Combining Breast and Ovarian Operations Increases Complications

Dominic Henn, M.D.; Janos A. Barrera, M.D.; Dharshan Sivaraj, B.S.; John Q. Lin, B.S.; Nada M. Rizk, M.S.; Irene Ma, M.D.; Geoffrey C. Gurtner, M.D.; Gordon K. Lee, M.D.; Rahim S. Nazerali, M.D., M.H.S.

Disclosures

Plast Reconstr Surg. 2022;149(5):1050-1059.

Abstract and Introduction

Abstract

Background: Breast cancer resulting from a genetic mutations, such as BRCA1 or BRCA2, is seen in 5 to 10 percent of patients. More widespread genetic testing has increased the number of affected women undergoing prophylactic mastectomy and oophorectomy. Recent studies have yielded mixed results regarding complication rates after combined breast and ovarian operations. The authors compared surgical outcomes of breast operations performed in combination with salpingo-oophorectomies or as separate procedures.

Methods: The authors retrospectively analyzed surgical complications and length of hospital stay in 145 female patients, from which 87 had undergone combined breast surgery and salpingo-oophorectomy, and 58 had undergone these procedures separately. Multivariate logistic regression models were used to calculate odds ratios and 95 percent confidence intervals.

Results: Patients undergoing combined breast and ovarian operations experienced higher rates of overall complications (46.5 percent versus 19 percent; p < 0.001), infections (22.2 percent versus 8.6 percent; p < 0.05), and delayed wound healing (13.2 percent versus 0 percent; p < 0.05) related to the breast surgery, when compared with patients undergoing separate procedures. Multivariate logistic regression analysis confirmed a significant association between combined surgery and overall postoperative complications (OR, 5.87; 95 percent CI, 2.03 to 16.91; p= 0.02). Patients undergoing tissue expander–based breast reconstruction combined with ovarian surgery had significantly longer hospital stays compared to patients undergoing separate procedures (3.5 days versus 1.8 days;

Table 1. Demographics and Baseline Characteristics
Characteristic	Separate (%)*	Combined (%)†	p
No. of patients	58	87
Mean age ± SD, yr	53.79 ± 9.43	51.03 ± 9.02	0.08
Mean BMI ± SD, kg/m²	27.77 ± 6.01	25.83 ± 6.33	0.07
Ethnicity
White, non-Hispanic	30 (51.7)	58 (67.4)	0.08
Asian	9 (15.5)	13 (15.1)	1.00
Other, non-Hispanic	1 (1.7)	1 (1.2)	1.00
Hispanic/Latino	18 (31.0)	14 (16.3)	0.04‡
Active smoker	14 (24.1)	24 (27.9)	0.70
Diabetes mellitus	9 (15.5)	11 (12.8)	0.63
Cardiovascular disease	10 (17.2)	19 (22.1)	0.53
ASA class ≥ 3	9 (15.5)	16 (18.6)	0.66
History of chemotherapy for breast cancer	35 (60.3)	42 (48.8)	0.23
History of radiation therapy for breast cancer	28 (48.3)	34 (39.5)	0.31
History of chemotherapy for gynecologic cancer	2 (3.4)	6 (7.0)	0.28
History of radiation therapy for gynecologic cancer	3 (5.2)	4 (4.7)	1.00

BMI, body mass index; ASA, American Society of Anesthesiologists.
*Patients with separately performed breast and ovarian operations.
†Patients with combined breast and ovarian operations under the same anesthesia.
‡Statistically significant.

Table 2. Oncologic Diagnosis and Mutations/Variants in Breast Cancer Susceptibility Genes
Characteristic	Separate (%)*	Combined (%)†	p
No. of patients	58	87
Breast cancer	51 (87.93)	78 (90.00)	0.59
Gynecologic cancer	9 (15.52)	1 (1.14)	0.001‡
Mutations/genetic variants	31(53.4)	52 (59.8)	0.49
BRCA1	12 (20.69)	19 (21.84)	1.00
BRCA2	16 (27.59)	25 (28.74)	1.00
CHEK2	0	1 (1.14)
PALB2	0	1 (1.14)
RAD51C	0	1 (1.14)
RAD50	1 (1.72)	1 (1.14)
NBN	1 (1.72)	1 (1.14)
TP53	0	1 (1.14)
BRCA1 VUS	1 (1.72)	1 (1.14)
ATM VUS	0	1 (1.14)
Negative test for BRCA1 and BRCA2	23 (39.66)	28 (32.18)	0.47
Mutation status unknown	5 (8.62)	7 (8.04)	0.90

VUS, variant of unknown significance.
*Patients with separately performed breast and ovarian operations, combined.
†Patients with combined breast and ovarian operations under the same anesthesia.
‡Statistically significant.

