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Preoperative Anemia and Postoperative Outcomes in Immediate Breast Reconstructive Surgery: A Critical Analysis of 10,958 Patients from the ACS-NSQIP Database
Karim A. Sarhane, MD, MSc, Jose M. Flores, MPH, Carisa M. Cooney, MPH, Francis Abreu, Bsc, Marcelo Lacayo-Baez, MD, Pablo Baltodano, MD, Zuhaib Ibrahim, MD, Mohammad Alrakan, MD, Gerald Brandacher, MD, Gedge D. Rosson, MD.
Johns Hopkins University, Baltimore, MD, USA.

PURPOSE: Preoperative anemia is independently associated with adverse outcomes in patients undergoing general and cardiac surgery. However, outcomes after breast reconstruction are not well established. We aimed to assess the effect of preoperative anemia on 30-day postoperative morbidity and length of hospital stay (LOS) in patients undergoing immediate breast reconstruction following mastectomy.
METHODS: Patients who underwent immediate breast reconstruction from 2008 to 2010 were identified from the American College of Surgeons National Surgical Quality Improvement Program (a prospective, risk adjusted, outcomes-based registry from selected hospitals worldwide). De-identified data were obtained for 30-day postoperative morbidity and LOS, as well as demographics, preoperative and perioperative risk factors. Specific morbidity variables included cardiac, respiratory, neurological, urinary tract, flap/prosthesis, wound and venous thromboembolism outcomes. Logistic regression was used to assess the crude and adjusted effect of anemia (defined as a hematocrit concentration <36%) on postoperative 30-day morbidity, and on LOS. We also evaluated the potential dose-response relationship of such effects.
RESULTS: The study population included 10,958 patients, of whom 1,666 (15.20%) had preoperative anemia. Crude odds ratios (ORs) for 30-day morbidity and increased LOS were significantly higher in anemic patients than in those without anemia, ORunadjusted = 1.33 (p<0.008) and ORunadjusted = 1.30 (p<0.001), respectively. This trend prevailed after extensive adjustment for confounding, yielding an ORadjusted = 1.38 (p<0.03) for 30-day morbidity and ORadjusted=1.28 (p<0.01) for increased length of stay. Furthermore, there was a dose-dependent increase in 30-day morbidity with decreasing hematocrit levels.
CONCLUSION: These results provide new insight into the effect of anemia on immediate breast reconstruction outcomes, demonstrating an independent association between preoperative anemia and increased risk of 30-day morbidity and LOS. This finding strongly recommends the treatment of anemia before immediate breast reconstruction. Preoperative anemia is easy to screen for, and in most cases, inexpensive to treat. Further prospective studies are warranted to explore the efficacy, safety, and cost-effectiveness of such preoperative anemia management.


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