1
|
Ciudad P, Bolletta A, Kaciulyte J, Manrique OJ, Escandón JM. Primary LYmphedema Multidisciplinary Approach in Patients Affected by Primary Lower Extremity Lymphedema. J Clin Med 2024; 13:5161. [PMID: 39274373 PMCID: PMC11395934 DOI: 10.3390/jcm13175161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2024] [Revised: 08/26/2024] [Accepted: 08/28/2024] [Indexed: 09/16/2024] Open
Abstract
Background: Primary lymphedema is a chronic condition caused by a developmental abnormality of the lymphatic system, leading to its malfunction. Various surgical options, including physiologic and excisional procedures, have been proposed. The aim of this study was to present a comprehensive algorithm for the treatment of primary lower extremity lymphedema: the Primary LYmphedema Multidisciplinary Approach (P-LYMA). Methods: Nineteen patients were treated following the P-LYMA protocol. Patients underwent pre- and postoperative complex decongestive therapy (CDT). A variety of physiologic and excisional procedures were performed, either independently or in combination. The primary outcome was to assess the circumferential reduction rate (CRR). The Lymphedema Quality of Life Score (LeQOLiS), reduction in the number of cellulitis episodes, and complications were recorded. Results: The mean CRR was 73 ± 20% at twelve months postoperatively. The frequency of cellulitis episodes per year decreased from a mean of 1.9 ± 0.8 preoperatively to 0.4 ± 0.6 during follow-up. Two patients experienced minor complications. The mean hospitalization time was 5 days. Patients' quality of life, as measured by the LeQOLiS, significantly improved from 70.4 ± 12 preoperatively to 24 ± 14 at twelve months postoperatively. Conclusions: The P-LYMA algorithm maximizes surgical outcomes and improves the quality of life in patients with primary lymphedema. CDT is essential for optimizing results.
Collapse
Affiliation(s)
- Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima 15082, Peru
- Academic Department of Surgery, Faculty of Medicine, Federico Villarreal National University, Lima 15084, Peru
| | - Alberto Bolletta
- Plastic Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56125 Pisa, Italy
| | - Juste Kaciulyte
- Unit of Plastic and Reconstructive Surgery, Department of Surgery "P.Valdoni", Sapienza University of Rome, Policlinico Umberto I, 00185 Rome, Italy
| | - Oscar J Manrique
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima 15082, Peru
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY 14642, USA
| | | |
Collapse
|
2
|
Grünherz L, Barbon C, von Reibnitz D, Gousopoulos E, Uyulmaz S, Giovanoli P, Vetter D, Gutschow CA, Lindenblatt N. Analysis of different outcome parameters and quality of life after different techniques of free vascularized lymph node transfer. J Vasc Surg Venous Lymphat Disord 2024:101934. [PMID: 38925528 DOI: 10.1016/j.jvsv.2024.101934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 05/28/2024] [Accepted: 06/09/2024] [Indexed: 06/28/2024]
Abstract
OBJECTIVE Vascularized lymph node transfer (VLNT) has become an important surgical technique in the treatment of lymphedema. Considering the different available regions available for flap harvest, we aimed to analyze different donor sites for VLNT with respect to donor site morbidity, impact on limb volume, and patient-reported outcome measurements (PROMs). METHODS A single-center prospective study of all patients undergoing VLNT at the Department of Plastic Surgery and Hand Surgery of the University Hospital Zurich between September 2016 and 2023 was conducted. Lymph nodes were harvested either from the omentum (gastroepiploic [GE]-VLNT), the lateral thoracic wall (LTW), or the superficial inguinal region (SI-VLNT). Volume measurements and PROMs were assessed preoperatively and at different postoperative intervals. RESULTS Overall, 70 patients with upper limb lymphedema (21%) or lower limb lymphedema (79%) with different lymphedema stages were included. There were 49 patients who underwent GE-VLNT, followed by LTW-VLNT (n = 16) and SI-VLNT (n = 5). Lymph node harvest from the SI was associated with a significantly higher frequency of seroma development. The average percentage volume loss related in comparison to the preoperative volume of the affected limb was 9% after GE-VLNT, 10% after LTW-VLNT, and 5% after SI-VLNT without a significant difference between the groups. PROMs revealed significant improvements for physical functioning, symptoms and psychological well-being, with no differences between the VLNT techniques. CONCLUSIONS VLNT leads to a significant improvement of quality of life and can decrease limb volume effectively, regardless of the selection of donor site. GE-VLNT has become our flap of choice owing to its low donor site morbidity and its properties that allow a double transplantation while avoiding a second donor site.
Collapse
Affiliation(s)
- Lisanne Grünherz
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Carlotta Barbon
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Donata von Reibnitz
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | | | - Semra Uyulmaz
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Pietro Giovanoli
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Diana Vetter
- Department of Visceral and Transplant Surgery, University Hospital Zurich, Zurich, Switzerland
| | | | - Nicole Lindenblatt
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland.
| |
Collapse
|
3
|
Lo Torto F, Kaciulyte J, Di Meglio F, Marcasciano M, Greco M, Ribuffo D. Orthotopic vascularized lymph node transfer in breast cancer-related lymphedema treatment: Functional and life quality outcomes. Microsurgery 2024; 44:e31147. [PMID: 38342994 DOI: 10.1002/micr.31147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 11/27/2023] [Accepted: 01/04/2024] [Indexed: 02/15/2024]
Abstract
INTRODUCTION Breast cancer-related lymphedema (BCRL) is a chronic disease that occurs up to 65% of breast cancer survivors. Traditional treatment is conservative, but new surgeries as lymphaticovenous anastomosis (LVA) and vascularized lymph node transfer (VLNT) are at disposal. This study aims to investigate the orthotopic VLNT efficacy in BCRL. Results in terms of limbs' reduction rates and quality of life improvement are compared with the outcomes reported in Literature. PATIENTS AND METHODS During patients' selection, inclusion criteria were monolateral ISL stage II or III BCRL with pathologic lymphoscintigraphy imaging and a minimum of previous 6 months of unsuccessful conservative treatment. Bilateral lymphedema, local recurrence or systemic metastasis, acute infection of the limb and deep venous trombosis were exclusion criteria. Surgery consisted in VLNT from the gastroepiploic region to the axilla with axillary scar dissection. RESULTS From August 2019 to December 2021, 25 patients were included. At the preoperative scintigraphy exam, mean lymph transport index (TI) was 30 (range; 22.7-29.3). Nine of them (36%) were ISL stage II and 16 (64%) were stage III. Average follow-up was 13.5 months (range; 12-19 months). VLN flaps' survival rate was 100%. One year after surgery, the mean Circumferential Reduction Rate (CRR) resulted 44.62 (range; 27.4-60.3). Infections' rates presented a statistically significant reduction, from an average of 2.4 (range; 1-4) to 0.2 (range; 0-1) episodes per year. Life quality index measured with the LYMQOL questionnaire showed significant improvement after 1 year, from a mean score of 3.28 (range; 2-5) to 8.12 (range; 7-9). CONCLUSION When compared with Literature evidence, the results of the current study are in line with both VLN inset ways related to BCRL treatment. An optimal therapeutic choice should consider benefits and drawbacks of each orthotopic and heterotopic VLNT, taking into account surgeon's preference and experience and patients' related factors and expectations.
