MROC研究：一项腹部皮瓣乳房重建后的并发症和患者报告的结果

编译：季玮儒   述评：杨犇龙、吴炅

摘  要

背景   

腹部皮瓣重建是最常见的自体乳房重建方式。本研究比较了带蒂下腹横行腹直肌（PTRAM）皮瓣，游离下腹横行腹直肌（FTRAM）皮瓣，腹壁下动脉穿支（DIEP）皮瓣和腹壁浅表动脉（SIEA）皮瓣重建术后的并发症和患者报告的结局（PRO）。  

方法   

本研究在11个中心对行腹部皮瓣乳房重建患者的供区和乳房的并发症进行了前瞻性地评估，并通过BREAST-Q和PROMIS量表进行了患者报告结局的测评。研究采用了混合效应回归模型来评估手术方式对结局的影响。 

结果   

研究对720名入组患者进行了至少1年的随访，其中587名患者进行了2年的随访。结果显示，SIEA皮瓣乳房重建组供体部位的并发症发生率高于DIEP皮瓣乳房重建组（OR = 2.7，p = 0.001），SIEA皮瓣重建组患者的第1年腹部功能满意度得分高于DIEP皮瓣乳房重建组（平均差为4.72，P = 0.053，用0到100来衡量）。然而这一差异在第2年随访中并不显著。在术后2年腹部功能满意度得分方面，PTRAM组比DIEP组低7.2（P = 0.006），比SIEA组低7.8（p = 0.03），FTRAM组比DIEP组低4.9（p = 0.04）。双侧乳房重建患者的腹部功能满意度得分明显低于单侧乳房重建组。 

结论    

尽管所有的腹部皮瓣都是乳房重建手术的可行选择，但行DIEP和SIEA皮瓣乳房重建的患者与行PTRAM和FTRAM皮瓣乳房重建的相比具有更高的腹部功能满意度。SIEA皮瓣具有不损伤筋膜的优点，但较高的供区并发症率可能会降低患者的满意度。

 述评  

腹部作为皮瓣供区具有组织量大,血供丰富，重建乳房自然、柔软,可同时进行腹壁整形,供区可直接拉拢缝合等诸多优点，成为乳腺切除术后自体组织皮瓣重建术的优选。本研究的患者队列来自北美11个中心，是一项随访长达两年余的前瞻性研究，评估了不同腹部皮瓣的安全性和患者报告结局（PRO）。研究结果显示，DIEP和SIEA皮瓣具有更高的腹部功能满意度，但SIEA皮瓣供区并发症较高，这与我们已知的SIEA皮瓣对供区损伤较小的优势似乎相悖，一方面可能是因为前瞻性收集数据造成偏移，另外腹壁下浅血管作为供区血管，需要分离更长的距离，会造成供区血清肿、切口愈合不良率增高。

对于乳房重建术后的评价系统主要包括医生和患者两方面，患者报告结局的评估不仅可以间接反映患者的生活质量，还可以指导临床医师对重建手术的选择和实施。BREAST-Q量表是目前应用最为广泛、评估最为全面的量表之一，其报告结果不仅可以反映患者满意度及生活质量，还可以直接反映患者对治疗、护理及决策辅助等方面的需求。与发达国家相比，国内乳房重建手术的开展仍相当有限，国内临床工作者对乳房重建术后患者满意度的重视程度也远远不够。随着我们这方面工作的不断深入，相信我们对乳房重建患者术后满意度评估工具的重视程度也将不断提高，期待国内有更多这方面的前瞻性研究成果出炉，这也将成为提高乳腺癌患者乳房重建术后生活质量的巨大推动力。

Plast Reconstr Surg. 2018 Feb;141(2):271-281. 

Complications and Patient-Reported Outcomes after Abdominally Based Breast Reconstruction: Results of the Mastectomy Reconstruction Outcomes Consortium Study.

Jessica Erdmann-Sager, M.D.1, Edwin G. Wilkins, M.D., M.S.2, Andrea L. Pusic, M.D., M.H.S.4,Ji Qi, M.S.2, Jennifer B. Hamill, M.P.H.2, Hyungjin Myra Kim, Sc.D.3, Gretchen E. Guldbrandsen,B.A.1, Yoon S. Chun, M.D.1

1、Division of Plastic Surgery, Brigham and Women’s Hospital, Boston, MA
2、Section of Plastic Surgery, University of Michigan Medical School, Ann Arbor, MI
3、Department of Biostatistics, University of Michigan Medical School, Ann Arbor, MI
4、Memorial Sloan Kettering Cancer Center, New York, NY

Corresponding Author: Yoon S. Chun, M.D., Brigham and Women’s Hospital, 75 Francis Street Boston, MA 02115 USA, [e-mail]
Financial Disclosure Statement: The BREAST-Q is owned by Memorial Sloan Kettering Cancer Center and the University of British Columbia. Dr. Pusic is a co-developer of the BREAST-Q and receives royalties when it is used in “for profit” industry-sponsored clinical trials.
Presented At: The American Society of Plastic Surgeons Annual Meeting, 2016, in Los Angeles, California

ACKNOWLEDGEMENTS: Edwin G. Wilkins, M.D., M.S. and Andrea L. Pusic, M.D., M.H.S. for devising, funding, and leading MROC. Hyungjin Myra Kim, Sc.D. and Ji Qi, M.S. for performing statistical analysis. Jennifer B. Hamill, M.P.H. and Gretchen Guldbrandsen, B.A. for coordinating MROC and the BWH site, respectively. All of the plastic surgeons and patients who participated in MROC.

Abstract

BACKGROUND:

Abdominal flap reconstruction is the most popular form of autologous breast reconstruction. The current study compared complications and patient-reported outcomes after pedicled transverse rectus abdominis myocutaneous (TRAM), free TRAM, deep inferior epigastric perforator (DIEP), and superficial inferior epigastric artery (SIEA) flaps.

METHODS:

Patients undergoing abdominally based breast reconstruction at 11 centers were prospectively evaluated for abdominal donor-site and breast complications. Patient-reported outcomes were measured by the BREAST-Q and Patient-Reported Outcomes Measurement Information System surveys. Mixed-effects regression models were used to assess the effects of procedure type on outcomes.

RESULTS:

Seven hundred twenty patients had 1-year follow-up and 587 had 2-year follow-up. Two years after reconstruction, SIEA compared with DIEP flaps were associated with a higher rate of donor-site complications (OR, 2.7; p = 0.001); however, SIEA flaps were associated with higher BREAST-Q abdominal physical well-being scores compared with DIEP flaps at 1 year (mean difference, 4.72, on a scale from 0 to 100; p = 0.053). This difference was not significant at 2 years. Abdominal physical well-being scores at 2 years postoperatively were lower in the pedicled TRAM flap group by 7.2 points (p = 0.006) compared with DIEP flaps and by 7.8 points (p = 0.03) compared with SIEA flaps, and in the free TRAM flap group, scores were lower by 4.9 points (p = 0.04) compared with DIEP flaps. Bilateral reconstruction had significantly lower abdominal physical well-being scores compared with unilateral reconstruction.

CONCLUSIONS:

Although all abdominally based flaps are viable breast reconstruction options, DIEP and SIEA flaps are associated with higher abdominal physical well-being than pedicled and free TRAM flaps. Although SIEA flaps offer the advantage of not violating the fascia, higher rates of donor-site complications may diminish patient satisfaction.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, II.