Predictors of Major Postoperative Complications in Oncologic Reconstructive Surgery: A Single-Center Cohort Study in a Resource-Limited Setting

Abstract

Introduction: Oncologic reconstructive surgery is essential for restoring form and function but carries a high risk of postoperative complications in resource-limited environments. Identifying robust, readily available predictors is critical for risk stratification and improving surgical outcomes in these settings.

Materials and Methods: A retrospective cohort study was conducted on 69 adult patients who underwent complex reconstructive surgery following oncologic resection at a tertiary center in Yemen (2018–2024). The procedures included local flaps (n = 41, 59.4%), skin grafts (n = 19, 27.5%), and regional/distant flaps (n = 9, 13.0%). Data on demographics, comorbidities, defect characteristics, ASA classification, and preoperative serum albumin were collected. The primary outcome was a major postoperative complication (Clavien-Dindo grade ≥III), assessed over a 30-day postoperative period. Independent predictors were identified through multivariable logistic regression.

Results: The cohort was predominantly male (68.1%, n=47) with a mean age of 54.1 years. Head and neck reconstruction (71.0%, n=49) for basal cell carcinoma (63.8%, n=44) was most common. The major complication rate was 29.0% (n=20), including surgical site infection (11.6%, n=8) and flap/graft failure (8.7%, n=6). The presence of a major complication was strongly associated with worse clinical outcomes, resulting in a 100% procedural failure rate (p<0.001), a 45.0% unplanned readmission rate (p<0.001), and a significantly longer median hospital stay (12.0 vs. 6.0 days, p<0.001). Multivariable analysis identified defect size >50 cm² (adjusted Odds Ratio [aOR] 3.65, 95% CI: 1.55–8.59, p<0.01), ASA class III (aOR 2.85, 95% CI: 1.25–6.50, p=0.01), and preoperative hypoalbuminemia (< 3.5 g/dL) (aOR 2.70, 95% CI: 1.15–6.33, p=0.02) as independent predictors.

Conclusion: Large defect size, higher ASA class, and hypoalbuminemia were independent predictors of major postoperative complications in this resource-limited setting. These factors are associated with increased procedural failure, readmission, and extended hospital stays, providing a practical framework for preoperative risk assessment. Key limitations of this study include its retrospective, single-center design and moderate sample size. Despite this, these findings enable targeted nutritional and surgical optimization to mitigate complications. Further prospective, multi-center studies are necessary to validate and expand upon these findings.