Collapse
Affiliation(s)
- Federico Lo Torto
- Unit of Plastic and Reconstructive Surgery, Department of Surgery "P. Valdoni", Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Juste Kaciulyte
- Unit of Plastic and Reconstructive Surgery, Department of Surgery "P. Valdoni", Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Filippo Di Meglio
- Unit of Plastic and Reconstructive Surgery, Department of Surgery "P. Valdoni", Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Marco Marcasciano
- Division of Plastic Surgery, Department of Experimental and Clinical Medicine, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Manfredi Greco
- Division of Plastic Surgery, Department of Experimental and Clinical Medicine, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Diego Ribuffo
- Unit of Plastic and Reconstructive Surgery, Department of Surgery "P. Valdoni", Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| |
Collapse
|
4
|
Elia R, Chen HC, Cazzato G, Di Summa PG, Giudice G, Maruccia M. Evaluation of modulation of immunity by lymph node transfer: A preliminary histological evidence in lymphedema patients. Microsurgery 2024; 44:e31123. [PMID: 37788091 DOI: 10.1002/micr.31123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Revised: 09/07/2023] [Accepted: 09/21/2023] [Indexed: 10/05/2023]
Abstract
BACKGROUND The exact knowledge of the local biological and immunological effects of vascularized lymph node transfer (VLNT) continues to be an emerging science but a positive control positive control over infectious and immune-mediated processes is often advocated. Knowing the characterization of the inflammatory infiltrate associated with lymphedema, the aim of this paper is to verify the hypothesis that VLNT is able to modulate the inflammatory and immune microenvironment of lymphedematous tissue by evaluating any modification of the local inflammatory cell infiltrate. PATIENTS AND METHODS A prospectively database of patients who received VLN transfer for lower extremity lymphedema between January 2018 and December 2020 was reviewed. Nine patients diagnosed with extremities' stage II secondary lymphedema were included, with a mean age of 55.3 (range 39-66 years) years. Gastroepiploic lymph node transfer was performed in all patients and transferred heterotopically. Full thickness 6-mm skin punch biopsies were obtained from all voluntary lymph node transfer patients at identical sites of the lymphedematous limb during the surgical procedure of VLNT (T0) and 1 year later (T1). Immunohistochemistry was performed using antibodies against the following markers: anti-CD3; anti-CD4; anti-CD8; anti-CD68. Data at T0 were compared to those at T1. RESULTS Post-operative course was uneventful in all cases experiencing a significant reduction (almost a third) in terms of cellulitis episodes: The median duration of follow-up for patients was 28.3 months (range 12-40). The analysis of the density of the inflammatory cells as a whole revealed a significant reduction at T1 compared to T0. Specifically, CD3 expression levels turned from 16.36 ± 3.421 (cells/mm2 ) pre-operatively to 7.6 ± 1.511 (cells/mm2 ) post-operatively (p < .0001). CD4+ cells turned from 7.270 ± 3.421 (cells/mm2 ) at T0 to 4.815 ± 1.511 cells/mm2 at T1 (p = .0173). CD8 expression values decreased from 4.360 ± 3.421 (cells/mm2 ) to 2.753 ± 1.451 (cell/mm2 ) at T1 (p = .0003). Monocyte/macrophage marker CD68 varied from 8.208 ± 2.314 (cells/mm2 ) at T0 to 7.600 ± 1876 (cells/mm2 ) at T1 (p = .0003). CONCLUSION VLNT decreases skin and subcutaneous tissues' infiltration of inflammatory cells, providing one explanation for the positive control of lymph node transfer procedure over infectious and immune-mediated processes.
Collapse
Affiliation(s)
- Rossella Elia
- Division of Plastic and Reconstructive Surgery, Department of Precision and Regenerative Medicine and Jonic Area, University of Bari, Bari, Italy
| | - Hung-Chi Chen
- Department of Plastic Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Gerardo Cazzato
- Section of Pathology, Department of Precision and Regenerative Medicine and Jonic Area, University of Bari, University of Bari "Aldo Moro", Bari, Italy
| | - Pietro G Di Summa
- Department of Plastic, Reconstructive and Aesthetic Surgery, Centre Hospitalier Universitaire Vaudois (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Giuseppe Giudice
- Division of Plastic and Reconstructive Surgery, Department of Precision and Regenerative Medicine and Jonic Area, University of Bari, Bari, Italy
| | - Michele Maruccia
- Division of Plastic and Reconstructive Surgery, Department of Precision and Regenerative Medicine and Jonic Area, University of Bari, Bari, Italy
| |
Collapse
|
5
|
Maruccia M, Giudice G, Ciudad P, Manrique OJ, Cazzato G, Chen HC, Elia R. Lymph Node Transfer and Neolymphangiogenesis: From Theory to Evidence. Plast Reconstr Surg 2023; 152:904e-912e. [PMID: 36940155 DOI: 10.1097/prs.0000000000010434] [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: 03/21/2023]
Abstract
BACKGROUND Vascularized lymph node transfer (VLNT) has proven to be a valuable treatment for patients with advanced stages of lymphedema. Although spontaneous neolymphangiogenesis has been advocated to explain the positive effects of VLNT, there is still a lack of supportive biological evidence. The aim of this study was to demonstrate the postoperative formation of new lymphatic vessels using histologic skin sections from the lymphedematous limb. METHODS Patients with lymphedema of the extremities who had undergone gastroepiploic vascularized lymph node flap surgery between January of 2016 and December of 2018 were identified. Full-thickness 6-mm skin-punch biopsy specimens were obtained from patients at identical sites of the lymphedematous limb during the VLNT surgical procedure (T0) and 1 year later (T1). The histologic samples were immunostained with anti-podoplanin/gp36 antibody. RESULTS A total of 14 patients with lymph node transfer were included. At the 12-month follow-up, the mean circumference reduction rate was 44.3 ± 4.4 at the above-elbow/above-knee level and 60.9 ± 7 at the below-elbow/below-knee level. Podoplanin expression values were, on average, 7.92 ± 1.77 vessels/mm 2 at T0 and 11.79 ± 3.38 vessels/mm 2 at T1. The difference between preoperative and postoperative values was statistically significant ( P = 0.0008). CONCLUSION This study provides anatomic evidence that a neolymphangiogenic process is induced by the VLNT procedure because new functional lymphatic vessels can be detected in close proximity to the transferred lymph nodes. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
Collapse
Affiliation(s)
- Michele Maruccia
- From the Division of Plastic and Reconstructive Surgery, Department of Emergency and Organ Transplantation, University of Bari
| | - Giuseppe Giudice
- From the Division of Plastic and Reconstructive Surgery, Department of Emergency and Organ Transplantation, University of Bari
| | - Pedro Ciudad
- Department of Plastic, Reconstructive, and Burn Surgery, Arzobispo Loayza National Hospital
| | - Oscar J Manrique
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center
| | - Gerardo Cazzato
- Section of Pathology, Department of Emergency and Organ Transplantation, University of Bari "Aldo Moro"
| | - Hung-Chi Chen
- Department of Plastic Surgery, China Medical University Hospital
| | - Rossella Elia
- From the Division of Plastic and Reconstructive Surgery, Department of Emergency and Organ Transplantation, University of Bari
| |
Collapse
|
6
|
Meuli JN, Guiotto M, Elmers J, Mazzolai L, di Summa PG. Outcomes after microsurgical treatment of lymphedema: a systematic review and meta-analysis. Int J Surg 2023; 109:1360-1372. [PMID: 37057889 PMCID: PMC10389392 DOI: 10.1097/js9.0000000000000210] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 01/03/2023] [Indexed: 04/15/2023]
Abstract
BACKGROUND Microsurgical treatment options for lymphedema consist mainly of lymphovenous anastomosis (LVA) and vascularized lymph node transfers (VLNTs). There are no standard measurements of the effectiveness of these interventions and reported outcomes vary among studies. METHODS A systematic review and meta-analysis were performed based on a structured search in Embase, Medline, PubMed, Cinahl, Cochrane, and ProQuest in October 2020, with an update in February 2022. Firstly, a qualitative summary of the main reported outcomes was performed, followed by a pooled meta-analysis of the three most frequently reported outcomes using a random effects model. Randomized controlled trials, prospective cohorts, retrospective cohorts, and cross-sectional and case-control studies that documented outcomes following microsurgery in adult patients were included. Studies of other surgical treatments (liposuction, radical excision, lymphatic vessel transplantation) or without reported outcomes were excluded. The study protocol was registered on PROSPERO (International Prospective Register of Systematic Reviews) (ID: CRD42020202417). No external funding was received for this review. RESULTS One hundred fifty studies, including 6496 patients, were included in the systematic review. The qualitative analysis highlighted the three most frequently reported outcomes: change in circumference, change in volume, and change in the number of infectious episodes per year. The overall pooled change in excess circumference across 29 studies, including 1002 patients, was -35.6% [95% CI: -30.8 to -40.3]. The overall pooled change in excess volume across 12 studies including 587 patients was -32.7% [95% CI: -19.8 to -45.6], and the overall pooled change in the number of cutaneous infections episodes per year across 8 studies including 248 patients was -1.9 [95% CI: -1.4 to -2.3]. The vast majority of the studies included were case series and cohorts, which were intrinsically exposed to a risk of selection bias. CONCLUSION The currently available evidence supports LVA and vascularized lymph node transfers as effective treatments to reduce the severity of secondary lymphedema. Standardization of staging method, outcomes measurements, and reporting is paramount in future research in order to allow comparability across studies and pooling of results.
