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Shulkin A, Efanov JI. Enhancing outcomes in severe lymphedema through combined treatment strategies. World J Clin Cases 2025; 13:98825. [PMID: 40291580 PMCID: PMC11718565 DOI: 10.12998/wjcc.v13.i12.98825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2024] [Revised: 11/19/2024] [Accepted: 12/17/2024] [Indexed: 01/07/2025] Open
Abstract
Lymphedema, particularly in its advanced stages, presents significant challenges in treatment, often necessitating a combination of therapies to manage symptoms effectively and improve patient outcomes. This article reviews the findings of Wang et al, regarding the use of lymphovenous anastomosis and complex decongestive therapy in treating severe, deformed stage III lymphedema with recurrent infections. The case report details the promising results achieved through this combined therapy, highlighting substantial reductions in limb volume and the complete resolution of recurrent lymphangitis. The patient experienced notable improvements in weight loss, physical function, and quality of life. Despite its strengths, the study has several limitations. It lacks specific details on the types of lymphovenous anastomoses performed and complex decongestive therapy protocols, such as frequency and adherence, making reproducibility difficult. The short follow-up period of six months limits understanding of long-term efficacy, and more consistent reporting of key metrics such as weight loss and body mass index would enhance outcome assessments. This article emphasizes the importance of integrating minimally invasive surgical techniques with conservative therapies to address both the symptoms and underlying causes of lymphedema. Further research is essential to standardize protocols and refine combined treatment strategies.
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Affiliation(s)
- Aidan Shulkin
- Plastic and Reconstructive Surgery, Department of Surgery, Centre hospitalier de l’Université de Montréal, Montreal H2X3E4, Quebec, Canada
| | - Johnny I Efanov
- Plastic and Reconstructive Surgery, Department of Surgery, Centre hospitalier de l’Université de Montréal, Montreal H2X3E4, Quebec, Canada
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Zapata-Ospina A, Lopera-Muñetón C, Betancur-Bedoya SP, Ángel-Bustos IC, Vásquez-Montoya MG. Effectiveness of Lymphovenular Anastomosis and Complex Decongestive Therapy for the Treatment of Lymphedema in Patients with Breast Cancer: A Systematic Review. Lymphat Res Biol 2024; 22:232-240. [PMID: 39320336 DOI: 10.1089/lrb.2024.0014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/26/2024] Open
Abstract
Background: Lymphedema is a common breast cancer side effect, with an average incidence of 30%. The gold standard conservative treatment for lymphedema is complex decongestive therapy (CDT), which includes manual lymphatic drainage, compression therapy, skin care, and exercise. Lymphovenular anastomosis (LVA) is a microsurgical technique that intends to redirect excess lymphatic fluid to the venous circulation; this procedure is usually performed when conservative treatment fails. Therefore, the objective of this study is to evaluate the effectiveness of LVA and CDT for the treatment of breast cancer-related lymphedema (BCRL). Methods and Results: The search was performed in CENTRAL, MEDLINE, Embase, PsycINFO, SCOPUS, and LILACS. Inclusion criteria were (1) population: women with BCRL; (2) intervention: treated with LVA and CDT; and (3) outcome: primary outcome was lymphedema reduction. Secondary outcome was quality of life. Risk of bias and quality of study reporting were also assessed. The search found 3872 articles, with 5 articles meeting the PICO (population, intervention, comparison, outcomes) criteria, 4 pre-post studies, and one observational cohort study. The total sample included 2763 patients. Follow-up was variable. The follow-up varies from 7.8 to 120 months, with an average of 35 months. Lymphedema reduction was obtained in the five studies. Conclusion: The present systematic review suggests that for patients with lymphedema secondary to breast cancer, the combination of both treatments is effective in reducing the size of the limb and improving quality of life. Low-quality evidence was found for both limb circumference reduction and quality of life. Additional research effort is needed to reduce bias and improve the quality of evidence, in order to better inform clinical practice and enhance the care and well-being of patients with BCRL.
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Affiliation(s)
- Alejandro Zapata-Ospina
- Lymphatic Surgeon at Hospital Pablo Tobón Uribe, Research Center Plastic Surgery and Supermicrosurgery, Hospital Pablo Tobón Uribe, Medellín, Colombia
| | - Catalina Lopera-Muñetón
- School of Physiotherapy, Research center (FISIOTER), Fundación Universitaria María Cano, Medellín, Colombia
| | - Silvia P Betancur-Bedoya
- School of Physiotherapy, Research center (FISIOTER), Fundación Universitaria María Cano, Medellín, Colombia
| | - Isabel C Ángel-Bustos
- School of Physiotherapy, Research center (FISIOTER), Fundación Universitaria María Cano, Medellín, Colombia
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Lee SO, Kim IK. Molecular pathophysiology of secondary lymphedema. Front Cell Dev Biol 2024; 12:1363811. [PMID: 39045461 PMCID: PMC11264244 DOI: 10.3389/fcell.2024.1363811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Accepted: 06/20/2024] [Indexed: 07/25/2024] Open
Abstract
Lymphedema occurs as a result of lymphatic vessel damage or obstruction, leading to the lymphatic fluid stasis, which triggers inflammation, tissue fibrosis, and adipose tissue deposition with adipocyte hypertrophy. The treatment of lymphedema is divided into conservative and surgical approaches. Among surgical treatments, methods like lymphaticovenular anastomosis and vascularized lymph node transfer are gaining attention as they focus on restoring lymphatic flow, constituting a physiologic treatment approach. Lymphatic endothelial cells form the structure of lymphatic vessels. These cells possess button-like junctions that facilitate the influx of fluid and leukocytes. Approximately 10% of interstitial fluid is connected to venous return through lymphatic capillaries. Damage to lymphatic vessels leads to lymphatic fluid stasis, resulting in the clinical condition of lymphedema through three mechanisms: Inflammation involving CD4+ T cells as the principal contributing factor, along with the effects of immune cells on the VEGF-C/VEGFR axis, consequently resulting in abnormal lymphangiogenesis; adipocyte hypertrophy and adipose tissue deposition regulated by the interaction of CCAAT/enhancer-binding protein α and peroxisome proliferator-activated receptor-γ; and tissue fibrosis initiated by the overactivity of Th2 cells, leading to the secretion of profibrotic cytokines such as IL-4, IL-13, and the growth factor TGF-β1. Surgical treatments aimed at reconstructing the lymphatic system help facilitate lymphatic fluid drainage, but their effectiveness in treating already damaged lymphatic vessels is limited. Therefore, reviewing the pathophysiology and molecular mechanisms of lymphedema is crucial to complement surgical treatments and explore novel therapeutic approaches.
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Finkelstein ER, Clark M, Ha M, Singh D, Xu KY, Mella-Catinchi J, Rasko Y. Lymphedema Surgical Education and Faculty Demographics in United States Plastic Surgery Residency Programs. J Reconstr Microsurg 2024; 40:348-356. [PMID: 37751881 DOI: 10.1055/a-2182-1315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Abstract
BACKGROUND Recent advancements in supermicrosurgery and promising preliminary outcomes have led to a surge in physiologic lymphedema surgery. This study is the first to evaluate lymphedema surgical education among U.S. plastic surgery residency programs, along with the background and experience of plastic surgeons subspecializing in the field. METHODS Cross-sectional evaluation of 103 accredited U.S. plastic surgery residency programs was performed in January 2023. Web-based searches of program curricula, faculty profiles, and main institutional pages indicated whether a program provided nonclinical or clinical exposure to lymphedema surgery. Review of online faculty profiles, surname searches, Doximity, and Scopus determined the perceived demographics, academic productivity, and procedures performed by lymphedema surgeons. RESULTS Compared with the 11 programs that incorporated lymphedema surgery into their online curriculum, 67 programs had a rotation site with a surgeon performing lymphedema procedures. Of the 33 programs without evidence of clinical exposure, 76% (n = 25) did not provide or specify providing elective time. Faculty perceived to be female or a race underrepresented in plastic surgery had significantly more assistant professor titles (p < 0.0214) and significantly fewer years of experience (p < 0.0293) than their counterparts. CONCLUSION Great variation in lymphedema surgical education exists among U.S. plastic surgery residency programs. While few programs incorporate lymphedema surgery into their advertised curriculum, programs without clinical exposure frequently did not provide elective time to obtain it. Faculty that were female or a race underrepresented in plastic surgery were most often early in their career, suggesting lymphedema surgeons may grow increasingly diverse in years to come.
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Affiliation(s)
- Emily R Finkelstein
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Meaghan Clark
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Michael Ha
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | - Devinder Singh
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Kyle Y Xu
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Juan Mella-Catinchi
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Yvonne Rasko
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Maryland Medical Center, Baltimore, Maryland
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Dionyssiou D, Nguyen D, Topalis A, Deptula P, Paukshto M, Zaitseva T, Demiri E, Cheva A, Rockson S. Treatment of Rat Lymphedema by Propeller Lymphatic Tissue Flap Combined with Nanofibrillar Collagen Scaffolds. J Reconstr Microsurg 2024; 40:145-155. [PMID: 37142251 DOI: 10.1055/a-2086-0269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
BACKGROUND The aim of our study was to evaluate a new propeller vascularized lymphatic tissue flap (pVLNT) combined with aligned nanofibrillar collagen scaffolds (CS) (BioBridge) in reducing lymphedema in the rat lymphedema model. METHODS Unilateral left hindlimb lymphedema was created in 15 female Sprague-Dawley rats following inguinal and popliteal lymph nodes (LN) resection and radiation. An inguinal pVLNT was elevated from the contralateral groin and transferred through a skin tunnel to the affected groin. Four collagen threads were attached to the flap and inserted in the hindlimb at the subcutaneous level in a fan shape. The three study groups consisted of group A (control), group B (pVLNT), and group C (pVLNT + CS). Volumetric analysis of both hindlimbs was performed using micro-computed tomography imaging before the surgery (at initial time point) and then at 1 and 4 months, postoperatively, and the relative volume difference (excess volume) was measured for each animal. Lymphatic drainage was assessed by indocyanine green (ICG) fluoroscopy for number and morphology of new collectors and the time required for ICG to move from injection point to the midline. RESULTS Four months after the induction of lymphedema, an increased relative volume difference remained in group A (5.32 ± 4.74%), while there was a significant relative volume reduction in group B (-13.39 ± 8.55%) and an even greater reduction in group C (-14.56 ± 5.04%). ICG fluoroscopy proved the functional restoration of lymphatic vessels and viability of pVLNT in both B and C groups. Notably, only group C demonstrated statistically significant improvements in lymphatic pattern/morphology and in the number of lymphatic collectors as compared with the control group A. CONCLUSION The pedicle lymphatic tissue flap combined with SC is an effective procedure for the treatment of lymphedema in rats. It can be easily translated into treatment of humans' lower and upper limb lymphedema and further clinical studies are warranted.
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Affiliation(s)
- Dimitrios Dionyssiou
- Department of Plastic Surgery, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dung Nguyen
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Stanford, California
| | - Anastasios Topalis
- Department of Plastic Surgery, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Peter Deptula
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Stanford, California
| | | | | | - Efterpi Demiri
- Department of Plastic Surgery, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Angeliki Cheva
- Laboratory of Pathology, Medical School, Aristotle University, Thessaloniki, Greece
| | - Stanley Rockson
- Center for Lymphatic and Venous Disorders, Stanford University School of Medicine, Stanford, California
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Rafn BS, Bodilsen A, von Heymann A, Lindberg MJ, Byllov S, Andreasen TG, Johansen C, Christiansen P, Zachariae R. Examining the efficacy of treatments for arm lymphedema in breast cancer survivors: an overview of systematic reviews with meta-analyses. EClinicalMedicine 2024; 67:102397. [PMID: 38152415 PMCID: PMC10751832 DOI: 10.1016/j.eclinm.2023.102397] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 12/07/2023] [Accepted: 12/11/2023] [Indexed: 12/29/2023] Open
Abstract
Background Lymphedema affects one in six breast cancer survivors making it a global healthcare challenge. There is considerable debate about the efficacy of different treatments for lymphedema. We aimed to summarize the current evidence for treatments for lymphedema in breast cancer survivors. Methods In this overview of systematic reviews with meta-analyses (SRMAs), five databases were searched for SRMAs of randomised controlled trials (RCTs) reporting effects of medications, surgery, exercise, laser therapy, acupuncture, kinesio taping, or complex decongestive physiotherapy (CDP) for breast cancer-related lymphedema published from database inception up to March 7, 2023. Data extraction was performed for the SRMAs and RCTs, and SRMAs were appraised with AMSTAR2. Random effects meta-analyses of the RCTs provided estimates of the pooled effects sizes (Hedges' g) for each treatment modality. This study is registered with PROSPERO, CRD42020184813. Findings 1569 studies were identified by the search and eighteen SRMAs with 51 RCTs were included, investigating manual lymphatic drainage (MLD), compression pump, exercise, kinesio taping, laser, and acupuncture. Overall, the methodological quality of the SRMAs was low. SRMAs reached different conclusions for all treatment modalities, except for kinesio taping where the two SRMAs found no effect. The analysis of 40 RCTs with 1970 participants revealed a small effect across all interventions compared to any control (g = 0.20, p = 0.047, I2 = 0.79), corresponding to volume reductions of 119.7 ml (95% CI 135-104) and 88.0 ml (95% CI 99-77) in the intervention and control groups, respectively, and a small effect of exercise (g = 0.26, p = 0.022, I2 = 0.44). The between-group differences in volume reduction were small and did not reach statistical significance for any one treatment modality. Interpretation Based on the available data, there is no evidence of superiority of any one treatment on volume reduction nor any solid research refuting these treatments. Thus, definitive conclusions to inform clinical practice about the efficacy of these treatments cannot be drawn. Due to poor-quality evidence, more research is needed to untangle the efficacy of each treatment component for different stages of lymphedema. Funding Danish Cancer Society.
