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既往研究几乎没有关于即刻、延迟、二次乳房重建术后手术部位感染和非感染性伤口并发症的数据。 2017年7月19日，《美国医学会杂志外科学分册》在线发表圣路易斯华盛顿大学医学院的研究报告，对接受乳房切除术患者即刻、延迟、二次植入或自体乳房重建术后手术部位感染和非感染性伤口并发症的发生率进行了比较。结果发现，即刻与延迟、二次植入重建相比，手术部位感染、非感染性伤口并发症发生率显著较高；相比之下，即刻、延迟、二次自体重建术后手术部位感染、非感染性伤口并发症发生率发生率相似。因此，延迟与即刻植入重建相比，可能有利于某些高风险患者减少伤口并发症风险。 该队列回顾研究入组2004年1月1日～2011年12月31日进行乳房切除术的18～64岁女性17293例（平均年龄50.4±8.5岁），数据来自12个州的商业保险公司索赔数据库，并于2015年1月1日～2017年2月7日进行分析。乳房切除术后，7天内重建被认为即刻重建，7天后重建被认为延迟重建，即刻重建后再次重建被认为二次重建。根据国际疾病分类第9版临床修订（ICD-9-CM）手术部位感染和非感染性伤口并发症诊断代码衡量主要结局。 结果发现，61.4%的乳房切术后女性接受了即刻或延迟重建。 即刻、延迟、二次植入重建相比：
即刻、延迟、二次自体重建相比
即刻植入重建后，有、无手术部位感染的女性相比：
二次植入重建后，接受、未接受辅助放疗的女性相比：
即刻重建后，有、无伤口并发症相比，乳房手术显著较多：
综上所述：
JAMA Surg. 2017 Jul 19. [Epub ahead of print] Comparison of Wound Complications After Immediate, Delayed, and Secondary Breast Reconstruction Procedures. Margaret A. Olsen; Katelin B. Nickel; Ida K. Fox; Julie A. Margenthaler; Anna E. Wallace; Victoria J. Fraser. Washington University School of Medicine, St Louis, Missouri; HealthCore, Inc, Wilmington, Delaware. This cohort study compares the incidence of surgical site infection and noninfectious wound complications after immediate, delayed, and secondary implant and autologous breast reconstruction in patients undergoing mastectomy. QUESTION: Does the incidence of wound complications differ after implant and autologous immediate, delayed, and secondary breast reconstruction? FINDINGS: In this cohort study of 17293 patients who underwent mastectomy, the incidence of surgical site infection was significantly higher after immediate (8.9%) compared with delayed (6.0%) and secondary (3.3%) implant reconstructions, with similar results for noninfectious wound complications. In contrast, the incidence of surgical site infection was similar after immediate (9.8%), delayed (13.9%), and secondary (11.6%) autologous reconstructions. MEANING: Delayed implant rather than immediate implant reconstruction may be beneficial in some high-risk patients to reduce the risk of wound complications. IMPORTANCE: Few data are available concerning surgical site infection (SSI) and noninfectious wound complications (NIWCs) after delayed (DR) and secondary reconstruction (SR) compared with immediate reconstruction (IR) procedures in the breast. OBJECTIVE: To compare the incidence of SSI and NIWCs after implant and autologous IR, DR, and SR breast procedures after mastectomy. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study included women aged 18 to 64 years undergoing mastectomy from January 1, 2004, through December 31, 2011. Data were abstracted from a commercial insurer claims database in 12 states and analyzed from January 1, 2015, through February 7, 2017. EXPOSURES: Reconstruction within 7 days of mastectomy was considered immediate. Reconstruction more than 7 days after mastectomy was considered delayed if the mastectomy did not include IR or secondary if the mastectomy included IR. MAIN OUTCOMES AND MEASURES: International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes for SSI and NIWCs. RESULTS: Mastectomy was performed in 17293 women (mean [SD] age, 50.4 [8.5] years); 61.4% of women had IR or DR. Among patients undergoing implant reconstruction, the incidence of SSI was 8.9% (685 of 7655 women) for IR, 5.7% (21 of 369) for DR, and 3.2% (167 of 5150) for SR. Similar results were found for NIWCs. In contrast, the incidence of SSI was similar after autologous IR (9.8% [177 of 1799]), DR (13.9% [19 of 137]), and SR (11.6% [11 of 95]) procedures. Compared with women without an SSI after implant IR, women with an SSI after implant IR were significantly more likely to have another SSI (47 of 412 [11.4%] vs 131 of 4791 [2.7%]) and an NIWC (24 of 412 [5.8%] vs 120 of 4791 [2.5%]) after SR. The incidence of SSI (24 of 379 [6.3%] vs 152 of 5286 [2.9%]) and NIWC (22 of 379 [5.8%] vs 129 of 5286 [2.4%]) after implant SR was higher in women who had received adjuvant radiotherapy. Wound complications after IR were associated with significantly more breast surgical procedures (mean of 1.92 procedures [range, 0-9] after implant IR and 1.11 [range, 0-6] after autologous IR) compared with women who did not have a complication (mean of 1.37 procedures [range, 0-8] after implant IR and 0.87 [range, 0-6] after autologous IR). CONCLUSIONS AND RELEVANCE: The incidence of SSI and NIWCs was slightly higher for implant IR compared with delayed or secondary implant reconstruction. Women who had an SSI or NIWC after implant IR had a higher risk for subsequent complications after SR and more breast operations. The risk for complications should be carefully balanced with the psychosocial and technical benefits of IR. Select high-risk patients may benefit from consideration of delayed rather than immediate implant reconstruction to decrease breast complications after mastectomy. DOI: 10.1001/jamasurg.2017.2338 |
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