Collapse
Affiliation(s)
| | | | | | - Lucia Mazzolai
- Angiology Division, Heart and Vessel Department, Lausanne University Hospital, University of Lausanne, Switzerland
| | | |
Collapse
|
7
|
Roka-Palkovits J, Freystätter C, Tinhofer IE, Keck M, Steinbacher J, Meng S, Weninger WJ, Cheng MH, Tzou CHJ. Retroauricular lymph node flap: An anatomic and surgical feasibility study. J Surg Oncol 2023; 127:1103-1108. [PMID: 36912899 DOI: 10.1002/jso.27234] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 02/26/2023] [Indexed: 03/14/2023]
Abstract
BACKGROUND The study investigated the anatomy of the retroauricular lymph node (LN) flap and evaluate its surgical feasibility as a new donor site for a free LN flap in lymphedema surgery. METHODS Twelve adult cadavers were examined. The course and perfusion of the anterior auricular artery (AAA) and the location and sizes of the retroauricular LNs were studied. RESULTS The AAA was available in 87% and absent in 13% specimens. The AAA's origin had a mean vertical distance of 12.2 ± 6.9 mm and a mean horizontal distance of 19.1 ± 4.2 mm from the superior attachment of the ear. The mean diameter of the AAA was 0.8 ± 0.2 mm. The mean number of LN per region was 7.7 ± 2.3, with an average LN size of 4.1 ± 1.9 × 3.2 ± 1.7 mm. The LN were categorized into anterior (G1) and posterior (G2) groups, with a total of 59 and 10 LN, respectively. In a cluster analysis, three LN clusters could be detected across the anterior group (G1). CONCLUSIONS The retroauricular LN flap is a delicate but feasible flap with reliable anatomy, containing a mean of 7.7 LNs.
Collapse
Affiliation(s)
- Julia Roka-Palkovits
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Hospital of the Divine Savior (Krankenhaus Goettlicher Heiland), Vienna, Austria
| | - Christian Freystätter
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Austria
| | - Ines E Tinhofer
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Hospital of the Divine Savior (Krankenhaus Goettlicher Heiland), Vienna, Austria
| | - Maike Keck
- Department of Plastic and Reconstructive Surgery, Agaplesion Diakonieklinikum Hamburg, Hamburg, Germany.,Department of Plastic and Reconstructive Surgery, University of Luebeck, Luebeck, Germany
| | - Johannes Steinbacher
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Hospital of the Divine Savior (Krankenhaus Goettlicher Heiland), Vienna, Austria
| | - Stefan Meng
- Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria.,Department of Radiology, Hanusch Hospital, Vienna, Austria
| | - Wolfgang J Weninger
- Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
| | - Ming-Huei Cheng
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chieh-Han J Tzou
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Hospital of the Divine Savior (Krankenhaus Goettlicher Heiland), Vienna, Austria.,Faculty of Medicine, Sigmund Freud University, Vienna, Austria.,Lymphedema Center, TZOU MEDICAL., Vienna, Austria
| |
Collapse
|
8
|
Kaya B, Tang YB, Chen SH, Chen HC. Technical details for inset of flaps in transfer of double-level gastroepiploic lymph node flaps for lower extremity lymphedema. Asian J Surg 2023; 46:794-800. [PMID: 35850907 DOI: 10.1016/j.asjsur.2022.07.034] [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] [Received: 05/12/2022] [Revised: 06/21/2022] [Accepted: 07/08/2022] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND In this study, the method that can be followed to ensure rapid and uncomplicated recovery of lymph node flap (LNF) applied in the medial of the ankle for lymphedema treatment was investigated. METHODS Thirty-seven patients with class II of lower limb lymphedema underwent transfer of gastroepiploic LNF to the medial ankle and popliteal fossa areas. At the popliteal fossa region, the wound could always be closed primarily by the advancement of neighboring skin. The wound closure could be classified into three types at the medial ankle area (A) The partially exposed LNF was covered with a split-thickness skin graft (STSG) (n = 9). (B) A larger local flap was elevated, and the donor site of the local flap was covered with STSG (n = 18). (C) The skin flap's donor site was treated with pre-tie sutures (n = 10). RESULTS In the popliteal region, there was no complication of wound healing. In the ankle region, the wound was coated by a thin layer of hematoma over the exposed LNF in 5 patients of group A. It healed secondarily except for one patient who needed a secondary skin graft. The healing was perfect in group B. In group C the healing was good, but there was a hypertrophic scar in 7 patients and required steroid injection later. CONCLUSION To avoid complications of the gastroepiploic LNF at the medial ankle, it should be entirely covered by an anteriorly-based local flap, and the donor site defect of the local flap can be treated with either pre-tie sutures or a skin graft.