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Affiliation(s)
- Bolette Skjødt Rafn
- Cancer Survivorship and Treatment Late Effects (CASTLE) - Danish Cancer Society National Research Center, Department of Oncology, Copenhagen University Hospital Rigshospitalet, Denmark
| | | | - Annika von Heymann
- Cancer Survivorship and Treatment Late Effects (CASTLE) - Danish Cancer Society National Research Center, Department of Oncology, Copenhagen University Hospital Rigshospitalet, Denmark
| | | | - Sofia Byllov
- Danish Breast Cancer Group Center and Clinic for Late Effects (DCCL), Aarhus University Hospital, Aarhus, Denmark
- Department of Plastic and Breast Surgery, Aarhus University Hospital, Denmark
| | - Tine Ginnerup Andreasen
- Danish Breast Cancer Group Center and Clinic for Late Effects (DCCL), Aarhus University Hospital, Aarhus, Denmark
- Department of Plastic and Breast Surgery, Aarhus University Hospital, Denmark
| | - Christoffer Johansen
- Cancer Survivorship and Treatment Late Effects (CASTLE) - Danish Cancer Society National Research Center, Department of Oncology, Copenhagen University Hospital Rigshospitalet, Denmark
| | - Peer Christiansen
- Danish Breast Cancer Group Center and Clinic for Late Effects (DCCL), Aarhus University Hospital, Aarhus, Denmark
- Department of Plastic and Breast Surgery, Aarhus University Hospital, Denmark
| | - Robert Zachariae
- Danish Breast Cancer Group Center and Clinic for Late Effects (DCCL), Aarhus University Hospital, Aarhus, Denmark
- Unit for Psycho-oncology and Health Psychology, Department of Oncology, Aarhus University Hospital, and Department of Psychology and Behavioural Sciences, Aarhus University, Denmark
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Rochlin DH, Sheckter CC, Brazio PS, Coriddi MR, Dayan JH, Mehrara BJ, Matros E. Commercial Insurance Rates and Coding for Lymphedema Procedures: The Current State of Confusion and Need for Consensus. Plast Reconstr Surg 2024; 153:245-255. [PMID: 37092977 PMCID: PMC11240848 DOI: 10.1097/prs.0000000000010591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2023]
Abstract
BACKGROUND Surgical treatment of lymphedema has outpaced coding paradigms. In the setting of ambiguity regarding coding for physiologic procedures [lymphovenous bypass (LVB) and vascularized lymph node transplant (VLNT)], we hypothesized that there would be variation in commercial reimbursement based on coding pattern. METHODS The authors performed a cross-sectional analysis of 2021 nationwide hospital pricing data for 21 CPT codes encompassing excisional (direct excision, liposuction), physiologic (LVB, VLNT), and ancillary (lymphangiography) procedures. Within-hospital ratios (WHRs) and across-hospital ratios (AHRs) for adjusted commercial rates per CPT code quantified price variation. Mixed effects linear regression modeled associations of commercial rate with public payer (Medicare and Medicaid), self-pay, and chargemaster rates. RESULTS A total of 270,254 commercial rates, including 95,774 rates for physiologic procedures, were extracted from 2863 hospitals. Lymphangiography codes varied most in commercial price (WHR, 1.76 to 3.89; AHR, 8.12 to 44.38). For physiologic codes, WHRs ranged from 1.01 (VLNT; free omental flap) to 3.03 (LVB; unlisted lymphatic procedure), and AHRs ranged from 5.23 (LVB; lymphatic channel incision) to 10.36 (LVB; unlisted lymphatic procedure). Median adjusted commercial rates for excisional procedures ($3635.84) were higher than for physiologic procedures ($2560.40; P < 0.001). Commercial rate positively correlated with Medicare rate for all physiologic codes combined, although regression coefficients varied by code. CONCLUSIONS Commercial payer-negotiated rates for physiologic procedures were highly variable both within and across hospitals, reflective of variation in CPT codes. Physiologic procedures may be undervalued relative to excisional procedures. Consistent coding nomenclature should be developed for physiologic and ancillary procedures.
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Affiliation(s)
- Danielle H. Rochlin
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center
| | - Clifford C. Sheckter
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University Medical Center
| | - Philip S. Brazio
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Cedars-Sinai Medical Center
| | - Michelle R. Coriddi
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center
| | - Joseph H. Dayan
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center
| | - Babak J. Mehrara
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center
| | - Evan Matros
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center
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Garza RM, Wong D, Chang DW. Optimizing Outcomes in Lymphedema Reconstruction. Plast Reconstr Surg 2023; 152:1131e-1142e. [PMID: 38019691 DOI: 10.1097/prs.0000000000010965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Describe current surgical techniques for treating primary and secondary lymphedema. 2. Optimize the surgical care of patients with lymphedema. SUMMARY Over the past decade, significant advances have been made in the surgical treatment of lymphedema. The most notable changes have been the reintroduction and evolution of physiologic techniques, including lymphovenous bypass-sometimes referred to as lymphovenous anastomosis in the literature-and vascularized lymph node transplant. These surgical modalities are now often used as first-line surgical options or may be combined with nonphysiologic approaches, including direct excision and suction-assisted lipectomy. Surgeons continue to debate the most appropriate sequence and combination of surgical treatment, particularly for patients at both extremes of the severity spectrum. Furthermore, debate remains around the need to apply different treatment approaches for patients with upper versus lower extremity involvement and primary versus secondary cause. In this article, we provide a summary of the surgical techniques currently used for both primary and secondary lymphedema and provide our recommendations for optimizing the surgical care of patients with lymphedema.
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Affiliation(s)
- Rebecca M Garza
- From the Section of Plastic and Reconstructive Surgery, Department of Surgery, The University of Chicago Medicine & Biological Sciences
| | - Daniel Wong
- From the Section of Plastic and Reconstructive Surgery, Department of Surgery, The University of Chicago Medicine & Biological Sciences
| | - David W Chang
- From the Section of Plastic and Reconstructive Surgery, Department of Surgery, The University of Chicago Medicine & Biological Sciences
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Tedeschi R. Biomechanical alterations in lower limb lymphedema: Implications for walking ability and rehabilitation. Phlebology 2023; 38:496-502. [PMID: 37413662 DOI: 10.1177/02683555231188236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/08/2023]
Abstract
BACKGROUND Lymphedema is a chronic progressive disease that results in interstitial edema in the limbs, and to a lesser extent in the genitals and face, due to damage to the lymphatic system. METHODS Research was conducted between July 2022 and September 2022 in biomedical databases: PubMed, Cochrane Central Register of Controlled Trials (Cochrane Library), and PEDro. RESULTS Two studies showed that lymphedema alters gait parameters by affecting mainly kinematic parameters, although kinetic parameters were found to be significantly altered, especially in patients with severe lymphedema. In other studies, using methods such as videos and questionnaires, difficulties in walking were found in the presence of lymphedema. The most common abnormality was antalgic gait. CONCLUSIONS Poor mobility can worsen the edema, which, in turn, can compromise joint range of motion. Gait analysis is an essential tool to evaluate and follow.
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Affiliation(s)
- Roberto Tedeschi
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
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Wan R, Hussain A, Kuruoglu D, Houdek MT, Moran SL. Prophylactic lymphaticovenous anastomosis (LVA) for preventing lymphedema after sarcoma resection in the lower limb: A report of three cases and literature review. Microsurgery 2023; 43:273-280. [PMID: 36226524 DOI: 10.1002/micr.30975] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 07/14/2022] [Accepted: 09/30/2022] [Indexed: 11/09/2022]
Abstract
Patients with soft tissue tumors of the lower extremities are at greater risk to develop postoperative disruption of lymphatic vessels. Currently, there is no widely effective cure for lymphatic dysfunction. Therefore, the best strategy is to prevent it and reconstruct efficient drainage as soon as the original pathway is damaged. We present a report of three prophylactic LVA cases after sarcoma resection in the lower limb, and a literature review to show the feasibility of prophylactic LVAs. The patients were 35, 73, and 77 years old, respectively, at the time of the procedure. All three patients had sarcoma in the medial thigh and underwent radiation therapy before the surgery. The locations of the LVAs include the medial thigh and medial and lateral calf. During the surgery, methylene blue and/or indocyanine green were injected to identify lymphatic vessels. Postoperative recovery was uneventful immediately after the surgery. At follow-up visits, all three patients reported improved functions with no significant swelling in the lower limb. One patient experienced a surgical wound infection that resolved after antibiotic admission. Two patients had a history of cardiac diseases, a major risk factor for developing postoperative lymphedema, but these two patients did not develop lymphedema with the treatment of prophylactic LVAs. These results suggest that prophylactic LVA may be an effective strategy to prevent secondary lymphedema after sarcoma resection. Further investigation is warranted.
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Affiliation(s)
- Rou Wan
- Division of Plastic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Arif Hussain
- Division of Plastic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Doga Kuruoglu
- Division of Plastic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Matthew T Houdek
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Steven L Moran
- Division of Plastic Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Seth I, Bulloch G, Gibson D, Seth N, Hunter-Smith DJ, Rozen WM. Quantification and Effectiveness of Vascularized Neck Lymph Node Transfer for Lymphedema: a Systematic Review and Meta-Analysis. Indian J Surg 2022. [DOI: 10.1007/s12262-022-03627-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Li M, Guo J, Zhao R, Gao JN, Li M, Wang LY. Sun-burn induced upper limb lymphedema 11 years following breast cancer surgery: A case report. World J Clin Cases 2022; 10:11987-11992. [PMID: 36405268 PMCID: PMC9669845 DOI: 10.12998/wjcc.v10.i32.11987] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 09/02/2022] [Accepted: 10/11/2022] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Upper arm lymphedema is a common complication one year after breast cancer surgery, which profoundly impacts patients' quality of life.
CASE SUMMARY We reported a case of lymphedema induced by prolonged sun exposure 11 years after breast cancer surgery.
CONCLUSION Breast screening, patient education and follow-up after hospital discharge could help to prevent upper-arm lymphedema.
