , et al. Shorter duration of femoral-popliteal bypass is associated with decreased surgical site infection and shorter hospital length of stay. J Am Coll Surg 2012; 215 (4) 512-518
  CrossrefPubMedGoogle Scholar
• 35 Shapiro M, Muñoz A, Tager IB, Schoenbaum SC, Polk BF. Risk factors for infection at the operative site after abdominal or vaginal hysterectomy. N Engl J Med 1982; 307 (27) 1661-1666
  CrossrefPubMedGoogle Scholar
• 36 LaPar DJ, Crosby IK, Ailawadi G , et al; Investigators for the Virginia Cardiac Surgery Quality Initiative. Blood product conservation is associated with improved outcomes and reduced costs after cardiac surgery. J Thorac Cardiovasc Surg 2013; 145 (3) 796-803 , discussion 803–804
  CrossrefPubMedGoogle Scholar
• 37 Shah MD, Goldstein DP, McCluskey SA , et al. Blood transfusion prediction in patients undergoing major head and neck surgery with free-flap reconstruction. Arch Otolaryngol Head Neck Surg 2010; 136 (12) 1199-1204
  CrossrefPubMedGoogle Scholar
• 38 Perisanidis C, Mittlböck M, Dettke M , et al. Identifying risk factors for allogenic blood transfusion in oral and oropharyngeal cancer surgery with free flap reconstruction. J Oral Maxillofac Surg 2013; 71 (4) 798-804
  CrossrefPubMedGoogle Scholar
• 39 Fischer JP, Nelson JA, Sieber B , et al. Transfusions in Autologous Breast Reconstructions: An analysis of risk factors, complications, and cost. Ann Plast Surg 2012; ; [Epub ahead of print]
  PubMedGoogle Scholar
• 40 Raghavan M, Marik PE. Anemia, allogenic blood transfusion, and immunomodulation in the critically ill. Chest 2005; 127 (1) 295-307
  CrossrefPubMedGoogle Scholar
• 41 Taylor RW, Manganaro L, O'Brien J, Trottier SJ, Parkar N, Veremakis C. Impact of allogenic packed red blood cell transfusion on nosocomial infection rates in the critically ill patient. Crit Care Med 2002; 30 (10) 2249-2254
  CrossrefPubMedGoogle Scholar
• 42 Hébert PC, Wells G, Blajchman MA , et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med 1999; 340 (6) 409-417
  CrossrefPubMedGoogle Scholar
• 43 Hébert PC, Yetisir E, Martin C , et al; Transfusion Requirements in Critical Care Investigators for the Canadian Critical Care Trials Group. Is a low transfusion threshold safe in critically ill patients with cardiovascular diseases?. Crit Care Med 2001; 29 (2) 227-234
  CrossrefPubMedGoogle Scholar
• 44 Bui LL, Smith AJ, Bercovici M, Szalai JP, Hanna SS. Minimising blood loss and transfusion requirements in hepatic resection. HPB (Oxford) 2002; 4 (1) 5-10
  CrossrefPubMedGoogle Scholar
• 45 Mariette D, Smadja C, Naveau S, Borgonovo G, Vons C, Franco D. Preoperative predictors of blood transfusion in liver resection for tumor. Am J Surg 1997; 173 (4) 275-279
  CrossrefPubMedGoogle Scholar
• 46 Nagino M, Kamiya J, Arai T, Nishio H, Ebata T, Nimura Y. One hundred consecutive hepatobiliary resections for biliary hilar malignancy: preoperative blood donation, blood loss, transfusion, and outcome. Surgery 2005; 137 (2) 148-155
  CrossrefPubMedGoogle Scholar
• 47 Alfieri S, Carriero C, Caprino P , et al. Avoiding early postoperative complications in liver surgery. A multivariate analysis of 254 patients consecutively observed. Dig Liver Dis 2001; 33 (4) 341-346
  CrossrefPubMedGoogle Scholar
• 48 Kooby DA, Stockman J, Ben-Porat L , et al. Influence of transfusions on perioperative and long-term outcome in patients following hepatic resection for colorectal metastases. Ann Surg 2003; 237 (6) 860-869 , discussion 869–870
  Google Scholar
• 49 Kim BD, VerHalen JP, Mlodinow AS, Kim JY. Intraoperative transfusion of packed red blood cells in microvascular free tissue transfer patients: Assessment of 30-day morbidity using the NSQIP dataset. J Reconstr Microsurg 2014; 30 (2) 103-114
  Article in Thieme ConnectPubMedGoogle Scholar
• 50 Lynch RJ, Englesbe MJ, Sturm L , et al. Measurement of foot traffic in the operating room: implications for infection control. Am J Med Qual 2009; 24 (1) 45-52
  PubMedGoogle Scholar
• 51 Dexter F, Epstein RH, Lee JD, Ledolter J. Automatic updating of times remaining in surgical cases using bayesian analysis of historical case duration data and “instant messaging” updates from anesthesia providers. Anesth Analg 2009; 108 (3) 929-940
  CrossrefPubMedGoogle Scholar