Collapse
Affiliation(s)
- Burak Kaya
- Department of Plastic Reconstructive and Aesthetic Surgery, Ankara University Faculty of Medicine, Ankara, Turkey; Ankara University Medical Design Application and Research Center (MEDITAM), Ankara, Turkey; China Medical University and China Medical University Hospital, Taichung, Taiwan
| | - Yueh-Bih Tang
- Department of Plastic Surgery, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Shih-Heng Chen
- Department of Plastic and Reconstructive Surgery, Chang Gung University and Medical Collage, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Hung-Chi Chen
- China Medical University and China Medical University Hospital, Taichung, Taiwan.
| |
Collapse
|
9
|
Manrique OJ, Bustos SS, Ciudad P, Adabi K, Chen WF, Forte AJ, Cheville AL, Jakub JW, McLaughlin SA, Chen HC. Overview of Lymphedema for Physicians and Other Clinicians: A Review of Fundamental Concepts. Mayo Clin Proc 2022; 97:1920-1935. [PMID: 32829905 DOI: 10.1016/j.mayocp.2020.01.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 10/17/2019] [Accepted: 01/06/2020] [Indexed: 12/16/2022]
Abstract
Lymphedema has historically been underrated in clinical practice, education, and scholarship to the detriment of many patients with this chronic, debilitating condition. The mechanical insufficiency of the lymphatic system causes the abnormal accumulation of protein-rich fluid in the interstitium, which triggers a cascade of adverse consequences such as fat deposition and fibrosis. As the condition progresses, patients present with extremity heaviness, itchiness, skin infections, and, in later stages, dermal fibrosis, skin papillomas, acanthosis, and other trophic skin changes. Correspondingly, lymphedema results in psychological morbidity, including anxiety, depression, social avoidance, and a decreased quality of life, encompassing emotional, functional, physical, and social domains. For this review, we conducted a literature search using PubMed and EMBASE and herein summarize the evidence related to the fundamental concepts of lymphedema. This article aims to raise awareness of this serious condition and outline and review the fundamental concepts of lymphedema.
Collapse
Affiliation(s)
- Oscar J Manrique
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, MN.
| | - Samyd S Bustos
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, MN
| | - Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Kian Adabi
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, MN
| | - Wei F Chen
- Division of Plastic and Reconstructive Surgery, University of Iowa, Iowa City
| | | | - Andrea L Cheville
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN
| | | | | | - Hung-Chi Chen
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| |
Collapse
|
10
|
Brown S, Mehrara BJ, Coriddi M, McGrath L, Cavalli M, Dayan JH. A Prospective Study on the Safety and Efficacy of Vascularized Lymph Node Transplant. Ann Surg 2022; 276:635-653. [PMID: 35837897 PMCID: PMC9463125 DOI: 10.1097/sla.0000000000005591] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE While vascularized lymph node transplant (VLNT) has gained popularity, there are a lack of prospective long-term studies and standardized outcomes. The purpose of this study was to evaluate the safety and efficacy of VLNT using all available outcome measures. METHODS This was a prospective study on all consecutive patients who underwent VLNT. Outcomes were assessed with 2 patient-reported outcome metrics, limb volume, bioimpedance, need for compression, and incidence of cellulitis. RESULTS There were 89 patients with the following donor sites: omentum (73%), axilla (13%), supraclavicular (7%), groin (3.5%). The mean follow-up was 23.7±12 months. There was a significant improvement at 2 years postoperatively across all outcome measures: 28.4% improvement in the Lymphedema Life Impact Scale, 20% average reduction in limb volume, 27.5% improvement in bioimpedance score, 93% reduction in cellulitis, and 34% of patients no longer required compression. Complications were transient and low without any donor site lymphedema. CONCLUSIONS VLNT is a safe and effective treatment for lymphedema with significant benefits fully manifesting at 2 years postoperatively. Omentum does not have any donor site lymphedema risk making it an attractive first choice.
Collapse
Affiliation(s)
- Stav Brown
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | | | | | | |
Collapse
|
11
|
Elia R, Chen HC, Di Taranto G, Ciudad P, Lo Torto F, Nacchiero E, Giudice G, Maruccia M. GASTROEPIPLOIC VASCULARIZED LYMPH NODE TRANSFER FOR EXTREMITIES’ LYMPHEDEMA: IS TWO BETTER THAN ONE? A RETROSPECTIVE CASE-CONTROL STUDY. J Plast Reconstr Aesthet Surg 2022; 75:3129-3137. [DOI: 10.1016/j.bjps.2022.04.105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 02/27/2022] [Accepted: 04/12/2022] [Indexed: 10/18/2022]
|
12
|
Ciudad P, Escandón JM, Manrique OJ, Bustos VP. Lessons Learnt from an 11-year Experience with Lymphatic Surgery and a Systematic Review of Reported Complications: Technical Considerations to Reduce Morbidity. Arch Plast Surg 2022; 49:227-239. [PMID: 35832669 PMCID: PMC9045509 DOI: 10.1055/s-0042-1744412] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Complications experienced during lymphatic surgery have not been ubiquitously reported, and little has been described regarding how to prevent them. We present a review of complications reported during the surgical management of lymphedema and our experience with technical considerations to reduce morbidity from lymphatic surgery. A comprehensive search across different databases was conducted through November 2020. Based on the complications identified, we discussed the best approach for reducing the incidence of complications during lymphatic surgery based on our experience. The most common complications reported following lymphovenous anastomosis were re-exploration of the anastomosis, venous reflux, and surgical site infection. The most common complications using groin vascularized lymph node transfer (VLNT), submental VLNT, lateral thoracic VLNT, and supraclavicular VLNT included delayed wound healing, seroma and hematoma formation, lymphatic fluid leakage, iatrogenic lymphedema, soft-tissue infection, venous congestion, marginal nerve pseudoparalysis, and partial flap loss. Regarding intra-abdominal lymph node flaps, incisional hernia, hematoma, lymphatic fluid leakage, and postoperative ileus were commonly reported. Following suction-assisted lipectomy, significant blood loss and transient paresthesia were frequently reported. The reported complications of excisional procedures included soft-tissue infections, seroma and hematoma formation, skin-graft loss, significant blood loss, and minor skin flap necrosis. Evidently, lymphedema continues to represent a challenging condition; however, thorough patient selection, compliance with physiotherapy, and an experienced surgeon with adequate understanding of the lymphatic system can help maximize the safety of lymphatic surgery.