Table 3. Surgical Procedures
Characteristic	Separate (%)*	Combined (%)†	p
No. of patients	58	87
Breast surgical procedures
Mastectomy	12 (20.7)	17 (19.5)	0.87
Mastectomy plus TE placement	16 (27.6)	25 (29.0)	1.00
Lumpectomy	9 (15.5)	10 (11.6)	0.61
Lumpectomy plus mastopexy	1 (1.7)	2 (2.3)	1.00
Breast implant placement	2 (3.4)	6 (7.0)	0.47
Autologous breast reconstruction	18 (31.0)	27 (31.4)	1.00
Mastectomy and immediate breast reconstruction with free TRAM flap	14 (24.1)	21 (24.4)	1.00
Mastectomy and immediate breast reconstruction with DIEP flap	1 (1.7)	1 (1.2)	1.00
Delayed breast reconstruction with free TRAM flap	2 (3.4)	5 (5.8)	0.70
Breast reconstruction with LD flap and implant	1 (1.7)	0 (0)	0.40
Gynecologic surgical procedures
Salpingo-oophorectomy	48 (82.8)	68 (78.2)	0.64
Salpingo-oophorectomy plus hysterectomy	10 (17.2)	19 (22.1)	0.53
Gynecologic surgical modalities
Laparoscopic	48 (82.8)	79 (90.8)	0.35
Robotic assisted laparoscopic	8 (13.8)	4 (4.6)	0.11
Open	2 (3.5)	4 (4.6)	1.00
Cumulative procedure times
Autologous breast reconstruction plus gynecologic surgery			0.01‡,§
Mean	11.9	9.7
Range	4.5–14.3	4.7–15.2
Median	12.45	9.5
IQR	10.5–13.4	8.4–11.6
Other breast surgery and gynecologic surgery			0.003‡,\|\|
Mean	6.4	4.8
Range	2.5–12.9	2.7–8.4
Median	5.8	4.5
IQR	4.3–8.8	3.5–5.5
Regional anesthesia
Transverse abdominis plane block	14 (25.1)	21 (24.1)	1.00

TE, tissue expander; TRAM, transverse rectus abdominis musculocutaneous; DIEP, deep inferior epigastric perforator, LD, latissimus dorsi; IQR, interquartile range.
*Patients with separately performed breast and ovarian operations.
†Patients with combined breast and ovarian operations under the same anesthesia.
§Mann-Whitney test.
||t test.
‡Statistically significant.

Table 4. Postoperative Complications and Length of Hospital Stay
Characteristic	Separate (%)*	Combined (%)†	p
Breast complications
Overall	11 (19)	40 (46.5)	0.001‡
Delayed wound healing	0 (0)	9 (13.2)	0.01‡
Wound dehiscence	0 (0)	1 (1.2)	1.00
Skin necrosis	1 (1.7)	2 (2.3)	1.00
Hematoma	5 (8.6)	7 (8.1)	1.00
Infection	5 (8.6)	19 (22.2)	0.04‡
Fat necrosis	1 (1.7)	8 (9.3)	0.09
Seroma	4 (6.9)	10 (11.6)	0.40
Surgical revision for complication	5 (8.6)	15 (17.4)	0.15
Gynecologic complications
Overall	2 (3.4)	11 (12.8)	0.08
Delayed wound healing	0 (0)	2 (2.3)	0.52
Hematoma	0 (0)	4 (4.7)	0.15
Infection	2 (3.4)	6 (7.0)	0.48
Surgical revision for complication	1 (1.7)	1 (1.2)	1.00
Length of hospital stay, days
Breast surgery
Mean ± SD	1.7 ± 1.7	—
Median	1.0	—
IQR	0.3–3.0	—
Ovarian surgery			^—
Mean ± SD	0.8 ± 1.0	—
Median	0.4	—
IQR	0–1.0	—
Total hospital stay			<0.0001‡,§
Mean ± SD	2.5 ± 2.3	3.2 ± 1.6
Median	1.8	3.0
IQR	1.0–3.7	2.0–4.3
Time until initiation of adjuvant therapy, days
Time until initiation of adjuvant radiation therapy			0.21§
Mean ± SD	102 ± 38	84 ± 50
Median	111.0	77.0
IQR	66.0–128.0	32.75–131.8
Time until initiation of adjuvant chemotherapy			0.49§
Mean ± SD	52 ± 44	66 ± 52
Median	38.5	46.5
IQR	15.8–78.3	26.8–98.3

IQR, interquartile range.
*Patients with separately performed breast and ovarian operations.
†Patients with combined breast and ovarian operations under the same anesthesia.
‡Statistically significant.
§Mann-Whitney test.