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Affiliation(s)
- Min Li
- Department of Breast Surgery, Shanxi Bethune Hospital, Shanxi Academy of Medical Science, Taiyuan 030032, Shanxi Province, China
| | - Jun Guo
- Department of Breast Surgery, Shanxi Bethune Hospital, Shanxi Academy of Medical Science, Taiyuan 030032, Shanxi Province, China
| | - Rong Zhao
- Department of Breast Surgery, Shanxi Bethune Hospital, Shanxi Academy of Medical Science, Taiyuan 030032, Shanxi Province, China
| | - Jin-Nan Gao
- Department of Breast Surgery, Shanxi Bethune Hospital, Shanxi Academy of Medical Science, Taiyuan 030032, Shanxi Province, China
| | - Ming Li
- Department of Cancer Research Institute, University of South Australia, Adelaide 5000, Australia
| | - Lin-Ying Wang
- Department of Breast Surgery, Shanxi Bethune Hospital, Shanxi Academy of Medical Science, Taiyuan 030032, Shanxi Province, China
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Verhey EM, Kandi LA, Lee YS, Morris BE, Casey WJ, Rebecca AM, Marks LA, Howard MA, Teven CM. Outcomes of Lymphovenous Anastomosis for Lower Extremity Lymphedema: A Systematic Review. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2022; 10:e4529. [PMID: 36225843 PMCID: PMC9542573 DOI: 10.1097/gox.0000000000004529] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 07/27/2022] [Indexed: 06/16/2023]
Abstract
UNLABELLED Lymphovenous anastomosis (LVA) is a microsurgical treatment for lymphedema of the lower extremity (LEL). This study systematically reviews the most recent data on outcomes of various LVA techniques for LEL in diverse patients. METHODS A comprehensive literature search was conducted in the Ovid MEDLINE, Ovid EMBASE, and Scopus databases to extract articles published through June 2021. Studies reporting data on objective postoperative improvement in lymphedema and/or subjective improvement in quality of life for patients with LEL were included. Extracted data comprised demographics, number of patients and lower limbs, duration of symptoms before LVA, surgical technique, duration of follow-up, and objective and subjective outcomes. RESULTS A total of 303 articles were identified and evaluated, of which 74 were ultimately deemed eligible for inclusion in this study, representing 6260 patients and 2554 lower limbs. The average patient age ranged from 22.6 to 76.14 years. The duration of lymphedema before LVA ranged from 12 months to 11.4 years. Objective rates of improvement in lymphedema ranged from 23.3% to 100%, with the greatest degree of improvement seen in patients with early-stage LEL. CONCLUSIONS LVA is a safe and effective technique for the treatment of LEL of all stages. Several emerging techniques and variations may lead to improved patient outcomes.
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Affiliation(s)
- Erik M. Verhey
- From the Mayo Clinic Alix School of Medicine, Mayo Clinic, Scottsdale, Ariz
| | - Lyndsay A. Kandi
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Mayo Clinic, Phoenix, Ariz
| | - Yeonsoo S. Lee
- From the Mayo Clinic Alix School of Medicine, Mayo Clinic, Scottsdale, Ariz
| | - Bryn E. Morris
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Mayo Clinic, Phoenix, Ariz
| | - William J. Casey
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Mayo Clinic, Phoenix, Ariz
| | - Alanna M. Rebecca
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Mayo Clinic, Phoenix, Ariz
| | - Lisa A. Marks
- Mayo Clinic Libraries, Mayo Clinic, Scottsdale, Ariz
| | - Michael A. Howard
- Division of Plastic Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Chad M. Teven
- Division of Plastic Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill
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14
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Physical and Functional Outcomes of Simultaneous Vascularized Lymph Node Transplant and Lymphovenous Bypass in the Treatment of Lymphedema. Plast Reconstr Surg 2022; 150:169-180. [PMID: 35583944 DOI: 10.1097/prs.0000000000009247] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The authors analyze the outcomes of simultaneous vascularized lymph node transplant and lymphovenous bypass for treatment of primary and secondary lymphedema. To the best of their knowledge, this is the largest study to date with long-term outcome data of this novel approach. METHODS Three hundred twenty-eight patients who underwent physiologic surgical treatment over a 5.5-year period were evaluated using a prospective database and chart review. Preoperative characteristics, operative details, and postoperative outcomes (volume difference change, Lymphedema Life Impact Scale score) were assessed. Statistical analysis including multivariate regression was performed. RESULTS Two hundred twenty patients (67.1 percent) underwent simultaneous vascularized lymph node transplant and lymphovenous bypass. Mean body mass index was 26.9 ± 4.7 kg/m 2 . Ninety-two patients (41.8 percent) had lymphedema of the lower extremity, 121 (55.0 percent) had upper extremity involvement, and seven had lymphedema of upper and lower extremities (3.2 percent). Average duration of lymphedema was 95.4 ± 103.6 months. Thirty patients (13.6 percent) had primary lymphedema and 190 patients (86.4 percent) had secondary lymphedema. The majority improved and experienced volume reduction of an average 21.4 percent at 1 year ( p < 0.0001), 36.2 percent at 2 years ( p < 0.0001), 25.5 percent at 3 years ( p = 0.1), and 19.6 percent at 4 years. Median Lymphedema Life Impact Scale scores were 7.0 points lower ( p < 0.0001) at 3 months and improved progressively over time to 27.5 points lower at 3 years postoperatively ( p < 0.005). CONCLUSIONS Simultaneous vascularized lymph node transplant and lymphovenous bypass is an appropriate and effective approach for both early and advanced stages of primary and secondary lymphedema, with significant objective and subjective improvements. Volume reduction in the affected limb was observed at all time points postoperatively, with significant improvement in Lymphedema Life Impact Scale scores. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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15
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Fallahian F, Tadisina KK, Xu KY. Efficacy of Microsurgical Treatment of Primary Lymphedema: A Systematic Review. Ann Plast Surg 2022; 88:195-199. [PMID: 34398594 DOI: 10.1097/sap.0000000000002862] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Treatment of lymphedema remains a challenging clinical problem. Lymphatic surgery has recently gained momentum as an effective method to treat both early- and late-stage disease. In particular, "physiologic" microsurgical techniques including vascularized lymph node transplant and lymphovenous bypass/anastomosis have been shown to be effective in treating even advanced lymphedema. Most published reports describe techniques and success in secondary lymphedema. Traditionally, physiologic surgery was not believed to be useful in the treatment of primary lymphedema where baseline lymphatic function is abnormal. However, recent studies have shown a benefit in these cases. The objective of this study is to evaluate outcomes and complications of physiologic microsurgical treatment for primary lymphedema. METHODS The electronic databases of PubMed, Scopus, and MEDLINE were searched using key words "primary lymphedema" and "surgery" (also vascularized lymph node transplant, lymphovenous bypass, microsurgery). Only human studies published between 2000 and 2021 were included. Studies that only included ablative or resection surgeries were excluded. RESULTS A total of 10 studies comprising 254 patients with primary lymphedema who underwent 357 physiologic microsurgical operations were included. Lymphovenous bypass comprised 88% of cases, and in the patients who underwent vascularized lymph node transplant, all but 1 flap survived. Regardless of type of operative intervention, all studies showed a statistically significant improvement in lymphedema, through either reduction in limb circumference or edema volume or improvement in quality of life. DISCUSSION Physiologic lymphatic surgery has shown success and improvement for patients with primary lymphedema. Based on current literature, physiologic surgical treatment of primary lymphedema should be considered when treating this patient population.
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Affiliation(s)
| | | | - Kyle Y Xu
- Division of Plastic Surgery, University of Miami Miller School of Medicine, Miami, FL
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16
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Bolletta A, di Taranto G, Losco L, Elia R, Sert G, Ribuffo D, Cigna E, Chen HC. Combined lymph node transfer and suction-assisted lipectomy in lymphedema treatment: A prospective study. Microsurgery 2022; 42:433-440. [PMID: 34994481 DOI: 10.1002/micr.30855] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 09/22/2021] [Accepted: 11/29/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Recent studies have analyzed the combination of suction-assisted lipectomy (SAL) and vascularized lymph node transfer (VLNT) in lymphedema treatment, reporting positive outcomes. However, it is difficult to draw conclusions due to the heterogeneity of the studies. Aim of this prospective study is to evaluate the effectiveness of the combination of VLNT and SAL in lymphedema treatment. PATIENTS AND METHODS Between January 2016 and May 2019, 94 patients with upper or lower limb stage IIb-III lymphedema were enrolled and treated with the gastroepiploic VLNT followed by SAL. Patients were prospectively evaluated through circumference measurement and clinical examination, including number of episodes of cellulitis. RESULTS Among patients enrolled in the study 83 were affected by lower limb lymphedema (LLL) and 11 were affected by upper limb lymphedema (ULL). Average follow-up was 3 ± 0.8 years. In the LLL group, the mean circumference reduction rates (CRR) were 60.4, 56.9, 29.6, and 55.4% above and below the knee, above the ankle, and at the foot level, respectively. A statistically significant difference was noted at all the levels (p < .05), but above the ankle (p = .059). Regarding the ULL group, the mean CRR were 80.7, 60.7, 65.0 and 49.6% above and below the elbow, at wrist and at mid-hand, respectively. CRR were reported at all the levels but no statistical difference was noted. The number of episodes of cellulitis dropped significantly (p < .05). CONCLUSION This study supports the use of VLNT+SAL in lymphedema grades IIb-III, with important implications for the clinical practice.
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Affiliation(s)
- Alberto Bolletta
- Department of Plastic Surgery, China Medical University Hospital, Taichung, Taiwan.,Plastic Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Giuseppe di Taranto
- Department of Plastic Surgery, China Medical University Hospital, Taichung, Taiwan.,Plastic Surgery Unit, Department of surgery, Sapienza University of Rome, Italy
| | - Luigi Losco
- Department of Plastic Surgery, China Medical University Hospital, Taichung, Taiwan.,Plastic Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Rossella Elia
- Department of Plastic Surgery, China Medical University Hospital, Taichung, Taiwan.,Unit of Plastic and Reconstructive Surgery, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Gokhan Sert
- Department of Plastic Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Diego Ribuffo
- Plastic Surgery Unit, Department of surgery, Sapienza University of Rome, Italy
| | - Emanuele Cigna
- Plastic Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Hung-Chi Chen
- Department of Plastic Surgery, China Medical University Hospital, Taichung, Taiwan
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17
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Guerrini S, Gentili F, Mazzei FG, Gennaro P, Volterrani L, Mazzei MA. Magnetic resonance lymphangiography: with or without contrast? ACTA ACUST UNITED AC 2021; 26:587-595. [PMID: 33032980 DOI: 10.5152/dir.2020.19482] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Lymphedema is an important medical issue around the world, caused by an anomalous collection of fluid in soft tissue due to congenital malformations or stenosis or obstruction of lymphatic vessels. Magnetic resonance lymphangiography (MRL) is an emerging technique focused on noninvasive or minimally invasive imaging of lymphatics with the goal to diagnose and treat lymphedema. This review will briefly discuss lymphatic imaging starting with lymphography and radionuclide lymphoscintigraphy up to the newest methods, focusing on MRL, a rising technique, and highlighting the technical aspects fundamental for achieving high-resolution MRL.
