Subscribe to RSS
DOI: 10.1055/s-0042-1742730
National Outcomes of Prophylactic Lymphovenous Bypass during Axillary Lymph Node Dissection
![](https://www.thieme-connect.de/media/jrm/202208/lookinside/thumbnails/10-1055-s-0042-1742730_210291-1.jpg)
Abstract
Background Breast cancer treatment, including axillary lymph node excision, radiation, and chemotherapy, can cause upper extremity lymphedema, increasing morbidity and health care costs. Institutions increasingly perform prophylactic lymphovenous bypass (LVB) at the time of axillary lymph node dissection (ALND) to reduce the risk of lymphedema but reports of complications are lacking. We examine records from the American College of Surgeons (ACS) National Surgery Quality Improvement Program (NSQIP) database to examine the safety of these procedures.
Methods Procedures involving ALND from 2013 to 2019 were extracted from the NSQIP database. Patients who simultaneously underwent procedures with the Current Procedural Terminology (CPT) codes 38999 (other procedures of the lymphatic system), 35201 (repair of blood vessel), or 38308 (lymphangiotomy) formed the prophylactic LVB group. Patients in the LVB and non-LVB groups were compared for differences in demographics and 30-day postoperative complications including unplanned reoperation, deep vein thrombosis (DVT), wound dehiscence, and surgical site infection. Subgroup analysis was performed, controlling for extent of breast surgery and reconstruction. Multivariate logistic regression was performed to identify predictors of reoperation.
Results The ALND without LVB group contained 45,057 patients, and the ALND with LVB group contained 255 (0.6%). Overall, the LVB group was associated with increased operative time (288 vs. 147 minutes, p < 0.001) and length of stay (1.7 vs. 1.3 days, p < 0.001). In patients with concurrent mastectomy without immediate reconstruction, the LVB group had a higher rate of DVTs (3.0 vs. 0.2%, p = 0.009). Reoperation, wound infection, and dehiscence rates did not differ across subgroups. Multivariate logistic regression showed that LVB was not a predictor of reoperations.
Conclusion Prophylactic LVB at time of ALND is a generally safe and well-tolerated procedure and is not associated with increased reoperations or wound complications. Although only four patients in the LVB group had DVTs, this was a significantly higher rate than in the non-LVB group and warrants further investigation.
Keywords
lymphovenous bypass - lymphovenous anastomosis - LYMPHA - lymph node dissection - lymphedemaPublication History
Received: 09 September 2021
Accepted: 27 December 2021
Article published online:
14 February 2022
© 2022. Thieme. All rights reserved.
Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA
-
References
- 1 McLaughlin SA, Wright MJ, Morris KT. et al. Prevalence of lymphedema in women with breast cancer 5 years after sentinel lymph node biopsy or axillary dissection: objective measurements. J Clin Oncol 2008; 26 (32) 5213-5219
- 2 Hayes S, Di Sipio T, Rye S. et al. Prevalence and prognostic significance of secondary lymphedema following breast cancer. Lymphat Res Biol 2011; 9 (03) 135-141
- 3 Shih YC, Xu Y, Cormier JN. et al. Incidence, treatment costs, and complications of lymphedema after breast cancer among women of working age: a 2-year follow-up study. J Clin Oncol 2009; 27 (12) 2007-2014
- 4 Taghian NR, Miller CL, Jammallo LS, O'Toole J, Skolny MN. Lymphedema following breast cancer treatment and impact on quality of life: a review. Crit Rev Oncol Hematol 2014; 92 (03) 227-234
- 5 Johnson AR, Kimball S, Epstein S. et al. Lymphedema incidence after axillary lymph node dissection: quantifying the impact of radiation and the lymphatic microsurgical preventive healing approach. Ann Plast Surg 2019; 82 (4S, suppl 3): S234-S241
- 6 Kim M, Kim SW, Lee SU. et al. A model to estimate the risk of breast cancer-related lymphedema: combinations of treatment-related factors of the number of dissected axillary nodes, adjuvant chemotherapy, and radiation therapy. Int J Radiat Oncol Biol Phys 2013; 86 (03) 498-503
- 7 DiSipio T, Rye S, Newman B, Hayes S. Incidence of unilateral arm lymphoedema after breast cancer: a systematic review and meta-analysis. Lancet Oncol 2013; 14 (06) 500-515
- 8 Kissin MW, Querci della Rovere G, Easton D, Westbury G. Risk of lymphoedema following the treatment of breast cancer. Br J Surg 1986; 73 (07) 580-584
- 9 Boyages J, Vicini FA, Shah C, Koelmeyer LA, Nelms JA, Ridner SH. The risk of subclinical breast cancer-related lymphedema by the extent of axillary surgery and regional node irradiation: a randomized controlled trial. Int J Radiat Oncol Biol Phys 2021; 109 (04) 987-997
- 10 Naoum GE, Roberts S, Brunelle CL. et al. Quantifying the impact of axillary surgery and nodal irradiation on breast cancer-related lymphedema and local tumor control: long-term results from a prospective screening trial. J Clin Oncol 2020; 38 (29) 3430-3438
- 11 Basta MN, Gao LL, Wu LC. Operative treatment of peripheral lymphedema: a systematic meta-analysis of the efficacy and safety of lymphovenous microsurgery and tissue transplantation. Plast Reconstr Surg 2014; 133 (04) 905-913
