The Keys to Optimising Breast Wounds: A Meta-Analysis

Background: Breast disease and breast cancer management form a major part of healthcare delivery. Surgical site occurrence (SSO) poses septic and oncological risks to patients. This study undertook a meta-analysis to identify key risk factors and interventions that may alter the incidence of SSO in patients undergoing breast surgery. Methods: An ethically approved, PROSPERO-registered meta-analysis following PRISMA guidelines and Cochrane Handbook for Systematic Reviews was undertaken of all published English articles using electronic databases from 2010 to 2017 incorporating MeSH terms “risk factors”, “surgical site infections”, “breast surgery”, and “interventions”. Articles scoring > 10 for non-comparative studies and >15 for comparative studies, using MINORS criteria were included. The OR or RR using random-effects, Mantel-Haenszel method were computed for each risk factor and intervention respectively with RevMan 5. Results: The pre-operative factors affecting breast surgery SSO were diabetes mellitus (OR = 2.52, CI = 1.78 - 3.59, p < 0.001), smoking (OR = 2.39, CI = 1.57 - 3.63, p < 0.001), ASA ≥ III (OR = 2.37, CI = 1.51 - 3.74, p < 0.001), obese versus non-obese (OR = 1.84, CI = 1.52 - 2.24, p < 0.001), over-weight/obese versus normal BMI (OR = 1.70, CI = 1.36 - 2.13, p < 0.001), hypertension (OR = 1.63, CI = 1.39 - 1.90, p < 0.001), and antibiotics prophylaxis (RR = 0.58, CI = 0.36 - 0.95, p = 0.03). The intraoperative factors were surgical wound classifications 3 - 4 (OR = 6.16, CI = 2.52 - 15.02, p < 0.001), surgical drains (OR = 2.80, CI = 1.06 - 7.38, p = 0.04), and axillary lymph node dissection (OR = 1.46, CI = 1.18 - 1.80, p < 0.001). The post-operative factors were adjuvant radiotherapy (OR = 1.77, CI = 1.26 - 2.50, p = 0.001), re-operated patients (OR = 1.65, CI = 1.01 - 2.70, p = 0.05), post-operative antibiotics (RR = 0.57, CI = 0.33 - 0.98, p = 0.04), and drain antisepsis care (RR = 0.15, CI = 0.03 - 0.82, p = 0.03). Conclusions: This study identified key factors associated with increased risk of breast surgery wound occurrence. It will facilitate the development of a peri-operative breast wound bundle to optimize outcomes.