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Affiliation(s)
- Susanna Guerrini
- Department of Radiological Sciences, Diagnostic Imaging, University of Siena, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Francesco Gentili
- Department of Radiological Sciences, Diagnostic Imaging, University of Siena, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Francesco Giuseppe Mazzei
- Department of Radiological Sciences, Diagnostic Imaging, University of Siena, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Paolo Gennaro
- Department of Maxillofacial Surgery, Diagnostic Imaging, University of Siena, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Luca Volterrani
- Department of Medical, Surgical and Neurosciences, Diagnostic Imaging, University of Siena, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Maria Antonietta Mazzei
- Department of Medical, Surgical and Neurosciences, Diagnostic Imaging, University of Siena, Azienda Ospedaliera Universitaria Senese, Siena, Italy
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18
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Retrograde Manual Lymphatic Drainage following Vascularized Lymph Node Transfer to Distal Recipient Sites for Extremity Lymphedema: A Retrospective Study and Literature Review. Plast Reconstr Surg 2021; 148:425e-436e. [PMID: 34432699 DOI: 10.1097/prs.0000000000008252] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Vascularized lymph node transfer is an efficacious treatment for extremity lymphedema. This study investigated the outcome of retrograde manual lymphatic drainage for vascularized lymph node transfer to distal recipient sites. METHODS Lymphedema patients who underwent either complete decongestive therapy or vascularized lymph node transfer between 2013 and 2018 were retrospectively included. Retrograde manual lymphatic drainage was started with intermittent manual compression and the assistance of a sphygmomanometer and proximal-to-distal massage of the limb 1 month postoperatively. Outcomes evaluations used the circumferential reduction rate and the Lymphedema-Specific Quality-of-Life Questionnaire. Outcomes of vascularized lymph node transfer to proximal versus distal recipient sites in the literature between 2006 and 2018 were also compared. RESULTS One hundred thirty-eight unilateral extremity lymphedema patients, including 68 patients in the complete decongestive therapy group and 70 patients in the vascularized lymph node transfer group, were included. The mean circumferential reduction rate of 38.9 ± 2.5 percent in the vascularized lymph node transfer group was statistically greater than the 13.2 ± 10.1 percent rate in the complete decongestive therapy group (p = 0.01). At a mean follow-up of 36 months, the improvement of overall Lymphedema-Specific Quality-of-Life Questionnaire score from 3.8 ± 0.3 to 7.5 ± 1.8 in the vascularized lymph node transfer group was statistically greater than that in the complete decongestive therapy group (from 4.7 ± 0.9 to 5.0 ± 1.9; p < 0.01). In total, 536 lymphedema patients who underwent 548 vascularized lymph node transfers in 23 published articles were reviewed; the distal recipient-site group was found to have more efficacious results than the proximal recipient-site group. CONCLUSION Vascularized lymph node transfer to a distal recipient site with standard retrograde manual lymphatic drainage significantly improved circumferential reduction rates and Lymphedema-Specific Quality-of-Life Questionnaire scores. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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19
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Gupta N, Verhey EM, Torres-Guzman RA, Avila FR, Jorge Forte A, Rebecca AM, Teven CM. Outcomes of Lymphovenous Anastomosis for Upper Extremity Lymphedema: A Systematic Review. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3770. [PMID: 34476159 PMCID: PMC8386908 DOI: 10.1097/gox.0000000000003770] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 06/21/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Lymphovenous anastomosis (LVA) is an accepted microsurgical treatment for lymphedema of the upper extremity (UE). This study summarizes and analyzes recent data on the outcomes associated with LVA for UE lymphedema at varying degrees of severity. METHODS A literature search was conducted in the PubMed database to extract articles published through June 19, 2020. Studies reporting data on postoperative improvement in limb circumference/volume or subjective improvement in quality of life for patients with primary or secondary lymphedema of the UE were included. Extracted data consisted of demographic data, number of patients and upper limbs, duration of symptoms before LVA, surgical technique, follow-up, and objective and subjective outcomes. RESULTS A total of 92 articles were identified, of which 16 studies were eligible for final inclusion comprising a total of 349 patients and 244 upper limbs. The average age of patients ranged from 38.4 to 64 years. The duration of lymphedema before LVA ranged from 9 months to 7 years. The mean length of follow-up ranged from 6 months to 8 years. Fourteen studies reported an objective improvement in limb circumference or volume measurements following LVA, ranging from 0% to 100%. Patients included had varying severity of lymphedema, ranging from Campisi stage I to IV. The maximal improvement in objective measurements was found in patients with lower stage lymphedema. CONCLUSION LVA is a safe, effective technique for the treatment of UE lymphedema refractory to decompressive treatment. Results of LVA indicate greater efficacy in earlier stages of lymphedema before advanced lymphatic sclerosis.
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Affiliation(s)
- Nikita Gupta
- From the Mayo Clinic Alix School of Medicine, Scottsdale, Ariz
| | - Erik M. Verhey
- University of Notre Dame, Department of Biological Sciences, Notre Dame, Ind
| | - Ricardo A. Torres-Guzman
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Mayo Clinic, Jacksonville, Fla
| | - Francisco R. Avila
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Mayo Clinic, Jacksonville, Fla
| | - Antonio Jorge Forte
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Mayo Clinic, Jacksonville, Fla
| | - Alanna M. Rebecca
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Mayo Clinic, Jacksonville, Fla
| | - Chad M. Teven
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Mayo Clinic, Phoenix, Ariz
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20
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Jiga LP, Campisi CC, Jandali Z, Ryan M, Maruccia M, Santecchia L, Cherubino M, Georgiadis J. Role of the Cadaver Lab in Lymphatic Microsurgery Education: Validation of a New Training Model. J INVEST SURG 2021; 35:758-767. [PMID: 34157922 DOI: 10.1080/08941939.2021.1937756] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Microsurgical transplantation of vascularized lymph nodes (VLNT) or lymphatic vessels (VLVT) alongside derivative lymphaticovenous procedures are promising approaches for treatment of lymphedema. However, clinically relevant training models for mastering these techniques are still lacking. Here we describe a new training model in human cadaver and validate its use as training tool for microsurgical lymphatic reconstruction. METHODS 10 surgeons with previous exposure to microsurgery were trained in a controlled environment. Lymphatic vessel mapping and dissection in 4 relevant body regions, harvesting of five different VLNTs and one VLVT were performed in 5 fresh-frozen cadavers. The number of lymphatic vessels and lymph nodes for each VLNT were recorded. Finally, the efficacy of this model as training tool was validated using the Dundee Ready Education Environment Measure (DREEM). RESULTS The average cumulative DREEM score over each category was 30,75 (max = 40) while individual scoring for each relevant category revealed highly positive ratings from the perspective of teaching (39,3), training 40,5 (max = 48) and self perception of the training 30,5 (max = 32) from all participants. The groin revealed the highest number of lymphatic vessels (3.2 ± 0.29) as all other regions on the upper extremity, while the gastroepiploic VLNT had the highest number of lymph nodes (4.2 ± 0.37). CONCLUSIONS This human cadaver model represents a new, reproducible "all-in-one" tool for effective training in lymphatic microsurgery. Its unique diligence in accurately reproducing human lymphatic anatomy, should make this model worth considering for each microsurgeon willing to approach lymphatic reconstruction.
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Affiliation(s)
- Lucian P Jiga
- Department for Plastic, Aesthetic, Reconstructive and Hand Surgery, Evangelic Hospital, Oldenburg, Germany
| | - Corrado C Campisi
- Department of Surgery, Plastic, Reconstructive and Aesthetic Surgery, ICLAS, GVM Care & Research, Genoa, Italy
| | - Zaher Jandali
- Department for Plastic, Aesthetic, Reconstructive and Hand Surgery, Evangelic Hospital, Oldenburg, Germany
| | - Melissa Ryan
- Faculty of Medicine and Surgery, University of Pavia, Pavia, Italy
| | - Michele Maruccia
- Division of Plastic and Reconstructive Surgery, Department of Emergency and Organ Transplantation, "Aldo Moro" University, Bari, Italy
| | - Luigino Santecchia
- Orthopaedic Unit of Palidoro, Bambino Gesù Children's Hospital Research Institute, Rome, Italy
| | - Mario Cherubino
- Microsurgery and Hand Surgery Unit" ASST Sette Laghi, University of Insumbria, Varese, Italy
| | - Janniko Georgiadis
- Department Biomedical Cell & Systems, University Medical Center Groningen, Groningen, The Netherlands
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21
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Tang NSJ, Ramakrishnan A, Shayan R. Quality-of-life outcomes after operative management of primary and secondary lymphoedema: a systematic review. ANZ J Surg 2021; 91:2624-2636. [PMID: 33825306 DOI: 10.1111/ans.16764] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 02/27/2021] [Accepted: 03/06/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Lymphoedema is an incurable and progressive disease that affects not only physical function but overall quality of life. Surgical treatment options for the management of lymphoedema are being increasingly performed. This study aims to review post-operative health-related quality of life (HRQOL) following surgical treatment of lymphoedema. METHODS A systematic search of the PubMed and Medline databases was performed from the date of their inception until September 2018 to evaluate HRQOL following different surgical options for the treatment of lymphoedema. RESULTS One hundred and thirteen articles were identified. Twenty-one articles were included in the final review, comprising a total of 736 patients. HRQOL improvements appear to be sustained for at least 6-12 months post-operatively. In particular, major benefits were noted in the domains based around physical functioning. Patient satisfaction similarly mirrors HRQOL improvements, following an initial dip in the immediate post-operative period. CONCLUSION All surgical treatment modalities for the management of lymphoedema confer significant HRQOL improvements across a diverse range of health domains, with this critical outcome of surgery an important pre-operative consideration. Recommendations for ongoing research are suggested.
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Affiliation(s)
- Nicholas S J Tang
- Department of Plastic and Reconstructive Surgery, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Anand Ramakrishnan
- Department of Plastic and Reconstructive Surgery, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Surgery, The Royal Melbourne Hospital, The University of Melbourne, Melbourne, Victoria, Australia
| | - Ramin Shayan
- Department of Surgery, The Royal Melbourne Hospital, The University of Melbourne, Melbourne, Victoria, Australia
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22
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Abstract
ZusammenfassungDas Lymphödem ist eine multifaktorielle Erkrankung, die durch Ödem, interstitielle Fibrose und, im späteren Verlauf, durch Fettgewebsablagerungen charakterisiert ist. Das klinische Erscheinungsbild variiert je nach Stadium und geht mit unterschiedlich großen physischen, psychologischen und sozioökonomischen Einschränkungen einher.Ein Lymphödem kann sowohl primär aufgrund genetisch bedingter abnormer Entwicklungsabläufe auftreten als auch sekundär als Folge von Trauma, Bestrahlung oder Infektion. Die Unterscheidung in primäres und sekundäres Lymphödem gibt dabei neben der Ursache auch Rückschlüsse über die zu erwartenden Erfolgsaussichten einer mikrochirurgischen Intervention.In der plastischen und rekonstruktiven Chirurgie kann durch zweierlei Verfahren eine Verbesserung des Krankheitsbildes erzielt werden. Einerseits durch ablative Verfahren, wie beispielsweise die Liposuktion oder Resektion von überschüssigem Gewebe, und andererseits durch physiologische, mikro- und supermikrochirurgische Techniken zur Wiederherstellung des Lymphabtransportes, wie beispielsweise die vaskularisierte Lymphknotentransplantation („vascularized lymph node transfer“, VLNT) und die Anlage lymphovenöser Anastomosen (LVA).
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Affiliation(s)
- Ines E. Tinhofer
- Plastische und Rekonstruktive Chirurgie, Abteilung für Chirurgie, Göttlicher-Heiland-Krankenhaus
| | - Johannes Steinbacher
- Plastische und Rekonstruktive Chirurgie, Abteilung für Chirurgie, Göttlicher-Heiland-Krankenhaus
| | - Chieh-Han J. Tzou
- Plastische und Rekonstruktive Chirurgie, Abteilung für Chirurgie, Göttlicher-Heiland-Krankenhaus
- TZOU MEDICAL, Lymphödemzentrum Wien
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23
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Karlsson T, Karlsson M, Ohlin K, Olsson G, Brorson H. Liposuction of Breast Cancer-Related Arm Lymphedema Reduces Fat and Muscle Hypertrophy. Lymphat Res Biol 2021; 20:53-63. [PMID: 33656374 PMCID: PMC8892987 DOI: 10.1089/lrb.2020.0120] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background: Adipose tissue deposition is a known consequence of lymphedema. A previous study showed that the affected arm in patients with nonpitting breast cancer-related lymphedema (BCRL) had a mean excess volume of 73% fat and 47% muscle. This condition impairs combined physiotherapy as well as more advanced microsurgical methods. Liposuction is, therefore, a way of improving the effects of treatment. This study aims to evaluate the tissue changes in lymphedematous arms after liposuction and controlled compression therapy (CCT) in patients with nonpitting BCRL. Methods and Results: Eighteen women with an age of 61 years and a duration of arm lymphedema (BCRL) of 9 years were treated with liposuction and CCT. Tissue composition of fat, lean (muscle), and bone mineral was analyzed through dual energy X-ray absorptiometry (DXA) before, and at 3 and 12 months after surgery. Excess volumes were also measured with plethysmography. The median DXA preoperative excess volume was 1425 mL (704 mL fat volume, 651 mL lean volume). The DXA excess volume at 3 months after surgery was 193 mL (−196 mL fat volume, 362 mL lean volume). At 12 months after surgery, the median excess DXA volume was 2 mL (−269 mL fat volume, 338 mL lean volume). From before surgery to 3 months after surgery, the median DXA excess volume reduced by 85% (p < 0.001) (fat volume reduction 128% (p < 0.001), lean volume reduction 37% (p = 0.016)). From before surgery to 12 months after surgery, it reduced by 100% (p < 0.001) (fat volume reduction 139% [p < 0.001], lean volume reduction 54% [p = 0.0013]). Conclusions: Liposuction and CCT effectively remove the excess fat in patients with nonpitting BCRL, and a total reduction of excess arm volume is achievable. A postoperative decrease in excess muscle volume is also seen, probably due to the reduced weight of the arm postoperatively.
