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Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet].

Abdominal wall following free TRAM or DIEP flap reconstruction: a meta-analysis and critical review

X Man, JC Selber, and JM Serletti.

Review published: 2009.

Link to full article: [Journal publisher]

CRD summary

The authors concluded that deep inferior epigastric perforator (DIEP) flap reduced abdominal morbidity and increased flap-related complications compared with the free transverse rectus abdominis myocutaneous (TRAM) flap in breast reconstruction. The reliability of the conclusions is unclear given a number of weaknesses in the review methods and the poor quality of included studies.

Authors' objectives

To compare flap and donor-site complication rates after deep inferior epigastric perforator (DIEP) and free transverse rectus abdominis myocutaneous (TRAM) flap surgery for breast reconstruction.

Searching

MEDLINE (from inception to April 2007) and bibliographies of identified reviews and articles were searched for English-only publications. Search terms were reported.

Study selection

All studies that evaluated complication rates in patients who underwent either DIEP or free TRAM flap surgery for breast reconstruction were eligible for inclusion. Studies had to report study designs, number of patients enrolled and number of flaps performed. Case series with non-consecutive patient recruitment and studies with sample sizes of fewer than 10 patients were excluded. Outcomes of interest included complication rates of fat necrosis, flap loss, abdominal wall bulge, laxity or weakness and abdominal hernia.

The proportion of patients in DIEP and free TRAM flap groups were varied with regard to smoking status, obesity, previous radiotherapy and abdominal scarring. Mean age ranged from 38.6 to 56.1 years. Mean follow-up periods ranged from 9.8 to 74 months.

The authors did not state how many reviewers performed the study selection.

Assessment of study quality

The authors did not state that they assessed validity.

Data extraction

Event rates were used to calculate risk ratios (RR) and their 95% confidence intervals (CIs) for direct comparisons (DIEP versus TRAM) and event rates and 95% CIs were extracted for single-arm studies. Data were entered into a standardised data extraction form.

The authors did not state how many reviewers performed the data extraction.

Methods of synthesis

Pooled risk ratios (with 95% CIs) for the outcomes of fat necrosis, flap loss, abdominal bulge, laxity, weakness and hernia were calculated using Mantel-Haenszel fixed-effects methods where there was no evidence of heterogeneity; otherwise, the DerSimonian and Laird random-effects method was used. Pooled complication rates for DIEP and TRAM flap patients were calculated using a random-effects model for the outcomes of fat necrosis, flap loss, abdominal bulge, laxity, weakness and abdominal hernia). Cumulative complication rates (with 95% CIs) were calculated based on publication years. Subgroup analyses (all studies versus muscle-sparing free TRAM flap) were performed for the outcomes of fat necrosis, flap loss and abdominal bulge or hernia. Publication bias was assessed visually using funnel plots, and by Egger’s and Begg’s tests.

Results of the review

Thirty-six uncontrolled case-series studies (n=4,259 patients) were included in the review. Six studies (n=759 patients) evaluated complications in both DIEP and free TRAM flap patients. Sample sizes ranged from 10 to 718 patients.

DIEP and free TRAM flap outcomes:

The risk of fat necrosis was significantly higher in DIEP flap patients compared with free TRAM flap patients (RR 1.94, 95% CI 1.28 to 2.93; n=962 patients, five studies, p=0.07 for heterogeneity).

There was no significant difference in the risk of fat necrosis between muscle-sparing free TRAM flaps and full muscle free TRAM flaps (RR 0.91, 95% CI 0.47 to 1.78; n=613 patients, three studies, p=0.58 for heterogeneity).

The risk of flap loss was significantly higher in DIEP patients compared with free TRAM patients (RR 2.05, 95% CI 1.16 to 3.61; n=962 patients, five studies, p=0.04 for heterogeneity).

The risk of abdominal bulge or hernia was significantly lower in DIEP flap patients compared with free TRAM flap patients (RR 0.49, 95% CI 0.28 to 0.86; n=759 patients, five studies, p=0.57 for heterogeneity).

Pooled complication rates:

Pooled flap related complication rates (fat necrosis, total flap loss and abdominal bulge, laxity, or weakness) were higher in DIEP patients. Donor-site morbidity was higher in free TRAM patients.

Publication year analysis:

The cumulative pooled rate of partial flap loss in DIEP flap patients and partial flap loss and total flap loss in free TRAM patients decreased according to publication year.

No evidence of publication bias was found (funnel plot showed symmetry).

Authors' conclusions

Deep inferior epigastric perforator (DIEP) flap reduced abdominal morbidity but increased flap-related complications compared with the free transverse rectus abdominis myocutaneous (TRAM) flap in breast reconstruction.

CRD commentary

The review question was clearly stated. The limited search strategy might have resulted in the omission of other relevant papers, even though the funnel plot did not suggest evidence of publication bias. Non English-language papers were excluded, so language bias could have been present. No efforts were made to minimise the risk of reviewer error and bias during study selection, data extraction and quality assessment. No formal quality assessment was performed; however, all the included studies were uncontrolled observational studies, and hence of poor quality. Statistical combination of results was supported by absence of evidence of heterogeneity. Combination of direct comparison and single-arm complication rate data during data extraction weakened the validity of reported results. The reliability of the conclusions is unclear given the potential of reviewer error and bias in review methods and the poor quality of included studies.

Implications of the review for practice and research

The authors did not state any implications for practice or further research.

Funding

Not stated.

Bibliographic details

Man X, Selber JC, Serletti JM. Abdominal wall following free TRAM or DIEP flap reconstruction: a meta-analysis and critical review. Plastic and Reconstructive Surgery 2009; 124(3): 752-764. [PubMed: 19342994]

Indexing Status

Subject indexing assigned by NLM

MeSH

Abdominal Wall; Female; Humans; Mammaplasty /adverse effects /methods; Surgical Flaps /adverse effects

AccessionNumber

12009108587

Database entry date

03/03/2010

Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.

CRD has determined that this article meets the DARE scientific quality criteria for a systematic review.

Copyright © 2014 University of York.

PMID: 19342994

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