Table 5. Postoperative Complications and Length of Hospital Stay in Subgroup Analyses: Mastectomy and Tissue Expander Placement
Characteristic	Separate*	Combined†	p
No.	16	25
Breast complications
Overall	2 (12.5)	14 (56.0)	0.08
Delayed wound healing	0	7 (28.0)	0.03‡
Wound dehiscence	0	7 (28.0)	0.03‡
Skin necrosis	0	0.51	0.51
Hematoma	0	2 (8.0)	0.51
Infection	2 (12.5)	0	0.15
Fat necrosis	0	1 (4.0)	1
Seroma	0	1 (4.0)	1
Surgical revision for complication	0	1 (4.0)	1
Gynecologic complications
Overall	1 (6.3)	3 (12.0)	1
Delayed wound healing	0	1 (4.0)	1
Hematoma	0	0
Infection	1 (6.3)	0	1
Wound dehiscence	0	1 (4.0)	1
Seroma	0	1 (4.0)	1
Surgical revision for complication	0	0
Length of hospital stay, days
Total hospital stay			0.0002‡,§
Mean ± SD	1.8 ± 1.5	3.5 ± 1.5
Median	1.0	4.0
IQR	1.0–2.0	2.2–5.0

Table 6. Postoperative Complications and Length of Hospital Stay in Subgroup Analyses: Autologous Breast Reconstruction with Abdominal Free Flaps
	Separate (%)*	Combined (%)†	p
No.	17	27
Breast complications
Overall	4 (23.5)	13 (48.1)	0.19
Delayed wound healing	0	2	0.51
Wound dehiscence	0	0
Skin necrosis	0	1	1
Hematoma	2	1	0.54
Infection	2	7	0.45
Fat necrosis	0	4	0.15
Seroma	2	5	0.69
Reoperation	2	3	1
Gynecologic complications
Overall	1	4	0.63
Delayed wound healing	0	2	0.51
Hematoma	0	1	1
Infection	1	2	1
Wound dehiscence	0	0
Seroma	0	0
Surgical revision for complication	0	0
Length of hospital stay, days
Total hospital stay			0.6‡
Mean ± SD	3.5 ± 1.7	3.2 ± 1.5
Median	3.0	3.0
IQR	1.0–5.9	1.7–4.3

IQR, interquartile range.
*Patients with separately performed breast and ovarian operations.
†Patients with combined breast and ovarian operations under the same anesthesia.
‡t test.

Table 7. Logistic Regression Analysis for Overall Complications
	95% CI	OR	p	Adjusted p
Combined surgery*	2.03–16.91	5.87	<0.01†	0.02†
Age	0.93–1.01	0.974	0.272	0.99
BMI	0.98–1.12	1.05	0.211	0.99
Smoking	0.46–2.16	1.00	0.999	0.99
Diabetes	0.67–5.72	1.89	0.323	0.99
CVD	0.26–1.69	0.69	0.476	0.99
ASA class 3	0.35–2.45	0.93	0.911	0.99
Chemotherapy for breast cancer	0.58–3.19	1.34	0.569	0.99
Chemotherapy for gynecologic cancer	0.64–25.84	3.94	0.214	0.99
Radiation therapy for breast cancer	0.20–1.07	0.46	0.133	0.99
Radiation therapy for gynecologic cancer	0.32–10.25	1.81	0.565	0.99

BMI, body mass index; CVD, cardiovascular disease; ASA, American Society of Anesthesiologists.
*Combination of breast and ovarian surgery under the same anesthesia.
†Statistically significant.

Table 8. Logistic Regression Analysis for Breast Complications
	95% CI	OR	p	Adjusted p
Combined surgery*	2.30–14.90	5.56	<0.01†	0.05
Age	0.95–1.03	0.98	0.608	0.99
BMI	0.99–1.12	1.05	0.155	0.82
Smoking	0.30–1.45	0.67	0.402	0.82
Diabetes	1.07–9.36	3.05	0.087	0.82
CVD	0.21–1.45	0.57	0.332	0.82
ASA class 3	0.38–2.63	1.00	0.989	0.99
Chemotherapy for breast cancer	0.81–4.62	1.90	0.223	0.99
Chemotherapy for gynecologic cancer	0.62–2.31	3.62	0.232	0.82
Radiation therapy for breast cancer	0.21–1.23	0.52	0.217	0.82
Radiation therapy for gynecologic cancer	0.31–1.07	1.81	0.569	0.99

BMI, body mass index; CVD, cardiovascular disease; ASA, American Society of Anesthesiologists.
*Combination of breast and ovarian surgery under the same anesthesia.
†Statistically significant.