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Affiliation(s)
- Tobias Karlsson
- Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Magnus Karlsson
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Clinical and Molecular Osteoporosis Research Unit, Department of Orthopedics, Skåne University Hospital, Malmö, Sweden
| | - Karin Ohlin
- Department of Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, Sweden
| | - Gaby Olsson
- Department of Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, Sweden
| | - Håkan Brorson
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, Sweden
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24
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Vignes S, Albuisson J, Champion L, Constans J, Tauveron V, Malloizel J, Quéré I, Simon L, Arrault M, Trévidic P, Azria P, Maruani A. Primary lymphedema French National Diagnosis and Care Protocol (PNDS; Protocole National de Diagnostic et de Soins). Orphanet J Rare Dis 2021; 16:18. [PMID: 33407666 PMCID: PMC7789008 DOI: 10.1186/s13023-020-01652-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 12/19/2020] [Indexed: 11/10/2022] Open
Abstract
Primary lymphedema is a rare chronic pathology associated with constitutional abnormalities of the lymphatic system. The objective of this French National Diagnosis and Care Protocol (Protocole National de Diagnostic et de Soins; PNDS), based on a critical literature review and multidisciplinary expert consensus, is to provide health professionals with an explanation of the optimal management and care of patients with primary lymphedema. This PNDS, written by consultants at the French National Referral Center for Primary Lymphedema, was published in 2019 (https://has-sante.fr/upload/docs/application/pdf/2019-02/pnds_lymphoedeme_primaire_final_has.pdf).
Primary lymphedema can be isolated or syndromic (whose manifestations are more complex with a group of symptoms) and mainly affects the lower limbs, or, much more rarely, upper limbs or external genitalia. Women are more frequently affected than men, preferentially young. The diagnosis is clinical, associating mild or non-pitting edema and skin thickening, as confirmed by the Stemmer’s sign (impossibility to pinch the skin on the dorsal side or the base of the second toe), which is pathognomonic of lymphedema. Limb lymphoscintigraphy is useful to confirm the diagnosis. Other causes of swelling or edema of the lower limbs must be ruled out, such as lipedema. The main acute lymphedema complication is cellulitis (erysipelas). Functional and psychological repercussions can be major,
deteriorating the patient’s quality of life. Treatment aims to prevent those complications, reduce the volume with low-stretch bandages, then stabilize it over the long term by exercises and wearing a compression garment. Patient education (or parents of a child) is essential to improve observance.
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Affiliation(s)
- Stéphane Vignes
- Department of Lymphology and Reference Center for Rare Vascular Diseases, Cognacq-Jay Hospital, 15, rue Eugène-Millon, 75015, Paris, France.
| | | | - Laurence Champion
- Department of Nuclear Medicine, René Huguenin-Curie Hospital, 35, rue Dailly, 92210, Saint-Cloud, France
| | - Joël Constans
- Department of Vascular Medicine, Saint-André Hospital, CHU de Bordeaux, 1, rue Jean-Burguet, 33000, Bordeaux, France
| | - Valérie Tauveron
- Department of Dermatology and Reference Center for Rare Diseases and Vascular Malformations (MAGEC), CHRU Tours, 37044, Tours Cedex 9, France
| | - Julie Malloizel
- Department of Vascular Medicine, Rangueil Hospital, 1, avenue du Pr Jean-Poulhès, 31059, Toulouse, France
| | - Isabelle Quéré
- Department of Vascular Medicine and Reference Center for Rare Vascular Diseases, CHU Montpellier, 80, avenue Augustin-Fliche, 34090, Montpellier, France
| | - Laura Simon
- Department of Lymphology and Reference Center for Rare Vascular Diseases, Cognacq-Jay Hospital, 15, rue Eugène-Millon, 75015, Paris, France
| | - Maria Arrault
- Department of Lymphology and Reference Center for Rare Vascular Diseases, Cognacq-Jay Hospital, 15, rue Eugène-Millon, 75015, Paris, France
| | | | - Philippe Azria
- Department of Internal Medicine, Saint-Joseph Hospital, 185, rue Raymond-Losserand, 75014, Paris, France
| | - Annabel Maruani
- Department of Dermatology and Reference Center for Rare Diseases and Vascular Malformations (MAGEC), CHRU Tours, 37044, Tours Cedex 9, France.,INSERM 1246 - SPHERE, Universities of Tours and Nantes, 37000, Tours, France
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25
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Cellina M, Gibelli D, Martinenghi C, Soresina M, Menozzi A, Giardini D, Oliva G. Noncontrast Magnetic Resonance Lymphography in Secondary Lymphedema Due to Prostate Cancer. Lymphat Res Biol 2020; 19:355-361. [PMID: 33290157 DOI: 10.1089/lrb.2020.0034] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: As survival from malignancies continues to improve, a greater emphasis is being placed on the quality of life after cancer treatments. Lymphedema (LE) represents a common and devastating sequela of neoplastic therapies, even if its incidence in patients submitted to lymphadenectomy for prostatic cancer is still poorly documented. The purpose of the current study was to analyze the imaging findings provided by noncontrast magnetic resonance (MR) lymphography in secondary lower limb LE related to prostate cancer therapies. Methods and Results: Patients with diagnosed secondary LE related to prostatic cancer treatment who underwent noncontrast MR lymphography (NCMRL) between November 2019 and February 2020 were assessed. Image datasets were retrospectively reviewed for the severity of lymphedema and characteristics of the subcutaneous tissue, muscular compartment appearance, number of iliac and inguinal lymphatics, and number of locoregional lymph nodes. Ten patients with 17 affected lower extremities, nine right extremities, and eight left extremities were included in our analysis. Magnetic resonance imaging grading was classified as one in four extremities, two in five extremities, and three in eight lower extremities. Honeycomb pattern was observed in 15 extremities, without significant correlation with MR grading (p = 0.684); dermal thickening showed correlation with MR grading (p < 0.001), as well as reduction of muscular trophism (p = 0.021). We observed a significant correlation between the number of inguinal lymph nodes and recognizable inguinal lymphatics (p = 0.039). Conclusion: NCMRL is able to provide useful information for the management of secondary lower limb LE caused by prostate cancer treatments. Clinical Trials.gov ID: n.2019/ST/187.
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Affiliation(s)
- Michaela Cellina
- Department of Radiology, Ospedale Fatebenefratelli, ASST Fatebenefratelli Sacco, Milan, Italy.,Lymphedema Center, Nursing Home "La Madonnina", Milan, Italy
| | - Daniele Gibelli
- Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Milan, Italy
| | | | - Massimo Soresina
- Lymphedema Center, Nursing Home "La Madonnina", Milan, Italy.,Department of Plastic Surgery, Ospedale Fatebenefratelli, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Andrea Menozzi
- Lymphedema Center, Nursing Home "La Madonnina", Milan, Italy.,Department of Plastic Surgery, Ospedale Fatebenefratelli, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Denisa Giardini
- Lymphedema Center, Nursing Home "La Madonnina", Milan, Italy
| | - Giancarlo Oliva
- Department of Radiology, Ospedale Fatebenefratelli, ASST Fatebenefratelli Sacco, Milan, Italy
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Abstract
Physiologic surgical interventions, including lymphovenous bypass (LVB) and vascularized lymph node transplant (VLNT), are increasingly being used to treat lymphedema. LVB has been shown to be effective in improving the severity of lymphedema, particularly for patients with still-functional superficial lymphatic vessels that can be identified for bypass. However, in many patients, there is a paucity of functional lymphatic vessels for bypass and, thus, they are not ideal candidates for LVB alone. Unlike LVB, VLNT does not depend on the presence of functioning lymphatic vessels, but the effects of VLNT are delayed, as the proposed mechanisms of action require more time for optimal function. The author has offered a combined approach to microsurgical treatment of lymphedema for both the upper and lower extremities. Simultaneous VLNT and LVB are safe and effective for patients with both early and advanced stages of primary and secondary lymphedema. Our experience shows that a majority of patients can expect some long-term improvement, in both overall limb volume and quality of life, after surgical intervention with LVB and/or VLNT.
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Affiliation(s)
- David W Chang
- Section of Plastic and Reconstructive Surgery, Department of Surgery, The University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
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27
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Correlation of ICG lymphography and lymphoscintigraphy severity stage in secondary upper limb lymphedema. J Plast Reconstr Aesthet Surg 2020; 73:1982-1988. [DOI: 10.1016/j.bjps.2020.08.055] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 06/08/2020] [Accepted: 08/01/2020] [Indexed: 11/23/2022]
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Frueh FS, Jelvani B, Scheuer C, Körbel C, Kim BS, Giovanoli P, Lindenblatt N, Harder Y, Ampofo E, Menger MD, Laschke MW. Short-term molecular and cellular effects of ischemia/reperfusion on vascularized lymph node flaps in rats. PLoS One 2020; 15:e0239517. [PMID: 33021999 PMCID: PMC7537894 DOI: 10.1371/journal.pone.0239517] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Accepted: 09/08/2020] [Indexed: 11/26/2022] Open
Abstract
Vascularized lymph node (VLN) transfer is an emerging strategy to re-establish lymphatic drainage in chronic lymphedema. However, the biological processes underlying lymph node integration remain elusive. This study introduces an experimental approach facilitating the analysis of short-term molecular and cellular effects of ischemia/reperfusion on VLN flaps. Lymph node flaps were dissected pedicled on the lateral thoracic vessels in 44 Lewis rats. VLN flaps were exposed to 45 or 120 minutes ischemia by in situ clamping of the vascular pedicle with subsequent reperfusion for 24 hours. Flaps not exposed to ischemia/reperfusion served as controls. Lymph nodes and the perinodal adipose tissue were separately analyzed by Western blot for the expression of lymphangiogenic and angiogenic growth factors. Moreover, morphology, microvessel density, proliferation, apoptosis and immune cell infiltration of VLN flaps were further assessed by histology and immunohistochemistry. Ischemia for 120 minutes was associated with a markedly reduced cellularity of lymph nodes but not of the perinodal adipose tissue. In line with this, ischemic lymph nodes exhibited a significantly lower microvessel density and an increased expression of VEGF-D and VEGF-A. However, VEGF-C expression was not upregulated. In contrast, analyses of the perinodal adipose tissue revealed a more subtle decrease of microvessel density, while only the expression of VEGF-D was increased. Moreover, after 120 minutes ischemia, lymph nodes but not the perinodal adipose tissue exhibited significantly higher numbers of proliferating and apoptotic cells as well as infiltrated macrophages and neutrophilic granulocytes compared with non-ischemic flaps. Taken together, lymph nodes of VLN flaps are highly susceptible to ischemia/reperfusion injury. In contrast, the perinodal adipose tissue is less prone to ischemia/reperfusion injury.
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Affiliation(s)
- Florian S. Frueh
- Institute for Clinical and Experimental Surgery, Saarland University, Homburg, Saar, Germany
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- * E-mail:
| | - Bijan Jelvani
- Institute for Clinical and Experimental Surgery, Saarland University, Homburg, Saar, Germany
| | - Claudia Scheuer
- Institute for Clinical and Experimental Surgery, Saarland University, Homburg, Saar, Germany
| | - Christina Körbel
- Institute for Clinical and Experimental Surgery, Saarland University, Homburg, Saar, Germany
| | - Bong-Sung Kim
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Pietro Giovanoli
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Nicole Lindenblatt
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Yves Harder
- Department of Plastic, Reconstructive and Aesthetic Surgery, Ente Ospedaliero Cantonale (EOC), Lugano, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana (USI), Lugano, Switzerland
| | - Emmanuel Ampofo
- Institute for Clinical and Experimental Surgery, Saarland University, Homburg, Saar, Germany
| | - Michael D. Menger
- Institute for Clinical and Experimental Surgery, Saarland University, Homburg, Saar, Germany
| | - Matthias W. Laschke
- Institute for Clinical and Experimental Surgery, Saarland University, Homburg, Saar, Germany
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Ramachandran S, Chew KY, Tan BK, Kuo YR. Current operative management and therapeutic algorithm of lymphedema in the lower extremities. Asian J Surg 2020; 44:46-53. [PMID: 32950353 DOI: 10.1016/j.asjsur.2020.08.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 08/16/2020] [Accepted: 08/19/2020] [Indexed: 10/23/2022] Open
Abstract
Lymphedema is defined as the abnormal accumulation of interstitial fluid in subcutaneous tissues resulting from cancer, cancer treatment (surgery and/or radiotherapy), infection, inflammatory disorders, obesity, and hereditary syndromes. Surgical management of lymphedema can be broadly classified into two categories, reductive surgical techniques such as direct excision, suction assisted protein lipectomy (SAPL) or radical reduction with perforator preservation (RRPP); and physiological surgical procedures such as lymphaticovenous anastomosis (LVA) and vascularised lymph node transfer (VLNT). These techniques and their various combinations were evaluated. The results revealed patients with reversible lymphedema (ISL stage I, mild severity) benefit most from physiological procedures (LVA or VLNT) which can reduce the chance of disease progression to the chronic, solid phase. Reductive techniques such as SAPL, RPPP, or direct excision procedures should be reserved for patients with advanced - severe lymphedema (ISL stages II and especially stage III) as the surgical treatment of choice. In this study, current literature on the surgical treatment of lower extremity lymphedema is reviewed and discussed in conjunction with authors' clinical experiences. An algorithm is presented, based on clinical evidence and experience which aims to provide a structured approach to managing lower limb lymphedema.
