Impact of obesity on outcomes in breast reconstruction: analysis of 15,937 patients from the ACS-NSQIP datasets

Abstract

Background: Obesity is a growing epidemic in the United States (US) affecting more than 33% of adults. We aimed to use the World Health Organization (WHO) obesity stratification scheme to assess the overall risk of obese patients undergoing breast reconstruction using the ACS-NSQIP database from 2005 to 2010.

Study design: We reviewed the 2005 to 2010 ACS-NSQIP databases identifying encounters for Current Procedural Terminology (CPT) codes including either implant-based reconstruction (immediate, delayed, and tissue expander) or autologous reconstruction (pedicled transverse rectus abdominis myocutaneous [pTRAM], free TRAM, and latissimus dorsi flap with or without implant). Patients were classified and compared based on WHO obesity criteria: nonobese (body mass index [BMI] = 20 to 29.9 kg/m(2)), class I (BMI = 30 to 34.9 kg/m(2)), class II (BMI = 35 to 39.9 kg/m(2)), and class III (BMI > 40 kg/m(2)).

Results: During the study period 15,937 breast reconstructions were performed. The majority of reconstructions were immediate reconstructions (85.0%) and implant-based (79.1%). The incidence of obesity was 27.1%, with 16.3% defined as class I obese, 6.9% defined as class II obese, and 4.0% defined as class III obese. The WHO-classified obese patients tended to have a progressively higher incidence of comorbid conditions, higher American Society of Anesthesiologists (ASA) physical status (p < 0.001), longer operative times (p = 0.0001), and greater lengths of hospital stay (p = 0.0001). Progressively higher BMIs were associated with higher rates of complications, including wound (p < 0.001), medical (p < 0.001), infections (p < 0.001), major surgical (p < 0.001), graft and prosthesis loss (p < 0.001), and return to the operating room (p < 0.001).

Conclusions: This study characterized the effect of progressive obesity on the incidence of surgical and medical complications after breast reconstruction using a large, prospective multicenter dataset. Increasing obesity is associated with increased perioperative morbidity. Data derived from this cohort study can be used to risk-stratify patients, enhance risk counseling, and advocate for institutional reimbursement in obese patients undergoing breast reconstruction.

Keywords: ACS-NSQIP; American College of Surgeons National Surgical Quality Improvement Program; BMI; CPT; Current Procedural Terminology; OR; TRAM; WHO; World Health Organization; body mass index; odds ratio; transverse rectus abdominis myocutaneous.