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BACKGROUND: Successful intraoperative microvascular anastomoses are essential for deep inferior epigastric perforator (DIEP) flap survival. This study identifies factors associated with anastomotic failure during DIEP flap reconstruction and analyzes the impact of these anastomotic failures on post-operative patient outcomes and surgical costs. METHODS: A retrospective cohort study was conducted of patients undergoing DIEP flap reconstruction at two high-volume tertiary care centers from January 2017 to December 2020. Patient demographics, intraoperative management, anastomotic technique, and post-operative outcomes were collected. Data were analyzed using Student’s t-tests, chi-square analysis, and multivariate logistic regression. RESULTS: Of the 270 patients included in our study (mean age 52, majority Caucasian [74.5%]), intraoperative anastomotic failure occurred in 26 (9.6%) patients. Increased number of circulating nurses increased risk of anastomotic failure (Odds Ratio (OR) 1.02, 95% Confidence Interval (CI) 1.00-1.03, P<0.05). Presence of a junior resident also increased risk of anastomotic failure (OR 2.42, 95% CI 1.01-6.34, P<0.05). Increased surgeon years in practice was associated with decreased failures (OR 0.12, CI 0.02-0.60, P<0.05). Intraoperative anastomotic failure increased the odds of post-operative hematoma (OR 8.85, CI 1.35-59.1, P<0.05) and was associated with longer operating room times (bilateral DIEP: 2.25 hours longer, P<0.05), longer hospital stays (2.2 days longer, P<0.05), and higher total operating room cost ($28,529.50 versus $37,272.80, P<0.05). CONCLUSION: Intraoperative anastomotic failures during DIEP flap reconstruction are associated with longer, more expensive cases and increased rates of post-operative complications. Presence of increased numbers of circulators and junior residents was associated with increased risk of anastomotic failure. Future research is necessary to develop practice guidelines for optimizing patient and surgical factors for intraoperative anastomotic success.

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Aim: The aim of this systematic review was to summarize clinical and patient-reported outcomes (PROs) for various vascularized lymph node transfer (VLNT) donor sites and identify gaps in the literature to guide future research. Methods: A literature search of five databases was performed for articles related to VLNT that were published prior to November 2021. Studies that included clinical outcomes or PROs from at least five adult patients who received VLNTs to treat lymphedema were included. Results: Sixty-six studies met the study criteria. Most studies reported improved limb circumference/volume, reduction or discontinuation of conservative therapy, infection rate reduction, improved PROs, or postoperative imaging findings reflecting functional lymph nodes. There were significantly lower infection rates (P < 0.05) and a trend towards improved PROs in patients who received intra-abdominal flaps, but overall few studies reported these outcomes. There were no significant differences in complication rates at the donor or recipient site based on VLNT donor sites, or between intra-abdominal vs. extra-abdominal VLNT donor sites, although these outcomes are not uniformly reported. Conclusion: This meta-analysis identified that intra-abdominal donor sites have the potential to reduce postoperative infectious episodes more than extra-abdominal donor sites. Though recent investigations address many understudied VLNT donor sites, larger comparative studies and a standardized methodology are needed to better characterize postoperative outcomes, which can offer more concrete evidence to guide surgical practice.

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