National trends and safety of prophylactic lymphovenous bypass during axillary lymph node dissection: A decade-long analysis of 61,819 patients through the NSQIP database.

BACKGROUND

Post-mastectomy lymphatic reconstruction is increasingly common, yet its frequency and outcomes remain underexplored. This study evaluates national trends and safety outcomes of prophylactic lymphovenous bypass (LVB) following axillary lymph node dissection (ALND) over a 10-year period, including the COVID-19 era.

METHODS

A retrospective cohort study using the American College of Surgeons National Surgery Quality Improvement Program database from 2013-2022 analyzed 61,819 ALND cases, including 572 (0.93%) with concurrent LVB. LVB cases were identified via CPT codes (38999, 38308, 35206, 35236, 38305). Primary analysis evaluated temporal adoption trends. Secondary endpoints included 30-day postoperative complications [reoperation, deep vein thrombosis (DVT), wound dehiscence, surgical site infection (SSI), and sepsis].

RESULTS

LVB adoption increased steadily over the study period, demonstrating significant linear growth (0.24% annually; R²=0.88; p<0.001). Rates increased from 1.54 to 2.10% during the COVID-19 pandemic from 2019 to 2021. LVB patients had higher rates of any postoperative complication (9.3 vs. 7.0%; p=0.040), DVT (0.7 vs. 0.2%; p=0.032), and superficial SSI (4.5 vs. 2.7%; p=0.014). Rates of reoperation, wound dehiscence, and deep SSI were comparable. Among mastectomy patients without reconstruction, LVB patients had an increased rate of DVT (1.3 vs. 0.2%; p=0.042). Multivariate analysis trended toward decreased reoperation risk with LVB (OR 0.64; 95% CI 0.40-1.01; p=0.056).

CONCLUSION

This decade-long analysis demonstrates a 14.6-fold rise in prophylactic LVB during ALND. Although LVB had increased complications and DVT in select subgroups, reoperation rates were comparable to ALND alone. The trend toward reduced reoperation risk and expanding national use indicates increasing integration of lymphatic microsurgery into breast cancer care.