Collapse
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
- Academic Department of Surgery, School of Medicine Hipolito Unanue, Federico Villarreal National University, Lima, Perú
| | - Joseph M. Escandón
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York
| | - Oscar J. Manrique
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York
| | - Valeria P. Bustos
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical University, Boston, Massachusetts
| |
Collapse
|
13
|
Jejunal Mesenteric Vascularized Lymph Node Transplantation for Lymphedema: Outcomes and Technical Modifications. Plast Reconstr Surg 2022; 149:700e-710e. [PMID: 35157612 DOI: 10.1097/prs.0000000000008960] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND The jejunal mesentery supplied by the superior mesenteric vascular tree has emerged as a viable site for vascularized lymph node transplantation. Among other benefits, it has the advantage of avoidance of the risk of donor-site lymphedema. This article reports the technique and outcomes of a novel approach to jejunal mesenteric vascularized lymph node transplantation with flap harvest from the mesenteric root to reduce the risk of small bowel ischemic complications. METHODS A consecutive series of patients that underwent jejunal mesenteric vascularized lymph node transplantation to treat upper extremity lymphedema were included. Preoperative and postoperative measurements were taken at fixed intervals using standardized techniques including Perometer volumetry, LDex bioimpedance spectroscopy, the Lymphedema Life Impact Scale, and the Quick Disabilities of the Arm, Shoulder and Hand tool. Demographic, treatment, and outcomes data were collected, and descriptive statistics were used. RESULTS There were 25 patients included, all of whom had maximized their conservative therapy before undergoing surgery. At 12 months postoperatively reduction in limb volume difference was 36.7 percent (p < 0.001), reduction in LDex score was 41.4 percent (p = 0.0015), and reductions in the Lymphedema Life Impact Scale and Quick Disabilities of the Arm, Shoulder and Hand scores were 55.7 percent (p = 0.0019) and 47.5 percent (p = 0.027), respectively. In 11 patients, there was a history of cellulitis (multiple episodes in eight), and at up to 24 months' follow-up postoperatively, there were no episodes reported (p < 0.001). CONCLUSION Upper extremity lymphedema can be effectively treated surgically using the jejunal mesenteric vascularized lymph node transplantation, resulting in reduced limb volume and extracellular fluid, and improved patient-reported limb function and outcomes measures compared with optimized conservative therapy alone. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
Collapse
|
14
|
The Combination of Lymph Node Transfer and Excisional Procedures in Bilateral Lower Extremity Lymphedema: Clinical Outcomes and Quality of Life Assessment with Long-Term Follow-Up. J Clin Med 2022; 11:jcm11030570. [PMID: 35160022 PMCID: PMC8836833 DOI: 10.3390/jcm11030570] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 01/17/2022] [Accepted: 01/21/2022] [Indexed: 02/04/2023] Open
Abstract
Background: Bilateral lower extremity lymphedema is a rare and invalidating condition that poses a great challenge to the scientific community, and deeply affects the quality of life (QoL) of affected patients. A combined protocol consisting of lymph node transfer and a reductive method have never been reported for the treatment of this condition, except for small case series with brief follow-up periods. Methods: This retrospective study analyzed data of 29 patients, mean age 51 ± 17.1 years, who had been diagnosed with bilateral lower extremity lymphedema. Gastroepiploic vascularized lymph node transfer was performed in all the patients, and an excisional procedure was associated according to the clinical stage. Clinical history, circumferential limb measurements, complications, episodes of cellulitis, and responses to the Lymphedema Quality of Life Questionnaire were analyzed. Results: The mean follow-up was 38.4 ± 11.8 months. A significant reduction in the episodes of cellulitis per year was observed (p < 0.001). In our series, BMI and duration of symptoms were significantly related to the development of cellulitis during the postoperative period, p = 0.006 and p = 0.020, respectively. The LYMQoL questionnaire showed a significant quality of life improvement from 3.4 ± 0.9 to 6.2 ± 0.8 (p < 0.05). Conclusions: An integrated approach is essential for the treatment of bilateral lower extremity lymphedema: reductive and reconstructive methods are complementary to achieve a successful outcome. Timely treatment and BMI reduction are relevant in order to decrease the number of episodes of cellulitis. An attentive follow-up is necessary to identify recurrence and treat affected patients in time.
Collapse
|
15
|
Chang CC, Jan WL, Juan CH, Meng NH, Lin BS, Chen HC. Novel Wireless Bioimpedance Device for Segmental Lymphedema Analysis Post Dual-Site Free Vascularized Lymph Node Transfer: A Prospective Cohort Study. SENSORS 2021; 21:s21248187. [PMID: 34960279 PMCID: PMC8707995 DOI: 10.3390/s21248187] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 12/01/2021] [Accepted: 12/06/2021] [Indexed: 01/02/2023]
Abstract
An innovative wireless device for bioimpedance analysis was developed for post-dual-site free vascularized lymph node transfer (VLNT) evaluation. Seven patients received dual-site free VLNT for unilateral upper or lower limb lymphedema. A total of 10 healthy college students were enrolled in the healthy control group. The device was applied to the affected and unaffected limbs to assess segmental alterations in bioimpedance. The affected proximal limb showed a significant increase in bioimpedance at postoperative sixth month (3.3 [2.8, 3.6], p = 0.001) with 10 kHz currents for better penetration, although the difference was not significant (3.3 [3.3, 3.8]) at 1 kHz. The bioimpedance of the affected distal limb significantly increased after dual-site free VLNT surgery, whether passing with the 1 kHz (1.6 [0.7, 3.4], p = 0.030, postoperative first month; 2.8 [1.0, 4.2], p = 0.027, postoperative third month; and 1.3 [1.3, 3.4], p = 0.009, postoperative sixth month) or 10 kHz current ((1.4 [0.5, 2.7], p = 0.049, postoperative first month; 3.2 [0.9, 6.3], p = 0.003, postoperative third month; and 3.6 [2.5, 4.1], p < 0.001, postoperative sixth month). Bioimpedance alterations on the affected distal limb were significantly correlated with follow-up time (rho = 0.456, p = 0.029 detected at 10 kHz). This bioimpedance wireless device could quantitatively monitor the interstitial fluid alterations, which is suitable for postoperative real-time surveillance.
Collapse
Affiliation(s)
- Chang-Cheng Chang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, China Medical University Hospital, Taichung 404332, Taiwan; (C.-C.C.); (W.-L.J.)
- School of Medicine, College of Medicine, China Medical University, Taichung 404333, Taiwan
- Institute of Imaging and Biomedical Photonics, National Yang Ming Chiao Tung University, Tainan 711010, Taiwan
| | - Wei-Ling Jan
- Division of Plastic and Reconstructive Surgery, Department of Surgery, China Medical University Hospital, Taichung 404332, Taiwan; (C.-C.C.); (W.-L.J.)
| | - Cheng-Huei Juan
- Institute of Biomedical Science, China Medical University, Taichung 404333, Taiwan;
| | - Nai-Hsin Meng
- Department of Physical Medicine and Rehabilitation, China Medical University Hospital, Taichung 404332, Taiwan;
| | - Bor-Shyh Lin
- Institute of Imaging and Biomedical Photonics, National Yang Ming Chiao Tung University, Tainan 711010, Taiwan
- Correspondence: (B.-S.L.); (H.-C.C.); Tel.: +886-6-3032121-57835 (B.S.-L.); +886-4-22052121-1538 (H.-C.C.)
| | - Hung-Chi Chen
- Division of Plastic and Reconstructive Surgery, Department of Surgery, China Medical University Hospital, Taichung 404332, Taiwan; (C.-C.C.); (W.-L.J.)
- International Medical Service Center, China Medical University Hospital, Taichung 404332, Taiwan
- Correspondence: (B.-S.L.); (H.-C.C.); Tel.: +886-6-3032121-57835 (B.S.-L.); +886-4-22052121-1538 (H.-C.C.)
| |
Collapse
|
16
|
Daniel BW, Sonnenberg AM, Stern JE, Tannapfel A, Yamamoto T, Ring A. Intra-abdominal lymph node flaps in lymphedema therapy: An anatomical guide to donor site selection. J Surg Oncol 2021; 125:134-144. [PMID: 34634138 DOI: 10.1002/jso.26705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 09/21/2021] [Accepted: 09/25/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Secondary lymphedema is a leading sequela of cancer surgery and radiotherapy. The microsurgical transfer of lymph node flaps (LNFs) to affected limbs can improve the symptoms. The intra-abdominal cavity contains an abundant heterogenic source. The aim of this study is to aid selection among intra-abdominal LNFs. METHODS Eight LNFs were harvested in a microsurgical fashion at five sites in 16 cadavers: gastroepiploic, jejunal, ileal, ileocolic, and appendicular. These flaps were compared regarding size, weight, arterial diameter, and lymph node (LN) count after histologic verification. RESULTS One hundred and sixteen flaps were harvested. The exposed area correlated with the flap weight and volume (r2 = 0.86, r = 0.9). While gastroepiploic LNFs (geLNFs) showed the highest median weight of 99 ml, the jejunal LNFs (jLNFs) had the highest density with 3.8 LNs per 10 ml. The most reliable jLNF was 60 cm from the ligament of Treitz. Three or more LNs were contained in 94% of the jejunal, 88% of the ileal/ileocolic, and 63% of the omental LNs. The ileocolic LNF had the largest arterial diameter of 3 mm, yet the smallest volume. CONCLUSIONS jLNF and ileal LNF provide a reliable, high LN density for simultaneous, smaller recipient sites. geLNFs are more suitable for larger recipient sites.