- 12 Scaglioni MF, Arvanitakis M, Chen YC, Giovanoli P, Chia-Shen Yang J, Chang EI. Comprehensive review of vascularized lymph node transfers for lymphedema: Outcomes and complications. Microsurgery 2018; 38 (02) 222-229
- 13 Beederman M, Garza RM, Agarwal S, Chang DW. Outcomes for physiologic microsurgical treatment of secondary lymphedema involving the extremity. Ann Surg 2020
- 14 Garza RM, Chang DW. Lymphovenous bypass for the treatment of lymphedema. J Surg Oncol 2018; 118 (05) 743-749
- 15 Boccardo FM, Casabona F, Friedman D. et al. Surgical prevention of arm lymphedema after breast cancer treatment. Ann Surg Oncol 2011; 18 (09) 2500-2505
- 16 Boccardo F, Casabona F, De Cian F. et al. Lymphatic microsurgical preventing healing approach (LYMPHA) for primary surgical prevention of breast cancer-related lymphedema: over 4 years follow-up. Microsurgery 2014; 34 (06) 421-424
- 17 Johnson AR, Fleishman A, Tran BNN. et al. Developing a lymphatic surgery program: a first-year review. Plast Reconstr Surg 2019; 144 (06) 975e-985e
- 18 Jørgensen MG, Toyserkani NM, Sørensen JA. The effect of prophylactic lymphovenous anastomosis and shunts for preventing cancer-related lymphedema: a systematic review and meta-analysis. Microsurgery 2018; 38 (05) 576-585
- 19 Squitieri L, Rasmussen PW, Patel KM. An economic analysis of prophylactic lymphovenous anastomosis among breast cancer patients receiving mastectomy with axillary lymph node dissection. J Surg Oncol 2020; 121 (08) 1175-1178
- 20 DeSnyder SM, Yi M, Boccardo F. et al. American Society of Breast Surgeons' Practice Patterns for patients at risk and affected by breast cancer-related lymphedema. Ann Surg Oncol 2021
- 21 Steiner CA, Weiss AJ, Barrett ML, Fingar KR, Davis PH. Trends in bilateral and unilateral mastectomies in hospital inpatient and ambulatory settings, 2005–2013: statistical brief #201. In: Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Rockville MD: Agency for Healthcare Research and Quality (US); 2006
- 22 Tornese N. Coding for mastectomy – use the correct ICD-10 and CPT codes. Accessed July 2, 2021 at: https://www.outsourcestrategies.com/blog/coding-for-mastectomy-use-the-correct-icd-10-and-cpt-codes.html
- 23 Faul F, Erdfelder E, Buchner A, Lang AG. Statistical power analyses using G*Power 3.1: tests for correlation and regression analyses. Behav Res Methods 2009; 41 (04) 1149-1160
- 24 Shen Z, Sun J, Yu Y. et al. Oncological safety and complication risks of mastectomy with or without breast reconstruction: a Bayesian analysis. J Plast Reconstr Aesthet Surg 2021; 74 (02) 290-299
- 25 Olsen MA, Nickel KB, Margenthaler JA. et al. Development of a risk prediction model to individualize risk factors for surgical site infection after mastectomy. Ann Surg Oncol 2016; 23 (08) 2471-2479
- 26 Johnson AR, Asban A, Granoff MD. et al. Is immediate lymphatic reconstruction cost-effective?. Ann Surg 2021; 274 (06) e581-e588
- 27 Chang DW. Lymphaticovenular bypass for lymphedema management in breast cancer patients: a prospective study. Plast Reconstr Surg 2010; 126 (03) 752-758
- 28 Kwok AC, Goodwin IA, Ying J, Agarwal JP. National trends and complication rates after bilateral mastectomy and immediate breast reconstruction from 2005 to 2012. Am J Surg 2015; 210 (03) 512-516
- 29 Lese I, Biedermann R, Constantinescu M, Grobbelaar AO, Olariu R. Predicting risk factors that lead to free flap failure and vascular compromise: A single unit experience with 565 free tissue transfers. J Plast Reconstr Aesthet Surg 2021; 74 (03) 512-522
- 30 Blok YL, van Lierop E, Plat VD, Corion LUM, Verduijn PS, Krekel NMA. Implant Loss and Associated Risk Factors following Implant-based Breast Reconstructions. Plast Reconstr Surg Glob Open 2021; 9 (07) e3708
- 31 ACS NSQIP Participant Use Data File (PUF). Accessed July 22, 2021 at: https://www.facs.org/quality-programs/acs-nsqip/participant-use
- 32 Chang DW, Suami H, Skoracki R. A prospective analysis of 100 consecutive lymphovenous bypass cases for treatment of extremity lymphedema. Plast Reconstr Surg 2013; 132 (05) 1305-1314
- 33 Khavanin N, Gart MS, Berry T, Thornton B, Saha S, Kim JY. Sentinel lymph node biopsy versus axillary lymphadenectomy in patients treated with lumpectomy: an analysis of short-term outcomes. Ann Surg Oncol 2014; 21 (01) 74-80
- 34 Barry M, Weber WP, Lee S, Mazzella A, Sclafani LM. Enhancing the clinical pathway for patients undergoing axillary lymph node dissection. Breast 2012; 21 (04) 440-443
- 35 Carl HM, Walia G, Bello R. et al. Systematic review of the surgical treatment of extremity lymphedema. J Reconstr Microsurg 2017; 33 (06) 412-425
- 36 Rodriguez JR, Fuse Y, Yamamoto T. Microsurgical strategies for prophylaxis of cancer-related extremity lymphedema: a comprehensive review of the literature. J Reconstr Microsurg 2020; 36 (07) 471-479
- 37 Cakmakoglu C, Kwiecien GJ, Schwarz GS, Gastman B. Lymphaticovenous bypass for immediate lymphatic reconstruction in locoregional advanced melanoma patients. J Reconstr Microsurg 2020; 36 (04) 247-252
- 38 Campisi CC, Ryan M, Boccardo F, Campisi C. LyMPHA and the prevention of lymphatic injuries: a rationale for early microsurgical intervention. J Reconstr Microsurg 2014; 30 (01) 71-72