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Autologous breast reconstruction: Vanderbilt experience 1998-2005, independent predictors of displeasing outcomes
PLASTIC SURGERY II Autologous breast reconstruction: Vanderbilt experience 1998-2005, independent predictors of displeasing outcomes
Chronobiology of glucose diurnal variation in critical injury re-established after disruption because of changes in time zone
Joseph A Greco III, MD, Eric Castaldo, MD, Evelyn Wu, MS, Rafe Donahue, PhD, Lillian Nanney, PhD, J Jason Wendel, MD, Kevin Hagan, MD, R Bruce Shack, MD Vanderbilt University, Nashville, TN
Heather F Pidcoke, MD, Sandra M Wanek, MD, Jose Salinas, PhD, John B Holcomb, MD, FACS, Steven E Wolf, MD, FACS, Charles E Wade, PhD University of Texas, Health Science Center, San Antonio, San Antonio, TX
INTRODUCTION: Optimized surgical planning requires an appreciation for co-morbidities that impact outcomes. The purpose of this study is to delineate risk factors for complications after autologous breast reconstruction.
INTRODUCTION: Hyperglycemia is associated with morbidity and mortality that can be reduced with intensive insulin. Maintaining euglycemia is difficult, because glucose patterns in critical illness are poorly understood. Diurnal glucose variations are normal in healthy subjects, and persist in critical illness. We wondered whether chronobiology of glucose diurnal variation in injured patients from different time zones would differ for the first 48 hours of admission, and whether these patterns would synchronize with time.
METHODS: An institutional database was constructed of patients who underwent autologous breast reconstruction from 1998’2005; capturing age, diabetic/smoking status, pre-reconstruction radiation therapy (XRT), concomitant breast resection, pre-operative albumin, reconstruction type (Latissimus Dorsi (LD) versus TRAM), and BMI. The primary outcome was a non-infectious wound complication (NIWC)’a novel classification of wound problems (see table). Secondary outcomes were infection, hematoma, hernia (for TRAMs), and fat necrosis. A Cox regression model was tested using the preceding co-variates.
METHODS: Records were reviewed at a burn center for the years 2002 to 2004 for patients treated with insulin for 7 days (ages 18-45). Point-of-care(POC) glucometer values from military subjects were compared to civilian, and matched for time of day drawn. Trend analysis established the periodicity of patterns over the course of the first 7 days. The military group had a longer interval from injury to admission(6⫹/⫺5 days vs 1⫹/⫺5 days, p⬍0.001), and had greater time zone differences.
Table. Classification of Non-Infectious Wound Complications (NIWC) 1 Epidermolysis or loss of tissue and/or necrosis confined to mastectomy skin only; ⫹/⫺ need for debridement; flap skin preserved; no operative revision needed 2 Tissue loss or necrosis requiring local wound care including office debridement; no operative revision needed 3 Any flap tissue loss and/or necrosis requiring operative debridement; no operative revision needed 4 Any flap tissue loss and/or necrosis requiring operative debridement AND operative revision 5 Complete flap loss requiring salvage procedure
RESULTS: Military subjects (n⫽48) were similar to civilian (n⫽29) in age, gender, ISS and %BSA burned. In the first 48 hours, glucose patterns were different between groups (p⬍0.001), and a single peak (p) and nadir (nd) were seen (military p⫽13th hour, nd⫽35th; civilian p⫽3rd hour, nd⫽26th). Subsequently, the pattern became diurnal and peaks and troughs approximated between groups; by day 4 peaks and troughs were 2 hours apart, a statistically but not clinically significant difference. CONCLUSIONS: Glucose diurnal variation is disordered after time zones travel, becoming aligned within 4 days. ICU environmental factors may contribute to synchronicity of glucose diurnal patterns.
RESULTS: There were 200 flaps (171 TRAM & 29 LD) in 180 patients yielding: 19 infections (9.5%), 3 total flap losses (1.5%), 14 hematomas (7%), and 11 hernias (6%). Fat necrosis and any NIWC was 18% and 36% respectively. Mean follow-up was 13.1mos. (range 1.1-51.7mos.). Cox regression demonstrates that BMI⬎30 is an independent risk factor for any NIWC (HR⫽6.58; 95%CI 2.85 ’ 15.18; p⬍0.01) and NIWC requiring operation (NIWC ⬎⫽ 3)(HR⫽6.23; 95%CI 2.15 ’ 18.05; p⬍0.01). Increasing BMI is a risk factor for NIWC (p⬍0.01), NIWC requiring operation (p⬍0.01), and infection (p⬍0.01). No other variable was an indicator for undesirable outcomes.
Comparing FK-506 with basic fibroblast growth factor (b-FGF) on the repair of a peripheral nerve defect using an autogenous vein bridge model Kongkrit Chaiyasate, MD, Ian Jackson, MD, Vijay Mittal, MD Providence Hospital and Medical Centers, Southfield, MI INTRODUCTION: The limited availability of donor sites for nerve grafts and their inherent associated morbidity continue to stimulate research toward finding suitable alternatives. Experimental and clinical studies have shown that a vein segment used to bridge a peripheral nerve defect leads to good nerve repair. Both FK-506 and b-FGF have been reported to enhance peripheral nerve regeneration. This study compared the effect of FK-506 to b-FGF on peripheral nerve regeneration in a rat autogenous vein graft conduit model.
CONCLUSIONS: After adjusting for all variables in the model, these data suggest that BMI is a strong predictor of simple and complex non-infectious wound complications and of infection after autologous breast reconstruction. Obese patients should be counseled about a significantly increased risk of experiencing these undesirable outcomes.