Collapse
Affiliation(s)
- Bassem W Daniel
- Department of Plastic and Reconstructive Surgery, St. Rochus-Hospital, Castrop-Rauxel, Germany.,Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University and Medical College, Taoyuan City, Taiwan.,Department of Plastic Surgery, Freiburg University Medical Center, Freiburg, Germany
| | - Anna M Sonnenberg
- Department of Plastic and Reconstructive Surgery, St. Rochus-Hospital, Castrop-Rauxel, Germany.,Faculty of Medicine, Ruhr-University Bochum, Bochum, Germany
| | - Josef E Stern
- Department of Plastic and Reconstructive Surgery, St. Rochus-Hospital, Castrop-Rauxel, Germany
| | - Andrea Tannapfel
- Institute of Pathology, University Hospital Bergmannsheil, Ruhr-University Bochum, Bochum, Germany
| | - Takumi Yamamoto
- Department of Plastic and Reconstructive Surgery, Center Hospital of National Center for Global Health and Medicine, Tokyo, Japan
| | - Andrej Ring
- Department of Plastic and Reconstructive Surgery, St. Rochus-Hospital, Castrop-Rauxel, Germany.,Faculty of Medicine, Ruhr-University Bochum, Bochum, Germany
| |
Collapse
|
17
|
Li Y, Dong R, Li Z, Wang L, Long X. Intra-abdominal vascularized lymph node transfer for treatment of lymphedema: A systematic literature review and meta-analysis. Microsurgery 2021; 41:802-815. [PMID: 34562039 DOI: 10.1002/micr.30812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 07/27/2021] [Accepted: 09/10/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND As a promising treatment for lymphedema, vascularized lymph node transfer (VLNT) is associated with a risk of iatrogenic lymphedema. Intra-abdominal vascularized lymph node flap has been increasingly applied to minimize complication. METHODS PubMed, EMBASE, Web of Sciences, and Cochrane databases were searched systematically. Clinical articles describing the application of intra-abdominal flaps to treat lymphedema were included. Study characteristics, patient demographics, and operative details were recorded. Primary outcomes were recorded as circumference/volume reduction, episodes of cellulitis reduction and lymph flow assessment. Secondary outcomes were recorded as donor-site complication and recipient-site complication. RESULTS Twenty-one studies met the inclusion criteria with 594 patients in total. Donor-sites of flaps were omental/gastroepiploic, jejunal, ileocecal, and appendicular. The mean reduction rate ranged from 0.38% to 70.8%. Significant reduction in infectious episodes was reported in 10 studies. The pooled donor-site complication rate was 1.4% (95% CI, 0%-4.1%; I2 = 40%). The pooled recipient-site complication rate was 3.2% (95% CI, 1.4%-5.5%; I2 = 39%). The most common donor-site complication was minor ileus requiring prolonged nasogastric tube replacement. No donor site lymph disfunction occurred. CONCLUSION Intra-abdominal VLNT is an effective technique for patients with lymphedema with no obvious impairment to donor-site lymph function, as long as the operation is properly performed.
Collapse
Affiliation(s)
- Yunzhu Li
- Department of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Ruijia Dong
- Department of Plastic Surgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Zhujun Li
- Department of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Liquan Wang
- Department of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Xiao Long
- Department of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| |
Collapse
|
18
|
Surgical Treatment of Lymphedema: A Systematic Review and Meta-Analysis of Controlled Trials. Results of a Consensus Conference. Plast Reconstr Surg 2021; 147:975-993. [PMID: 33761519 DOI: 10.1097/prs.0000000000007783] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND The goal of this consensus conference, sponsored by the American Association of Plastic Surgeons, was to perform a systematic review and meta-analysis of controlled trials to examine both the benefits and risks of surgical treatment and surgical prevention of upper and lower extremity lymphedema. METHODS The panel met in Boston for a 3-day, face-to-face meeting in July of 2017. After an exhaustive review of the existing literature, the authors created consensus recommendations using the Grading of Recommendations, Assessment, Development and Evaluation criteria. Important directions for future research were also identified. RESULTS There is evidence to support that lymphovenous anastomosis can be effective in reducing severity of lymphedema (grade 1C). There is evidence to support that vascular lymph node transplantation can be effective in reducing severity of lymphedema (grade 1B). Currently, there is no consensus on which procedure (lymphovenous bypass versus vascular lymph node transplantation) is more effective (grade 2C). A few studies show that prophylactic lymphovenous bypass in patients undergoing extremity lymphadenectomy may reduce the incidence of lymphedema (grade 1B). More studies with longer follow-up are required to confirm this benefit. Debulking procedures such as liposuction are effective in addressing a nonfluid component such as fat involving lymphedema (grade 1C). There is a role for liposuction combined with physiologic procedures although the timing of each procedure is currently unresolved (grade 1C). CONCLUSIONS Many studies seem to support some efficacy of lymphovenous bypass and vascular lymph node transplantation. Many studies show the important role of lymphedema therapy and other procedures such as liposuction and debulking. The management of lymphedema is a challenging field with many promising advances. However, many questions remain unanswered.
Collapse
|
19
|
Jarvis NR, Torres RA, Avila FR, Forte AJ, Rebecca AM, Teven CM. Vascularized omental lymphatic transplant for upper extremity lymphedema: A systematic review. Cancer Rep (Hoboken) 2021; 4:e1370. [PMID: 33826249 PMCID: PMC8388172 DOI: 10.1002/cnr2.1370] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 02/20/2021] [Accepted: 03/01/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Vascularized omental lymphatic transplant (VOLT) is an increasingly popular treatment of extremity lymphedema given its promising donor site. While the success of VOLT in the treatment of lymphedema has been reported previously, several questions remain. AIM To further elucidate appropriate use of VOLT in the treatment of lymphedema, specifically addressing patient selection, harvest technique, and operative methods. METHODS AND RESULTS A systematic review of VOLT for upper extremity lymphedema was performed. Of 115 yield studies, seven were included for analysis based on inclusion and exclusion criteria. Included studies demonstrated significant reductions in extremity circumference/volume (average volume reduction, 22.7%-39.5%) as well as subjective improvements using patient-reported outcomes. Though studies are heterogenous and limited, when analyzed in aggregate, suggest the efficacy of VOLT in lymphedema treatment. CONCLUSION This is the largest systematic review of VOLT to date. VOLT continues to show promise as a safe and efficacious surgical intervention for lymphedema in the upper extremity. Further studies are warranted to more definitively identify patients for whom this technique is appropriate as well as ideal harvest and inset technique.