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Affiliation(s)
- Savitha Ramachandran
- Department of Plastic and Reconstructive Surgery, Singapore General Hospital, Singapore
| | - Khong-Yik Chew
- Department of Plastic and Reconstructive Surgery, Singapore General Hospital, Singapore
| | - Bien-Keem Tan
- Department of Plastic and Reconstructive Surgery, Singapore General Hospital, Singapore
| | - Yur-Ren Kuo
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Biological Sciences, National Sun Yat-sen University, Kaohsiung, Taiwan; SingHealth Duke-NUS Musculoskeletal Sciences Academic Clinical Programme, Singapore.
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Yildirim MEC, Chen SH, Weng HC, Mousavi SA, Chen HC. Treatment of toes as an integrated part of infection control for advanced lower limb lymphedema. J Plast Reconstr Aesthet Surg 2020; 74:168-173. [PMID: 32900654 DOI: 10.1016/j.bjps.2020.08.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 04/02/2020] [Accepted: 08/01/2020] [Indexed: 11/17/2022]
Abstract
The aim of this study was to compare the incidence of infection and verrucous hyperkeratosis in patients who underwent surgery for advanced lymphedema according to the algorithm designed by the senior author, and were treated concurrently with/without toe treatment. A case series (Between 2004-2015) of 46 patients with unilateral advanced lower limb lymphedema was reviewed. Lymphoscintigraphy was used for evaluation of lymphedema severity. The ICG lymphography was used for staging. Fibrosis and skin induration were reflected by the tonicity. They were divided into two groups: (1) patients who underwent further treatment of toes according to the algorithm, and (2) patients who did not have toe-related treatment. Infection episodes and verrucous hyperkeratosis were recorded. There were 21 and 25 patients in Groups 1 and 2, respectively. All lymphoscintigrams showed severe dermal backflow with severe stagnation by 2.5 h after injection of Tc-99 colloid. All patients were stage IV or V. Tonicity values of skin were <60. Group 1 was reduced to an average of 0.6 episodes per year in the past year of follow-up, and Group 2 was reduced to an average of 1.5 episodes per year in the past year of follow-up (p <0.001). The average frequency of preoperative cellulitis was 3.6 episodes per year. The occurrence of verrucous hyperkeratosis was observed in 14.3% and 32% of Groups 1 and 2, respectively. The incidences of cellulitis and verrucous hyperkeratosis were significantly lower in Group 1 than in Group 2 (p <0.001). To achieve successful control of infection, they should be treated carefully according to the strategy described above.
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Affiliation(s)
| | - Shih-Heng Chen
- Department of Plastic Surgery, Chang Gung Memorial Hospital, Taipei, Taiwan.
| | - Hui-Ching Weng
- Institute of Gerontology, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | | | - Hung Chi Chen
- Department of Plastic Surgery, China Medical University Hospital, Taichung, Taiwan.
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31
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Treatment of Post-mastectomy Lymphedema with Herbal Medicine: An Innovative Pilot Study. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2915. [PMID: 32766062 PMCID: PMC7339371 DOI: 10.1097/gox.0000000000002915] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 04/21/2020] [Indexed: 11/25/2022]
Abstract
Background Lymphedema of the arms or legs is a difficult clinical problem yet devoid of effective treatment. Lymphedema is the result of obstructed lymphatic flow secondary to chronic infection, parasitic infestation, or postsurgical obstruction (eg, after axillary dissections). We arranged this clinical trial to investigate whether patients with limb lymphedema can benefit from a standard dose of Astragalus plus Paeoniae rubra to improve the symptomatology, functional capacity, and quality of life (QOL). Method The pilot study was designed as a self-control clinical trial. Patients with post-mastectomy lymphedema were recruited. A double-herb formulation (Astragalus, Paeoniae rubra) with standard dosage was administered orally in a powdered form, 6 times per week for 6 months. Outcome measurements included standard limb volume changes measured by water displacement method; handgrip strength; and QOL for limb lymphedema questionnaire (LYMQOL). Results There were no reported adverse effects or complications; there were no episodes of infection during the period of study. There was a tendency of limb volume reduction by 6 months, which, however, did not reach statistical significance. There was a significant improvement in appearance and symptom scores as was assessed with the LYMQOL questionnaire. Conclusions The oral herbal formula improved the symptomatology and QOL among the pilot group of patients with post-mastectomy lymphedema. Side effects were absent, and there was a trend of lymphedema reduction.
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32
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Wang D, Lyons D, Skoracki R. Lymphedema: Conventional to Cutting Edge Treatment. Semin Intervent Radiol 2020; 37:295-308. [PMID: 32773955 DOI: 10.1055/s-0040-1713447] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Lymphedema of the extremities related to oncologic therapies such as cancer surgery, radiation therapy, and chemotherapy is a major long-term cause of morbidity for cancer patients. Both nonsurgical and surgical management strategies have been developed. The goals of these therapies are to achieve volume reduction of the affected extremity, a reduction in patient symptoms, and a reduction in associated morbidities such as recurrent soft-tissue infections. In this article, we review both nonsurgical and surgical management strategies. Traditional surgical therapy has focused on more ablative techniques such as the Charles procedure and suction-assisted lipectomy/liposuction. However, newer more physiologic surgical methods such as lymphovenous anastomoses and vascularized lymph node transfers have become a more common treatment modality for the management of this complex problem.
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Affiliation(s)
- Duane Wang
- Department of Plastic Surgery, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Daniel Lyons
- Department of Plastic Surgery, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Roman Skoracki
- Department of Plastic Surgery, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio
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33
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Yoon JA, Shin MJ, Kim JH. Indocyanine Green Lymphography and Lymphoscintigraphy Severity Stage Showed Strong Correlation in Lower Limb Lymphedema. Lymphat Res Biol 2020; 19:80-85. [PMID: 32721268 DOI: 10.1089/lrb.2020.0043] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: To examine the correlation between lymphedema severity on lymphoscintigraphy and indocyanine green (ICG) lymphography in patients with secondary lower extremity lymphedema. Methods and Results: The maximal circumference difference (MCD) between the two legs was recorded. Lymphoscintigraphy and ICG lymphography images were classified into type I to V according to dermal backflow (DB) stage and MD Anderson Cancer Center (MDACC) stage based on lymphatic flow preservation and how DB was extended. Correlation between the scales was analyzed. Forty-four patients attended our hospital for evaluation of secondary lower extremity lymphedema. The most common cause of lymphedema was a postoperative complication of a malignant tumor (32 patients; 72.5%). Correlation analysis showed that lymphoscintigraphy and ICG DB (anterior) stage (r = 0.92), lymphoscintigraphy and ICG DB (posterior) stage (r = 0.94), and lymphoscintigraphy and MDACC stage (r = 0.93) exhibited very strong positive correlations. Intrarater agreement between lymphoscintigraphy and ICG DB (posterior) stage was substantial (κ = 0.65), and moderate between lymphoscintigraphy and ICG DB (anterior) stage (κ = 0.59) and lymphoscintigraphy and MDACC stage (κ = 0.52). Lymphedema severity stages and MCDs exhibited moderate positive correlations. Conclusion: Lymphoscintigraphy and ICG lymphography stage were strongly and positively correlated. These studies can work synergistically as complementary studies of lymphedema severity.
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Affiliation(s)
- Jin A Yoon
- Department of Rehabilitation Medicine, Pusan National University School of Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Myung Jun Shin
- Department of Rehabilitation Medicine, Pusan National University School of Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Joo Hyoung Kim
- Department of Plastic and Reconstructive Surgery, Busan Cancer Center, Pusan National University Hospital and Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
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Ngo QD, Munot S, Mackie H, Czerniec S, Koelmeyer LA, Lam T, Heydon-White A, Suami H, Boyages J. Vascularized Lymph Node Transfer for Patients with Breast Cancer-Related Lymphedema Can Potentially Reduce the Burden of Ongoing Conservative Management. Lymphat Res Biol 2020; 18:357-364. [PMID: 31944882 DOI: 10.1089/lrb.2019.0048] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Vascularized lymph node transfer (VLNT) microsurgery is conducted in selected specialist lymphatic programs as a surgical treatment option for breast cancer-related lymphedema (BCRL) with variation in treatment outcomes. Methods and Results: Ten patients with BCRL underwent VLNT from 2012 to 2015. Donor sites were the inguinal (n = 6) or supraclavicular fossa/neck (n = 4) regions and recipient sites were the axilla (n = 6) or elbow regions (n = 4). Outcomes included changes in limb volume and extracellular fluid ratios, postoperative garment use, number of cellulitis episodes, and self-reported symptom improvement. At a mean follow-up of 46 months from surgery (range: 28-66 months), the excess volume in the affected arm had reduced (n = 4) or remained stable (n = 1) for 5 of 10 patients (50%) (mean change: -106.4 mL, range: -515.5 to +69.6 mL). Four of these five patients had also reduced (n = 3) or discontinued (n = 1) wearing compression garments and three reported a reduction in episodes of cellulitis. The remaining five patients had an increase of over 100 mL in postoperative excess volume (mean change: 295.8 mL, range: 142.1-382.8 mL). Three of these five patients reported noncompliance with compression garments. Despite the increase in limb volume, some patients reported softness in swelling (n = 3) and better response to conservative treatment (n = 1). Conclusion: Our results warrant continuation of VLNT as a surgical treatment option for patients with BCRL and show that the burden of conservative management such as wearing garments can be reduced over time for some patients. Longer term follow-up with standardized measures across all centers is required to further investigate VLNT.
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Affiliation(s)
- Quan D Ngo
- Australian Lymphoedema Education Research and Treatment (ALERT), Macquarie University Faculty of Medicine and Health Sciences, Sydney, Australia
| | - Sonali Munot
- Australian Lymphoedema Education Research and Treatment (ALERT), Macquarie University Faculty of Medicine and Health Sciences, Sydney, Australia
| | - Helen Mackie
- Australian Lymphoedema Education Research and Treatment (ALERT), Macquarie University Faculty of Medicine and Health Sciences, Sydney, Australia.,Mt. Wilga Rehabilitation Hospital, Hornsby, Australia
| | - Sharon Czerniec
- Australian Lymphoedema Education Research and Treatment (ALERT), Macquarie University Faculty of Medicine and Health Sciences, Sydney, Australia
| | - Louise A Koelmeyer
- Australian Lymphoedema Education Research and Treatment (ALERT), Macquarie University Faculty of Medicine and Health Sciences, Sydney, Australia
| | - Thomas Lam
- Australian Lymphoedema Education Research and Treatment (ALERT), Macquarie University Faculty of Medicine and Health Sciences, Sydney, Australia
| | - Asha Heydon-White
- Australian Lymphoedema Education Research and Treatment (ALERT), Macquarie University Faculty of Medicine and Health Sciences, Sydney, Australia
| | - Hiroo Suami
- Australian Lymphoedema Education Research and Treatment (ALERT), Macquarie University Faculty of Medicine and Health Sciences, Sydney, Australia
| | - John Boyages
- Australian Lymphoedema Education Research and Treatment (ALERT), Macquarie University Faculty of Medicine and Health Sciences, Sydney, Australia
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35
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Miller A. [Lymphedema-clinical picture and therapy]. Hautarzt 2020; 71:32-38. [PMID: 31912161 DOI: 10.1007/s00105-019-04523-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Local edema is a common symptom in many skin diseases, especially in inflammatory or allergic reactions. Diseases of the lymphatic system can also lead to edema with specific changes in the skin. Lymphedema is the result of primary genetic changes, which can also occur in the context of syndromes and can be traced to abnormal development of the lymphatic system. Secondary lymphedema usually develops after surgery, inflammatory reactions or chronic venous insufficiency (CVI). The microfiltrate that is transported in the tissue in healthy individuals via the lymphatic system is rich in proteins and induces fibrosis of the epidermis and dermis. In addition to edema, clinical signs include pachydermia, papillomatosis cutis lymphostatica, hyperkeratosis, lymph cysts, lymph fistulas, nail dystrophies and yellow nails. Basic therapy comprises complex decongestive therapy (CDT: manual lymph drainage, compression, physical exercise/sports, skin care and instructions regarding self-management). Intermittent compression can also be applied. Comorbidities such as obesity and diabetes mellitus may aggravate the situation and must be treated. Adequate therapy can reduce sequelae of the skin.