© 2007 by the American College of Surgeons Published by Elsevier Inc.
ISSN 1072-7515/07/$32.00
S58
Chronobiology of glucose diurnal variation in critical injury re-established after disruption because of changes in time zone
Joseph A Greco III, MD, Eric Castaldo, MD, Evelyn Wu, MS, Rafe Donahue, PhD, Lillian Nanney, PhD, J Jason Wendel, MD, Kevin Hagan, MD, R Bruce Shack, MD Vanderbilt University, Nashville, TN
Heather F Pidcoke, MD, Sandra M Wanek, MD, Jose Salinas, PhD, John B Holcomb, MD, FACS, Steven E Wolf, MD, FACS, Charles E Wade, PhD University of Texas, Health Science Center, San Antonio, San Antonio, TX
INTRODUCTION: Optimized surgical planning requires an appreciation for co-morbidities that impact outcomes. The purpose of this study is to delineate risk factors for complications after autologous breast reconstruction.
INTRODUCTION: Hyperglycemia is associated with morbidity and mortality that can be reduced with intensive insulin. Maintaining euglycemia is difficult, because glucose patterns in critical illness are poorly understood. Diurnal glucose variations are normal in healthy subjects, and persist in critical illness. We wondered whether chronobiology of glucose diurnal variation in injured patients from different time zones would differ for the first 48 hours of admission, and whether these patterns would synchronize with time.
METHODS: An institutional database was constructed of patients who underwent autologous breast reconstruction from 1998’2005; capturing age, diabetic/smoking status, pre-reconstruction radiation therapy (XRT), concomitant breast resection, pre-operative albumin, reconstruction type (Latissimus Dorsi (LD) versus TRAM), and BMI. The primary outcome was a non-infectious wound complication (NIWC)’a novel classification of wound problems (see table). Secondary outcomes were infection, hematoma, hernia (for TRAMs), and fat necrosis. A Cox regression model was tested using the preceding co-variates.
METHODS: Records were reviewed at a burn center for the years 2002 to 2004 for patients treated with insulin for 7 days (ages 18-45). Point-of-care(POC) glucometer values from military subjects were compared to civilian, and matched for time of day drawn. Trend analysis established the periodicity of patterns over the course of the first 7 days. The military group had a longer interval from injury to admission(6⫹/⫺5 days vs 1⫹/⫺5 days, p⬍0.001), and had greater time zone differences.
Table. Classification of Non-Infectious Wound Complications (NIWC) 1 Epidermolysis or loss of tissue and/or necrosis confined to mastectomy skin only; ⫹/⫺ need for debridement; flap skin preserved; no operative revision needed 2 Tissue loss or necrosis requiring local wound care including office debridement; no operative revision needed 3 Any flap tissue loss and/or necrosis requiring operative debridement; no operative revision needed 4 Any flap tissue loss and/or necrosis requiring operative debridement AND operative revision 5 Complete flap loss requiring salvage procedure
RESULTS: Military subjects (n⫽48) were similar to civilian (n⫽29) in age, gender, ISS and %BSA burned. In the first 48 hours, glucose patterns were different between groups (p⬍0.001), and a single peak (p) and nadir (nd) were seen (military p⫽13th hour, nd⫽35th; civilian p⫽3rd hour, nd⫽26th). Subsequently, the pattern became diurnal and peaks and troughs approximated between groups; by day 4 peaks and troughs were 2 hours apart, a statistically but not clinically significant difference. CONCLUSIONS: Glucose diurnal variation is disordered after time zones travel, becoming aligned within 4 days. ICU environmental factors may contribute to synchronicity of glucose diurnal patterns.
RESULTS: There were 200 flaps (171 TRAM & 29 LD) in 180 patients yielding: 19 infections (9.5%), 3 total flap losses (1.5%), 14 hematomas (7%), and 11 hernias (6%). Fat necrosis and any NIWC was 18% and 36% respectively. Mean follow-up was 13.1mos. (range 1.1-51.7mos.). Cox regression demonstrates that BMI⬎30 is an independent risk factor for any NIWC (HR⫽6.58; 95%CI 2.85 ’ 15.18; p⬍0.01) and NIWC requiring operation (NIWC ⬎⫽ 3)(HR⫽6.23; 95%CI 2.15 ’ 18.05; p⬍0.01). Increasing BMI is a risk factor for NIWC (p⬍0.01), NIWC requiring operation (p⬍0.01), and infection (p⬍0.01). No other variable was an indicator for undesirable outcomes.
Comparing FK-506 with basic fibroblast growth factor (b-FGF) on the repair of a peripheral nerve defect using an autogenous vein bridge model Kongkrit Chaiyasate, MD, Ian Jackson, MD, Vijay Mittal, MD Providence Hospital and Medical Centers, Southfield, MI INTRODUCTION: The limited availability of donor sites for nerve grafts and their inherent associated morbidity continue to stimulate research toward finding suitable alternatives. Experimental and clinical studies have shown that a vein segment used to bridge a peripheral nerve defect leads to good nerve repair. Both FK-506 and b-FGF have been reported to enhance peripheral nerve regeneration. This study compared the effect of FK-506 to b-FGF on peripheral nerve regeneration in a rat autogenous vein graft conduit model.
CONCLUSIONS: After adjusting for all variables in the model, these data suggest that BMI is a strong predictor of simple and complex non-infectious wound complications and of infection after autologous breast reconstruction. Obese patients should be counseled about a significantly increased risk of experiencing these undesirable outcomes.
© 2007 by the American College of Surgeons Published by Elsevier Inc.
ISSN 1072-7515/07/$32.00
S58