Collapse
Affiliation(s)
| | | | | | | | - Alanna M. Rebecca
- Division of Plastic and Reconstructive Surgery, Department of SurgeryMayo ClinicPhoenixArizonaUSA
| | - Chad M. Teven
- Division of Plastic and Reconstructive Surgery, Department of SurgeryMayo ClinicPhoenixArizonaUSA
| |
Collapse
|
20
|
Ward J, King I, Monroy-Iglesias M, Russell B, van Hemelrijck M, Ramsey K, Khan AA. A meta-analysis of the efficacy of vascularised lymph node transfer in reducing limb volume and cellulitis episodes in patients with cancer treatment-related lymphoedema. Eur J Cancer 2021; 151:233-244. [PMID: 34092349 DOI: 10.1016/j.ejca.2021.02.043] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 02/22/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND Lymphoedema after cancer treatment is a chronic and disabling complication that presents a significant health care burden during survivorship with limited treatment options. Vascularised lymph node transfer (VLNT) can reconstruct lymphatic flow to reduce limb volumes, but limited higher-order evidence exists to support its effectiveness. AIM The aim of the study was to systematically review and meta-analyse the effectiveness of VLNT in reducing upper limb (UL) or lower limb (LL) volume and cellulitis episodes in patients with cancer treatment-related lymphoedema (CTRL). METHODS PubMed, Medline (Ovid) and Embase databases were searched between January 1974 and December 2019. Full-length articles where VLNT was the sole therapeutic procedure for CTRL, reporting volumetric limb, frequency of infection episodes and/or lymphoedema-specific quality-of-life data, were included in a random-effects meta-analysis of circumferential reduction rate (CRR). Methodological quality was assessed using STROBE/CONSORT, and a novel, lymphoedema-specific scoring tool was used to assess lymphoedema-specific methodological reporting. Sensitivity analyses on the site of VLNT harvest and recipient location were performed. RESULTS Thirty-one studies (581 patients) were eligible for inclusion. VLNT led to significant limb volume reductions in UL (above elbow pooled CRRs [CRRP] = 42.7% [95% confidence interval (CI): 36.5-48.8]; below elbow CRRP = 34.1% [95% CI: 33.0-35.1]) and LL (above knee CRRP = 46.8% [95% CI: 43.2-50.4]; below knee CRRP = 54.6% [95% CI: 39.0-70.2]) CTRL. VLNT flaps from extra-abdominal donor sites were associated with greater volume reductions (CRRP = 49.5% [95% CI: 46.5-52.5]) than those from intra-abdominal donor sites (CRRP = 39.6% [95% CI: 37.2-42.0]) and synchronous autologous breast reconstruction/VLNT flaps (CRRP = 32.7% [95% CI: 11.1-54.4]) (p < 0.05). VLNT was also found to reduce the mean number of cellulitis episodes by 2.1 episodes per year (95% CI: -2.7- -1.4) and increased lymphoedema-specific quality-of-life scores (mean difference in Lymphoedema-Specific Quality of Life (LYMQOL) "overall domain" = +4.26). CONCLUSIONS VLNT is effective in reducing excess limb volume and cellulitis episodes in both UL and LL lymphoedema after cancer treatment. However, significant heterogeneity exists in outcome reporting, and standardisation of reporting processes is recommended.
Collapse
Affiliation(s)
- Joseph Ward
- Department of Plastic Surgery, The Royal Marsden NHS Foundation Trust, London, UK
| | - Ian King
- Department of Plastic Surgery, The Royal Marsden NHS Foundation Trust, London, UK
| | - Maria Monroy-Iglesias
- Department of Translational Oncology and Urology Research, King's College London, London, UK
| | - Beth Russell
- Department of Translational Oncology and Urology Research, King's College London, London, UK
| | - Mieke van Hemelrijck
- Department of Translational Oncology and Urology Research, King's College London, London, UK
| | - Kelvin Ramsey
- Department of Plastic Surgery, The Royal Marsden NHS Foundation Trust, London, UK
| | - Aadil A Khan
- Department of Plastic Surgery, The Royal Marsden NHS Foundation Trust, London, UK.
| |
Collapse
|
21
|
Schaverien MV, Asaad M, Selber JC, Liu J, Chen DN, Hall MS, Butler CE. Outcomes of Vascularized Lymph Node Transplantation for Treatment of Lymphedema. J Am Coll Surg 2021; 232:982-994. [PMID: 33766726 DOI: 10.1016/j.jamcollsurg.2021.03.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 01/18/2021] [Accepted: 03/01/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND A growing body of evidence supports the efficacy of surgical treatments for lymphedema. This study reports the outcomes of vascularized lymph node transplantation (VLNT) for the treatment of patients with lymphedema compared with maximal conservative treatment alone. STUDY DESIGN Consecutive patients undergoing VLNT to treat primary and secondary lymphedema affecting the upper or lower extremities were included. All patients were optimized preoperatively with conservative therapy. Demographic and treatment information was collected, and outcomes data were electronically captured prospectively; descriptive statistics were performed. RESULTS There were 134 patients included that had achieved maximal reductions by conservative therapy preoperatively. This series included jejunal mesenteric (n = 25), groin (n = 43), lateral thoracic (n = 31), omental or right gastroepiploic (n = 21), and submental (n = 14) VLN flaps. At 24 months postoperatively, there were significant reductions in limb volume change (mean [SD] 45.7% [8.7%]; p = 0.002) LDex score (mean [SD] 59.8% [8.7%]; p < 0.001), Lymphedema Life Impact Scale score (mean [SD] 61.6% [5.9]; p < 0.001), and cellulitis episodes (97.9%; p < 0.001). At 3 and 6 months postoperatively, limb volume change was significantly greater for the upper than the lower extremity, otherwise outcomes were similar. There were no flap losses and overall outcomes were similar between the different VLN flap types. CONCLUSIONS Treatment of lymphedema using VLNT resulted in progressive, significant reductions in limb volume, bioimpedance spectroscopy measurements of extracellular fluid, and episodes of cellulitis, with improved patient-reported outcomes and limb function measures compared with maximal conservative therapy alone. The complication rate was low and there were no significant outcomes differences between the VLNT types.
Collapse
Affiliation(s)
- Mark V Schaverien
- Department of Plastic Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX.
| | - Malke Asaad
- Department of Plastic Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jesse C Selber
- Department of Plastic Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jun Liu
- Department of Plastic Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Dawn N Chen
- Rehabilitation Services, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Melissa S Hall
- Department of Plastic Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Charles E Butler
- Department of Plastic Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| |
Collapse
|
22
|
Chen WF, Tuncer FB, Zeng W. Advanced Technical Pearls for Successful Supermicrosurgical Lymphaticovenular Anastomosis. Ann Plast Surg 2021; 86:S165-S172. [PMID: 33443891 DOI: 10.1097/sap.0000000000002689] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
ABSTRACT Lymphaticovenular anastomosis (LVA) is now accepted as one of the mainstays of surgical treatment of lymphedema. The unique advantages of LVA that set it apart from other procedures such as vascularized lymph node transfer are its safety and its minimally invasive nature. To date, there has been no report of worsening of disease as a result of LVA, even when performed unsuccessfully. Despite these notable advantages, the procedure is much less frequently performed compared with vascularized lymph node transfer because of inconsistent procedural outcome. In our experience, LVA is highly effective when performed with proper patient selection and meticulous technical execution. In this article, we share the senior author's LVA "tips and tricks" to help readers achieve greater success when performing this extraordinary supermicrosurgical procedure.