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Affiliation(s)
- Anya Miller
- Praxis für Dermatologie, Allergologie, Phlebologie, Lymphologie, Wilmersdorfer Str. 62, 10627, Berlin, Deutschland.
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Rickard J, Beilman G, Forrester J, Sawyer R, Stephen A, Weiser TG, Valenzuela J. Surgical Infections in Low- and Middle-Income Countries: A Global Assessment of the Burden and Management Needs. Surg Infect (Larchmt) 2019; 21:478-494. [PMID: 31816263 DOI: 10.1089/sur.2019.142] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background: The burden of surgical infections in low- and middle-income countries (LMICs) remains poorly defined compared with high-income countries. Although there are common infections necessitating surgery prevalent across the world, such as appendicitis and peptic ulcer disease, other conditions are more localized geographically. To date, comprehensive assessment of the burden of surgically treatable infections or sequelae of surgical infections in LMICs is lacking. Methods: We reviewed the literature to define the burden of surgical infections in LMICs and characterize the needs and challenges of addressing this issue. Results: Surgical infections comprise a broad range of diseases including intra-abdominal, skin and soft tissue, and healthcare-associated infections and other infectious processes. Treatment of surgical infections requires a functional surgical ecosystem, microbiology services, and appropriate and effective antimicrobial therapy. Systems must be developed and maintained to evaluate screening, prevention, and treatment strategies. Solutions and interventions are proposed focusing on reducing the burden of disease, improving surveillance, strengthening antibiotic stewardship, and enhancing the management of surgical infections. Conclusions: Surgical infections constitute a large burden of disease globally. Challenges to management in LMICs include a shortage of trained personnel and material resources. The increasing rate of antimicrobial drug resistance, likely related to antibiotic misuse, adds to the challenges. Development of surveillance, infection prevention, and antimicrobial stewardship programs are initial steps forward. Education is critical and should begin early in training, be an active process, and be sustained through regular programs.
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Affiliation(s)
- Jennifer Rickard
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Gregory Beilman
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Joseph Forrester
- Department of Surgery, Stanford University, Stanford, California, USA
| | - Robert Sawyer
- Department of Surgery, Homer Stryker MD School of Medicine, Western Michigan University, Kalamazoo, Michigan, USA
| | - Andrew Stephen
- Department of Surgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Thomas G Weiser
- Department of Surgery, Stanford University, Stanford, California, USA
| | - Julie Valenzuela
- Department of Surgery, Northwell Health, New Hyde Park, New York, USA
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Gianesini S, Obi A, Onida S, Baccellieri D, Bissacco D, Borsuk D, Campisi C, Campisi CC, Cavezzi A, Chi YW, Chunga J, Corda D, Crippa A, Davies A, De Maeseneer M, Diaz J, Ferreira J, Gasparis A, Intriago E, Jawien A, Jindal R, Kabnick L, Latorre A, Lee BB, Liew NC, Lurie F, Meissner M, Menegatti E, Molteni M, Morrison N, Mosti G, Narayanan S, Pannier F, Parsi K, Partsch H, Rabe E, Raffetto J, Raymond-Martimbeau P, Rockson S, Rosukhovski D, Santiago FR, Schul A, Schul M, Shaydakov E, Sibilla MG, Tessari L, Tomaselli F, Urbanek T, van Rijn MJ, Wakefield T, Wittens C, Zamboni P, Bottini O. Global guidelines trends and controversies in lower limb venous and lymphatic disease: Narrative literature revision and experts' opinions following the vWINter international meeting in Phlebology, Lymphology & Aesthetics, 23-25 January 2019. Phlebology 2019; 34:4-66. [PMID: 31495256 DOI: 10.1177/0268355519870690] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Guidelines are fundamental in addressing everyday clinical indications and in reporting the current evidence-based data of related scientific investigations. At the same time, a spatial and temporal issue can limit their value. Indeed, variability in the recommendations can be found both among the same nation different scientific societies and among different nations/continents. On the other side, Garcia already published in 2014 data showing how, after three years in average, one out of five recommendations gets outdated (Martinez Garcia LM, Sanabria AJ, Garcia Alvarez E, et al. The validity of recommendations from clinical guidelines: a survival analysis. CMAJ 2014;186(16):1211–1219). The present document reports a narrative literature revision on the major international recommendations in lower limb venous and lymphatic disease management, focusing on the different countries’ guidelines, trends and controversies from all the continents, while identifying new evidence-based data potentially influencing future guidelines. World renowned experts’ opinions are also provided. The document has been written following the recorded round tables scientific discussions held at the vWINter international meeting (22–26 January 2019; Cortina d’Ampezzo, Italy) and the pre- and post-meeting literature search performed by the leading experts.
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Affiliation(s)
| | - Andrea Obi
- 2 University of Michigan, Ann Arbor, MI, USA
| | | | | | | | - Denis Borsuk
- 6 Clinic of Phlebology and Laser Surgery, 'Vasculab' Ltd, Chelyabinsk, Russia
| | | | | | - Attilio Cavezzi
- 9 Eurocenter Venalinfa, San Benedetto del Tronto (AP), Italy
| | - Yung-Wei Chi
- 10 University of California, Davis Vascular Center, Sacramento, CA, USA
| | | | | | | | | | | | - Josè Diaz
- 15 Vanderbilt University Medical Center, Nashville, TN, USA
| | - Julio Ferreira
- 16 Instituto Brasilerio de Flebologia, Sao Paulo, Brazil
| | | | | | - Arkadiusz Jawien
- 19 Collegium Medicum, University of Nicolaus Copernicus, Bydgoszcz, Poland
| | | | | | | | | | - N C Liew
- 24 Putra University, Serdang, Malaysia
| | - Fedor Lurie
- 25 Jobst Vascular Institute, Toledo, OH, USA
| | | | | | | | | | | | | | | | - Kurosh Parsi
- 32 St. Vincent's Hospital, University of NSW, Sydney, Australia
| | | | | | | | | | - Stanley Rockson
- 37 Stanford University School of Medicine, Stanford, CA, USA
| | | | | | | | | | | | | | | | | | | | | | | | - Cees Wittens
- 44 Maastricht University Medical Center, Maastricht, Netherlands.,45 Uniklinik Aachen, Aachen, Germany
| | | | - Oscar Bottini
- 46 Universidad de Buenos Aires, Buenos Aires, Argentina
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Kraft CT, Eiferman D, Jordan S, Skoracki RJ. Complications after vascularized jejunal mesenteric lymph node transfer: A 3-year experience. Microsurgery 2019; 39:497-501. [PMID: 31283856 DOI: 10.1002/micr.30491] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Revised: 05/25/2019] [Accepted: 06/10/2019] [Indexed: 11/07/2022]
Abstract
BACKGROUND Vascularized lymph node transfer (VLNT) is a well-established method for the surgical management of refractory extremity lymphedema. Generally, donor lymph nodes are harvested from the axilla, groin, or supraclavicular area. However, these sites offer their own disadvantages and introduce risk for inducing lymphedema at the surgical donor site. In our experience, the jejunal mesentery can be an excellent source of lymph nodes without the risk of donor site lymphedema. Long term complications are unknown for this procedure; we report our experience, complication rates, and lessons learned. METHODS A retrospective review was performed for all patients at our institution undergoing surgical treatment of lymphedema using jejunal mesenteric VLNT from February 2015 to February 2018. Demographic data, length of follow up, and surgical complications were reviewed. RESULTS Twenty-nine patients have undergone jejunal VLNT at our institution during the three-year study period, with a total of 30 transfers. Five patients had a concurrent omental lymph node transfer. Average length of follow up was 17.6 months (range 1.0-36.8 months). There was one flap loss in this time frame (3.3%). Four patients developed hernias post-operatively (13.8%), and three had nonoperative small bowel obstructions (10.3%). One patient had a postoperative wound infection at the abdominal incision (3.4%). CONCLUSIONS Jejunal VLNT can be an effective option for surgical treatment of lymphedema, without the risk of postoperative donor site lymphedema. Patients and surgeons should be aware of the risks of hernia and small bowel obstruction with this method compared to other lymph node sources.
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Affiliation(s)
- Casey T Kraft
- Department of Plastic Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Daniel Eiferman
- Department of General Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Sumanas Jordan
- Department of Plastic Surgery, Northwestern University, Chicago, Illinois
| | - Roman J Skoracki
- Department of Plastic Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio
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Phillips GS, Gore S, Ramsden A, Furniss D. Lymphaticovenular anastomosis in the treatment of secondary lymphoedema of the legs after cancer treatment. J Plast Reconstr Aesthet Surg 2019; 72:1184-1192. [DOI: 10.1016/j.bjps.2019.03.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 02/11/2019] [Accepted: 03/10/2019] [Indexed: 11/27/2022]
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A Systematic Review of Outcomes After Genital Lymphedema Surgery: Microsurgical Reconstruction Versus Excisional Procedures. Ann Plast Surg 2019; 83:e85-e91. [PMID: 31135508 DOI: 10.1097/sap.0000000000001875] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Genital lymphedema (GL) surgery can be either palliative or functional. Palliative procedures involve excision of the affected tissue and reconstruction by either local flaps or skin grafts. Reconstructive procedures aim to restore lymphatic flow through microsurgical lymphaticovenous anastomoses (LVAs). This systematic analysis of outcomes and complication rates aims to compare outcomes between these surgical treatment options for GL. METHODS A systematic review of the PubMed database was performed with the following search algorithm: (lymphorrhea or lymphedema) and (genital or scrotal or vulvar) and (microsurgery or "surgical treatment"), evaluating outcomes, and complications after surgical treatment of GL. RESULTS Twenty studies published between 1980 and 2016 met the inclusion criteria (total, 151 patients). Three main surgical treatments for GL were identified. Surgical resection and primary closure or skin graft was the most common procedure (46.4%) with a total complication rate of 10%. Surgical resection and flap reconstruction accounted for 39.1% of the procedures with an overall complication rate of 54.2%. Lympho venous shunt (LVA) procedures (14.5%) had a total complication rate of 9%. CONCLUSIONS This review demonstrates a lack of consensus in both the preoperative assessment and surgical management of GL. Patients receiving excisional procedures tended to be later stage lymphedema. Patients in the excision and flap reconstruction group seemed to have the highest complication rates. Microsurgical LVAs may represent an alternative approach to GL, either alone or in combination with traditional procedures.
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Ciudad P, Sabbagh MD, Agko M, Huang TCT, Manrique OJ, L CR, Reynaga C, Delgado R, Maruccia M, Chen HC. Surgical Management of Lower Extremity Lymphedema: A Comprehensive Review. Indian J Plast Surg 2019; 52:81-92. [PMID: 31456616 PMCID: PMC6664851 DOI: 10.1055/s-0039-1688537] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Lymphedema refers to the accumulation of protein-rich fluid in the interstitial spaces. This can occur secondary to congenital malformation of the lymphatic channels or nodes or as a result of an insult that damages appropriately formed channels and nodes. Stagnant, protein-rich lymph initiates an inflammatory response that leads to adipocyte proliferation, fibrous tissue deposition, and increased susceptibility to infections. The end result is permanent disfigurement and dermal changes. Early and accurate diagnosis is essential, since lymphedema is a chronic and progressive problem. When lymphedema affects the lower extremity, it is important to manage it in a way that preserves function and mobility. Early diagnosis also allows for a proactive rather than reactive approach to treatment and utilization of novel physiologic procedures, such as lymphovenous anastomosis and vascularized lymph node transfer. Such interventions slow down disease progression and reduce morbidity by allowing the surgeon to salvage the remaining functional lymphatic channels. When physiologic procedures fail or when faced with a delayed presentation, the addition of excisional procedures can provide a more comprehensive treatment of this debilitating disease. The aim of this article is to review the most current concepts in the surgical management of lower extremity lymphedema.
