National Outcomes of Prophylactic Lymphovenous Bypass during Axillary Lymph Node Dissection

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.

The Association between Breast Cancer Related Lymphedema and Area Deprivation Index

“…In addition, the RATE-L risk assessment tool has yet to be externally validated on additional populations beyond its development dataset, so the risk categories presented here may not represent the true risk of lymphedema due to baseline differences between the patient populations. 18 Lastly, no patients in this study underwent surgical treatment or prevention of lymphedema, which have been shown to be safe and effective procedures that significantly improve quality of life 37,38 ; further study may elucidate a disparity in the utilization of these newer, more complex treatment techniques.…”

Immediate Lymphatic Reconstruction in 77 Consecutive Breast Cancer Patients: 2-year Follow-up

“…The decision to do ILR has been shown to be safe, but it does increase the operative time by an average of 99.2 minutes (approximately a 40 minute reduction in additional operative time related to ILR previously reported). 13 A large portion of that time is consumed by the setup of the microsurgery instruments and microscope.…”

“…The decision to do ILR has been shown to be safe, but it does increase the operative time by an average of 99.2 minutes (approximately a 40-minute reduction in additional operative time related to ILR previously reported). 13 A large portion of that time is consumed by the setup of the microsurgery instruments and microscope. Both in evidenced-based literature as well as in our institution's study population, the majority of patients who develop BCRL, do so in the first 2 years after their ALND.…”

United States insurance coverage of immediate lymphatic reconstruction

“…Additionally, there are currently no consensus guidelines for billing and coding for many lymphedema procedures such as ILR. Some sources use CPT codes 35 206, 38 999, and 38 308 for ILR, while the authors have also used 75 801 and 69 990 to bill for this procedure 33,38 . As insurance coverage for ILR increases and its use becomes more widespread, this will undoubtedly help to standardize billing practices.…”