Toronto, Ontario, Canada From the Division of Plastic and Reconstructive Surgery, Department of Surgery and Surgical Oncology, University Health Network; and the Division of Plastic and Reconstructive Surgery and the Lawrence S. Bloomberg Faculty of Nursing, University of Toronto.
Plast Reconstr Surg. 2014 Apr;133(4):774-782. doi: 10.1097/PRS.0000000000000024.
Previous studies comparing muscle-sparing transverse rectus abdominis myocutaneous (TRAM) versus deep inferior epigastric artery perforator (DIEP) free flaps have not considered procedure selection bias. Propensity score analysis provides a statistical approach to consider preoperative factors in flap selection, and was used to compare major complications (breast and abdominal) between these microsurgical breast reconstruction (free muscle-sparing TRAM versus DIEP).
This study evaluated major breast and abdominal complications in 292 consecutive patients (428 free abdominal flaps). Propensity scores were calculated for patient differences affecting flap selection (DIEP versus free muscle-sparing TRAM). Multivariate logistic models using selected covariates separately analyzed breast and abdominal complications between flap methods.
There were 83 major complications (28 percent): breast, 20 percent; abdomen, 8 percent. Using propensity scores, the adjusted odds of abdominal complications were significantly higher in free muscle-sparing TRAM than in DIEP flaps (OR, 2.73; 95 percent CI, 1.01 to 7.07). With prior chemotherapy, body mass index significantly increased abdominal complications (OR, 1.16; 95 percent CI, 1.01 to 1.34). Using propensity scores, there was no significant association between reconstruction method and breast complications; diabetics had significantly increased breast complications (OR, 4.19; 95 percent CI, 1.14 to 15.98). Previous abdominal operations (OR, 1.77; 95 percent CI, 0.96 to 3.30) and immediate reconstruction (OR, 1.86; 95 percent CI, 0.94 to 3.71) approached significance.
Propensity score analysis indicated significantly higher abdominal complications in free muscle-sparing TRAM compared with DIEP flaps. This study highlights the importance of separately evaluating recipient breast and donor abdominal complications and use of propensity scores to minimize procedure selection bias.
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
先前比较保留肌肉的横形腹直肌肌皮瓣（TRAM）与腹壁下动脉穿支皮瓣（DIEP）游离皮瓣的研究并未考虑手术选择偏倚。倾向评分分析为考虑皮瓣选择中的术前因素提供了一种统计学方法，并被用于比较这些显微乳房重建（游离保留肌肉的 TRAM 与 DIEP）的主要并发症（乳房和腹部）。
本研究评估了 292 例连续患者（428 例游离腹部皮瓣）的主要乳房和腹部并发症。为影响皮瓣选择的患者差异计算了倾向评分（DIEP 与游离保留肌肉的 TRAM）。使用选定的协变量分别对乳房和腹部并发症的皮瓣方法进行多变量逻辑模型分析。
共有 83 例主要并发症（28%）：乳房 20%，腹部 8%。使用倾向评分，游离保留肌肉的 TRAM 组腹部并发症的调整比值比显著高于 DIEP 皮瓣组（OR，2.73；95%CI，1.01 至 7.07）。有化疗史时，体质量指数显著增加腹部并发症（OR，1.16；95%CI，1.01 至 1.34）。使用倾向评分，重建方法与乳房并发症之间无显著关联；糖尿病患者乳房并发症显著增加（OR，4.19；95%CI，1.14 至 15.98）。既往腹部手术（OR，1.77；95%CI，0.96 至 3.30）和即刻重建（OR，1.86；95%CI，0.94 至 3.71）接近显著。
倾向评分分析表明，游离保留肌肉的 TRAM 组与 DIEP 皮瓣相比，腹部并发症显著增加。本研究强调了分别评估受体乳房和供体腹部并发症以及使用倾向评分最小化手术选择偏倚的重要性。
临床问题/证据水平：治疗性，III 级。