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Affiliation(s)
- Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru.,Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - M Diya Sabbagh
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota, United Sates
| | - Mouchammed Agko
- Section of Plastic Surgery, Medical College of Georgia, Augusta University, Augusta, Georgia
| | - Tony C T Huang
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota, United Sates
| | - Oscar J Manrique
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota, United Sates
| | - Carmen Román L
- Department of Physical and Rehabilitation Medicine, National Cancer Institute of Peru (INEN), Lima, Peru
| | - Cesar Reynaga
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Ricardo Delgado
- Department of Plastic and Reconstructive Surgery, National Cancer Institute of Peru (INEN), Lima, Peru
| | - Michele Maruccia
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Hung-Chi Chen
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
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Markkula SP, Leung N, Allen VB, Furniss D, Cochrane Breast Cancer Group. Surgical interventions for the prevention or treatment of lymphoedema after breast cancer treatment. Cochrane Database Syst Rev 2019; 2:CD011433. [PMID: 30779124 PMCID: PMC6379660 DOI: 10.1002/14651858.cd011433.pub2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Breast cancer is the most common type of cancer amongst women worldwide, and one distressing complication of breast cancer treatment is breast and upper-limb lymphoedema. There is uncertainty regarding the effectiveness of surgical interventions in both the prevention and management of lymphoedema affecting the arm after breast cancer treatment. OBJECTIVES 1. To assess and compare the efficacy of surgical interventions for the prevention of the development of lymphoedema (LE) in the arm after breast cancer treatment.2. To assess and compare the efficacy of surgical interventions for the treatment of established LE in the arm after breast cancer treatment. SEARCH METHODS We searched the Cochrane Breast Cancer Group's Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the WHO International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov for all prospectively registered and ongoing trials on 2 November 2017. Reference lists of included studies were also handsearched by three review authors for additional eligible trials. SELECTION CRITERIA All randomised controlled trials (RCTs) comparing a surgical intervention for the prevention or treatment of lymphoedema of the arm after breast cancer treatment to either standard intervention, placebo intervention, or another surgical intervention were included. Patients of both sexes and all ages who have had treatment for their breast cancer were considered. No limits were applied to language or study location. Three authors independently determined the eligibility of each study. DATA COLLECTION AND ANALYSIS Three authors independently extracted data for each included study using a pre-designed data extraction pro forma and used Cochrane's 'risk of bias' tool for assessing risk of bias. Dichotomous variables were analysed using the Mantel-Haenszel method to estimate risk ratios (RRs). Differences in continuous variables were expressed as mean differences (MDs). GRADE was used to assess the certainty of the evidence provided by the included studies. MAIN RESULTS Two studies involving 95 participants examined surgical interventions for preventing breast cancer-related lymphoedema. Both studies evaluated the efficacy of the lymphaticovenular anastomosis technique as part of a preventative management protocol. Both studies were deemed to be at unclear risk of bias overall. Statistical variation between the studies was low, which increases the reliability of the evidence. However, the two studies were conducted in the same centre. Lymphaticovenular anastomosis appears to result in a reduction in the incidence of lymphoedema compared to nonoperative management with a risk ratio of 0.20 (95% CI 0.06 to 0.63, P = 0.006; 95 participants; low-certainty evidence). The RCTs did not evaluate any of the secondary outcomes.One study involving 36 participants evaluated the effectiveness of vascularised lymph node transfer for treating breast cancer-related lymphoedema. The trial was deemed to be at unclear risk of bias. For participants suffering from stage 2 lymphoedema, the evidence suggested reductions in limb volume (MD -39.00%, 95% CI -47.37% to -30.63%, very low-certainty evidence), pain scores (MD -4.16, 95% CI -5.17 to -3.15, very low-certainty evidence), heaviness sensation (MD -4.27, 95% CI -5.74 to -2.80, very low-certainty evidence), mean number of infections/year (MD -1.22, 95% CI -2.00 to -0.44, very low-certainty evidence), and an improvement in overall function scores (MD -3.77, 95% CI -4.89 to -2.65, very low-certainty evidence) for those who had undergone vascularised lymph node transfer compared to those who had undergone no treatment. AUTHORS' CONCLUSIONS There is low-certainty evidence that lymphaticovenular anastomosis is effective in preventing the development of lymphoedema after breast cancer treatment based on the findings from two studies. One study providing very low-certainty evidence found that vascularised lymph node transfer is an efficacious option in the treatment of established stage 2 lymphoedema related to breast cancer. Important secondary outcomes in this review were rarely reported in the included studies. More high-quality RCTs are required to further elucidate the effectiveness of surgical interventions in the prevention and treatment of lymphoedema after breast cancer treatment. At the time of this review, no ongoing trials on this topic were identified.
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Affiliation(s)
- Silja P Markkula
- Helsinki University HospitalDepartment of Plastic SurgeryPL 266HelsinkiFinlandFIN‐00029 HUS
| | | | - Victoria B Allen
- St. Thomas' HospitalDepartment of InfectionWestminster Bridge RoadLondonUKSE1 7EH
| | - Dominic Furniss
- NDORMS, Oxford UniversityBotnar Research CentreWindmill RoadOxfordOxfordshireUKOX3 7HF
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Rationale for Study of the Deep Subfascial Lymphatic Vessels During Lymphoscintigraphy for the Diagnosis of Peripheral Lymphedema. Clin Nucl Med 2019; 44:91-98. [DOI: 10.1097/rlu.0000000000002400] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ciudad P, Manrique OJ, Adabi K, Huang TCT, Agko M, Trignano E, Chang WL, Chen TW, Salgado CJ, Chen HC. Combined double vascularized lymph node transfers and modified radical reduction with preservation of perforators for advanced stages of lymphedema. J Surg Oncol 2019; 119:439-448. [DOI: 10.1002/jso.25360] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 11/19/2018] [Accepted: 12/16/2018] [Indexed: 01/18/2023]
Affiliation(s)
- Pedro Ciudad
- Department of Plastic and Burn Surgery; Arzobispo Loayza National Hospital; Lima Peru
- Department of Plastic and Reconstructive Surgery; National Cancer Institute of Peru (INEN); Lima Peru
- Department of Plastic and Reconstructive Surgery; China Medical University; Taichung Taiwan
| | - Oscar J Manrique
- Division of Plastic and Reconstructive Surgery; Mayo Clinic; Rochester Minnesota
| | - Kian Adabi
- Division of Plastic and Reconstructive Surgery; Mayo Clinic; Rochester Minnesota
| | | | - Mouchammed Agko
- Department of Plastic Surgery; Medical College of Georgia; Augusta University; Augusta Georgia
| | - Emilio Trignano
- Department of Plastic and Reconstructive Surgery; China Medical University; Taichung Taiwan
| | - Wei-Ling Chang
- Department of Plastic and Reconstructive Surgery; China Medical University; Taichung Taiwan
| | - Tsung-Wei Chen
- Department of Pathology; China Medical University; Taichung Taiwan
| | - Christopher J. Salgado
- Division of Plastic, Reconstructive and Aesthetic Surgery; University of Miami Miller School of Medicine; Miami Florida
| | - Hung-Chi Chen
- Department of Plastic and Reconstructive Surgery; China Medical University; Taichung Taiwan
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Kataru RP, Mehrara BJ, Kim H. Investigative strategies on lymphatic vessel modulation for treating lymphedema in future medicine. PRECISION AND FUTURE MEDICINE 2018. [DOI: 10.23838/pfm.2018.00142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Qin ES, Bowen MJ, Chen WF. Diagnostic accuracy of bioimpedance spectroscopy in patients with lymphedema: A retrospective cohort analysis. J Plast Reconstr Aesthet Surg 2018; 71:1041-1050. [PMID: 29650264 DOI: 10.1016/j.bjps.2018.02.012] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 02/08/2018] [Accepted: 02/20/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND Bioimpedance spectroscopy (BIS) is used by healthcare specialists to diagnose lymphedema. BIS measures limb fluid content by assessing tissue resistance to the flow of electric current. However, there is debate regarding the validity of BIS in diagnosing early lymphedema. Indocyanine green (ICG) lymphography has been established as the most accurate diagnostic modality to date for lymphedema diagnosis. In this retrospective study, we test the sensitivity, specificity, and diagnostic accuracy of BIS in diagnosing lymphedema by referencing its results with ICG lymphography. METHODS Patients presented to the University of Iowa Lymphedema Center from 2015 to 2017 were evaluated with a standardized protocol that included history and physical examination, a validated lymphedema-specific quality-of-life assessment (LYMQOL), circumference -measurement-based index, BIS, and ICG lymphography. Diagnostic accuracy of BIS was assessed using ICG lymphography as a reference test. RESULTS Fifty-eight patients had positive ICG lymphography results, which confirmed the diagnosis of lymphedema. ICG lymphographic findings consistently correlated with clinical examination, LYMQOL evaluation, and lymphedema indices. By contrast, BIS demonstrated a false-negative rate of 36% - 21 out of 58 patients had normal BIS readings, but a positive ICG lymphography result. The 21 false-negative results occurred in patients with early-stage disease. Sensitivity and specificity for BIS were 0.64 and 1, respectively. CONCLUSION BIS carries an excessively high rate of false-negative results to be dependably used as a diagnostic modality for lymphedema. ICG lymphography highly correlates with other tracking modalities, and it remains the most reliable tool for diagnosing lymphedema.
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Affiliation(s)
- Evelyn S Qin
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Mindy J Bowen
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Wei F Chen
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.
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Tartaglione G, Visconti G, Bartoletti R, Gentileschi S, Salgarello M, Rubello D, Colletti PM. Stress Lymphoscintigraphy for Early Detection and Management of Secondary Limb Lymphedema. Clin Nucl Med 2018; 43:155-161. [PMID: 29293136 DOI: 10.1097/rlu.0000000000001963] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
UNLABELLED Cancer treatments with axillary or pelvic lymph nodes dissection and radiation place patients at lifelong risk for the development of secondary lymphedema. Our aim was to evaluate the role of stress lymphoscintigraphy for early detection and management of secondary lymphedema. METHODS Stress lymphoscintigraphy was performed within 1 year after surgery and the completion of chemotherapy and radiation treatments. All patients were classified by the International Society of Lymphology clinical stages from 0 to 3. A dose of 50 MBq of 99mTc-HSA-nanocolloidal in 0.4mL was injected intradermally at the first and fourth intermetacarpal spaces on the hand, for the upper limb with edema, or at the first intermetatarsal space and at the lateral malleolus for lower extremities. Two planar static scans at rest were acquired immediately after tracer injection. Stress scans were acquired after weight lifting for upper extremity or stepping for 2 minutes for lower-extremity edema. After that, the patients underwent prolonged muscular exercise limited by symptoms, and later scans were acquired at 60 minutes to visualize regional lymph nodes and the effects of sustained muscular exercise. Transport Index was evaluated. RESULTS Five patterns of lymphoscintigraphy were observed. In our experience, patients with types I to III pattern benefit from an exercise program as a first-line treatment. Patterns IVand V seem to be predictive of lymphedema. CONCLUSIONS The abnormal patterns found may provide the basis for earlier complex physical therapy or microsurgical treatment of lymphatic disorders in patients resulting in improved outcomes.
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Agko M, Ciudad P, Chen HC. Staged surgical treatment of extremity lymphedema with dual gastroepiploic vascularized lymph node transfers followed by suction-assisted lipectomy-A prospective study. J Surg Oncol 2018; 117:1148-1156. [PMID: 29355987 DOI: 10.1002/jso.24969] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Accepted: 12/08/2017] [Indexed: 01/03/2023]
Affiliation(s)
- Mouchammed Agko
- Department of Plastic Surgery; China Medical University Hospital; Taichung Taiwan
| | - Pedro Ciudad
- Department of Plastic Surgery; China Medical University Hospital; Taichung Taiwan
- Department of Biological Science and Technology; China Medical University; Taichung Taiwan
| | - Hung-Chi Chen
- Department of Plastic Surgery; China Medical University Hospital; Taichung Taiwan
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50
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Vascularized Jejunal Mesenteric Lymph Node Transfer: A Novel Surgical Treatment for Extremity Lymphedema. J Am Coll Surg 2017; 225:650-657. [DOI: 10.1016/j.jamcollsurg.2017.08.001] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2017] [Revised: 07/31/2017] [Accepted: 08/01/2017] [Indexed: 11/21/2022]
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