自体乳房重建中皮瓣相关并发症影响因素分析及术中使用吲哚菁绿造影的经济学效益

Multivariable analysis for flap-related complications in autologous breast reconstruction and economic analysis of intraoperative indocyanine green angiography

目的探讨自体乳房重建中皮瓣相关并发症的影响因素,以及术中使用吲哚菁绿(indocyanine green,ICG)造影的经济学效益。方法回顾分析2013年7月-2018年6月收治的符合选择标准的150例自体乳房重建的乳房切除术后患者(152个乳房)。对年龄、体质量指数、术前新辅助化疗(neoadjuvant chemotherapy,NC)、胸部放疗史、合并糖尿病、供区手术史、胸壁重建、重建时机、皮瓣类型、术中ICG造影进行单因素分析,初步筛选单因素分析中有统计学意义的临床因素,纳入皮瓣相关并发症及皮瓣局部坏死的logistic多因素回归分析(逐步后退法)。根据以上多因素分析结果,将患者分为4组:ICG+NC组(A组)、ICG+非NC组(B组)、非ICG+NC组(C组)、非ICG+非NC组(D组),计算每组患者的人均额外治疗费用(ICG造影费用+处理皮瓣相关并发症的费用)。结果术后152个皮瓣均成活。共有33个皮瓣发生皮瓣相关并发症,包括22个皮瓣局部坏死、9个局部感染、5个血肿、5个单纯脂肪液化、2个吻合口血栓形成。单因素分析显示,术前NC、皮瓣类型及术中ICG造影是发生皮瓣相关并发症的影响因素(P<0.05)。多因素分析显示,术前NC、未使用ICG造影是发生皮瓣相关并发症的危险因素(P<0.05),也是发生皮瓣局部坏死的危险因素(P<0.05)。对于NC患者,术中使用ICG造影会大大节省人均额外治疗费用,A组较C组人均额外治疗费用少花费1378元。对于未行NC者,术中使用ICG造影会增加人均额外治疗费用,B组较D组人均额外治疗费用多花费747元。结论在自体乳房重建中,ICG造影可降低皮瓣相关并发症的发生率,尤其是皮瓣局部坏死发生率;而NC则相反。对于非NC患者,ICG造影的性价比不高,经济条件允许下可使用;但对于NC患者,ICG造影性价比较高,建议使用。

Objective To investigate the influencing factors of flap-related complications and the economic benefits of intraoperative indocyanine green(ICG) angiography in the patients undergoing autologous breast reconstruction. Methods Between July 2013 and June 2018, the clinical data of 150 patients(152 breasts) who met the selection criteria after autologous breast reconstruction were analyzed retrospectively. Ten factors including age, body mass index, preoperative neoadjuvant chemotherapy(NC), chest radiation history, diabetes, abdominal operation history,chest wall reconstruction, reconstruction timing, flap type, intraoperative ICG angiography were analyzed by univariate analysis. Significant variables found in univariate analysis were used to perform backward multivariate logistic regression of flap related complications and local necrosis. According to the above multi factor analysis results, the patients were divided into 4 groups: ICG+NC group(group A), ICG+non-NC group(group B), non-ICG+NC group(group C), nonICG+non-NC group(group D). The average extra costs of surgical treatment(including ICG imaging cost+cost of handling flap related complications) of each group was calculated. Results All the 152 flaps survived. There were 33 flaprelated complications, including 22 regional necrosis, 9 regional infection, 5 hematoma, 5 simple fat liquefaction, and 2 anastomotic thrombosis. Univariate analysis showed that preoperative NC, flap type, and intraoperative ICG angiography had significant influence on the incidence of flap-related complications(P<0.05). Multivariate analysis showed that preoperative NC and non-ICG angiography were the risk factors of flap-related complications(P<0.05), and also the risk factors of regional flap necrosis(P<0.05). For patients who had NC, intraoperative ICG angiography could greatly save the average extra costs. The average extra costs in group A was 1 378 yuan less than that in group C. For the patients without NC, intraoperative ICG angiography would increase the average extra costs, which was 747 yuan in group B more than that in group D. Conclusion In autologous breast reconstruction, ICG angiography can reduce the incidence of flaprelated complications, especially the incidence of regional flap necrosis, while NC is the opposite. For patients without NC,ICG angiography is not cost-effective but still can be used if conditions permit. However, for those with NC, ICG angiography is cost-effective and recommended.