Implant loss rates within and after three months following surgery: Are new targets required?

ABSTRACTS

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Conclusion: The identification of treatable malignancy following P1 assessment confirms that placing an upper age limit for imaging patients over the age of 75 years attending symptomatic breast clinic and found to have no clinical abnormality could have a detrimental effect on the care of this group.

P061. Microbiological spectra of micro-organisms associated with breast implant loss Richard Daniels1, Daniel Leff1, Harun Thomas1, Jennifer Doyle1, Wayne Chicken1, Louise Teare2, Sascha Miles-Dua1, Simon Smith1 1 Chelmsford Breast Unit, Broomfield Hospital, Chelmsford, Essex, UK 2 Microbiology Department, Broomfield Hospital, Chelmsford, Essex, UK

http://dx.doi.org/10.1016/j.ejso.2014.02.059

P060. Implant loss rates within and after three months following surgery: Are new targets required? Richard Daniels, Harun Thomas, Daniel Leff, Jennifer Doyle, Wayne Chicken, Sascha Miles-Dua, Simon Smith Chelmsford Breast Unit, Broomfield Hospital, Chelmsford, Essex, UK Introduction: The ABS Oncoplastic guidelines include set targets for outcomes following implant-based reconstruction (e.g. <5% for implant loss, return to theatre and unplanned readmission at 3 months)1. However, both prior data and our own experience suggest that complications frequently occur more than 3 months following reconstruction. A local audit was performed to assess whether the ABS targets captured all of our units complications. Methods: A retrospective audit reviewed all implant-based breast reconstructions at the unit (2008-2013), specifically focusing on the details and timing of complications. Reasons for implant loss and subsequent interventional procedures were recorded. Results: Table A Complication and implant loss rates.

Introduction: ABS Oncoplastic guidelines for implant-based reconstruction set targets for implant loss, return to theatre and unplanned readmission at 3 months (<5%)1. Data from the National Audit (NMBRA 4th report) highlights challenges of achieving these targets (overall implant loss 9%). Infection is a major cause of implant loss, however there is little data from the United Kingdom to suggest causative organisms. Targeting prophylactic antibiotics to commonly occurring microbes may limit implant loss. Our current protocol is single-agent broad-spectrum singledose prophylaxis. Methods: A retrospective audit evaluated infection-related failures (i.e. implant-loss) following immediate breast reconstructions performed at Chelmsford Breast Unit (2008-2013). Microbiological cultures from infected wounds, or fluid at time of explanation were evaluated to indentify causative micro-organisms. Results:

Name of Organism

Number of cases

Staphylococcus aureus

5

% Of infections resulting in implant loss 56

Staphylococcus Spp

2

22

Year

n. Implant procedures

n. Complications

n. Implants lost

July 2008 onwards 2009 2010 2011 2012 2013 to 1st Nov Total

5

2

0

% Lost outside 3 month period (n) -

12 9 39 63 37

3 6 10 14 3

1 2 2 4 3

0 0 50 (1) 25 (1) 33 (1)

Klebsiella

1

11

165

38

12

25 (3)

Morganella

1

11

Corynebacterium Enterobacter cloacae

1 4

11 44

Unknown

1

11

Table B Causes of implant loss. Cause Infection Wound Failure Cosmesis/Capsule formation Total

n. 9 2 1 12

% Total implant loss 75% 17% 8% 100%

Sensitivities

Fusidic Acid, Gentamicin, Rifampicin, Tetracycline, Vancomycin, Flucloxacillin Gentamicin, Meropenem, Tazocin Co-Amoxiclav, Piperacillin/ Tazobactam, Vancomycin, Tazocin, Meropenem Gentamicin, Meropenem, Piperacillin/ Tazobactam Unknown Gentamicin, Meropenem, Piperacillin/ Tazobactam Unknown

Conclusions: The ABS target fails to capture late complications (i.e. occurring > 3/12 post-op) such as implant losses. Our review highlights that late implant loss remains a significant problem (25% of reconstruction failure). Based on our audit, we suggest that the 3 month period used in the target is insufficient to capture late implant loss and suggest that this should be extended. 1 Association of Breast Surgery & British Association of Plastic, Reconstructive and Aesthetic Surgeons; Nov 2012; Oncoplastic Breast Reconstruction: Guidelines for Best Practice; ed. Rainsbury D & Willett A

Conclusions: Staphylococcus Aureus accounts for approximately half of post-implant infections leading to reconstruction failure but which current prophylaxis should feasibly target (i.e. co-amoxiclav or flucloxacilin). However, Enterobacter was commonly observed and on this basis we suggest dual antibiotic prophylaxis with agents that cover gram positive, gram negative and anaerobic organisms. 1 Association of Breast Surgery & British Association of Plastic, Reconstructive and Aesthetic Surgeons; Nov 2012; Oncoplastic Breast Reconstruction: Guidelines for Best Practice; ed. Rainsbury D & Willett A

http://dx.doi.org/10.1016/j.ejso.2014.02.060

http://dx.doi.org/10.1016/j.ejso.2014.02.061