Collapse
Affiliation(s)
- Wei F Chen
- From the Center for Lymphedema Research and Reconstruction, Department of Plastic Surgery, Cleveland Clinic, Cleveland, OH
| | - Fatma Betul Tuncer
- From the Center for Lymphedema Research and Reconstruction, Department of Plastic Surgery, Cleveland Clinic, Cleveland, OH
| | - Weifeng Zeng
- Division of Plastic Surgery, Department of Surgery, University of Wisconsin, Madison, WI
| |
Collapse
|
23
|
Ciudad P, Agko M, Patel KM, Lo Torto F, Forte AJ, Chen HC. A single-stage triple-inset vascularized gastroepiploic lymph node transfers for the surgical treatment of extremity lymphedema. Microsurgery 2020; 41:97-99. [PMID: 33340162 DOI: 10.1002/micr.30696] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 07/23/2020] [Accepted: 12/04/2020] [Indexed: 11/08/2022]
Affiliation(s)
- Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru.,Division of Plastic Surgery, China Medical University Hospital, Taichung, Taiwan.,Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taiwan
| | - Mouchammed Agko
- Section of Plastic Surgery, Medical College of Georgia, Augusta University, Augusta, Georgia, USA
| | - Ketan M Patel
- Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Federico Lo Torto
- Department of Plastic and Reconstructive Surgery, Sapienza University of Rome, Umberto, Italy
| | - Antonio J Forte
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Hung-Chi Chen
- Division of Plastic Surgery, China Medical University Hospital, Taichung, Taiwan.,Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taiwan
| |
Collapse
|
24
|
Di Taranto G, Bolletta A, Chen SH, Losco L, Elia R, Cigna E, Rubino C, Ribuffo D, Chen HC. A prospective study on combined lymphedema surgery: Gastroepiploic vascularized lymph nodes transfer and lymphaticovenous anastomosis followed by suction lipectomy. Microsurgery 2020; 41:34-43. [PMID: 32845534 DOI: 10.1002/micr.30641] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 05/02/2020] [Accepted: 07/28/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND There is no consensus on the appropriate treatment of lymphedema. Proposed techniques include lymphaticovenous anastomosis (LVA), vascularized lymph nodes transfer (VLNT), and suction lipectomy (SL). The benefit of combined procedures has also been postulated. In this prospective study, a combined protocol is proposed as an alternative to single-procedure strategies. METHODS Between January 2016 and October 2018, we enrolled patients with secondary lymphedema of lower limbs, stage II-III according to the International Society of Lymphology, progressive swelling and skin tonicity >60. Thirty-seven consecutive patients were dichotomized into group I, undergoing VLNT, and group II undergoing VLNT and LVA. Gastroepiploic lymphnode flap was harvested through laparoscopy, and in the same operation, LVAs were performed in group II on the basis of indocyanine green lymphography and patent blue findings. Two weeks later, SL was performed in all the patients. Patients were prospectively evaluated through clinical examination, circumference measurement, and skin tonicity. RESULTS The average follow-up was 2 ± 0.8 years. The first consecutive 21 patients were treated with VLNT followed by SL. The next 16 patients underwent combined VLNT and LVA, followed by SL. A mean of 2.4 LVAs were performed. A significant difference in the postoperative circumference measurements was found overall (p < .05): 52.6 ± 18.9 above the knee, 42.9 ± 25 below the knee, 36.2 ± 37 at foot. The postoperative tonicity dropped by 12.7 ± 6.3% (p < .05). The episodes of cellulitis significantly decreased to 0.1 ± 0.3 (p < .05). CONCLUSIONS LVA, VLNT, and SL can be integrated together in a combined approach, in synergy to enhance the outcomes.
Collapse
Affiliation(s)
- Giuseppe Di Taranto
- Department of Plastic Surgery, China Medical University Hospital, Taichung, Taiwan.,Department of Plastic Surgery, University of Rome La Sapienza Department of Surgery, Rome, Italy
| | - Alberto Bolletta
- Department of Plastic Surgery, China Medical University Hospital, Taichung, Taiwan.,Department of Medical, Surgical and Experimental Sciences, Plastic Surgery Unit, Universita degli Studi di Sassari, Sassari, Italy
| | - Shih-Heng Chen
- Department of Plastic Surgery Taoyuan, Chang Gung Memorial Hospital Linkou Main Branch, Taoyuan, Taiwan
| | - Luigi Losco
- Department of Plastic Surgery, China Medical University Hospital, Taichung, Taiwan.,Dipartimento di Ricerca Traslazionale e delle Nuove Tecnologie in Medicina e Chirurgia, Università degli Studi di Pisa Facolta di Medicina e Chirurgia, Pisa, Italy
| | - Rossella Elia
- Department of Plastic Surgery, China Medical University Hospital, Taichung, Taiwan.,Universita degli Studi di Bari Dipartimento Emergenza e Trapianti di Organi, Division of Plastic and Reconstructive Surgery, Bari, Italy
| | - Emanuele Cigna
- Dipartimento di Ricerca Traslazionale e delle Nuove Tecnologie in Medicina e Chirurgia, Università degli Studi di Pisa Facolta di Medicina e Chirurgia, Pisa, Italy
| | - Corrado Rubino
- Department of Medical, Surgical and Experimental Sciences, Plastic Surgery Unit, Universita degli Studi di Sassari, Sassari, Italy
| | - Diego Ribuffo
- Department of Plastic Surgery, University of Rome La Sapienza Department of Surgery, Rome, Italy
| | - Hung-Chi Chen
- Department of Plastic Surgery, China Medical University Hospital, Taichung, Taiwan
| |
Collapse
|
25
|
Kaya B, Ciudad P, Chen SH, Para L, Chen HC. Technical details for harvesting gastro-epiploic lymph node flaps via mini-laparotomy incision. J Plast Reconstr Aesthet Surg 2020; 73:1630-1636. [PMID: 32475737 DOI: 10.1016/j.bjps.2020.05.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 02/08/2020] [Accepted: 05/09/2020] [Indexed: 10/24/2022]
Abstract
Laparoscopic harvest method to obtain gastro-epiploic lymph node flaps for lymphedema treatment has been previously described. In this article, the technical details of an alternative method - open approach via mini-laparotomy incision - for harvesting gastro-epiploic lymph node flaps and preparation of the flaps for the inset is presented. A total of 17 patients were included in this series of the mini-laparotomy approach. Blood loss was minimal during the surgery. The average duration of lymph node flap harvest was 65 min. The average length of hospital stay was 10 days. The period of the restricted diet was 1.5 days. The upper abdominal scar was acceptable, there were no postoperative hernia or bulging, and there were no complications related to bowel obstruction during the follow-up. The open approach harvest method via mini-laparotomy incision offers similar results to laparoscopic harvest method, and it is safe when applied with the right technique.
Collapse
Affiliation(s)
- Burak Kaya
- Department of Plastic Surgery, China Medical University and China Medical University Hospital, 2, Yuh-Der Road, Taichung 40447, Taiwan; Ankara University Faculty of Medicine, Ankara, Turkey
| | - Pedro Ciudad
- Department of Plastic Surgery, China Medical University and China Medical University Hospital, 2, Yuh-Der Road, Taichung 40447, Taiwan
| | | | - Luis Para
- Department of Plastic Surgery, China Medical University and China Medical University Hospital, 2, Yuh-Der Road, Taichung 40447, Taiwan
| | - Hung-Chi Chen
- Department of Plastic Surgery, China Medical University and China Medical University Hospital, 2, Yuh-Der Road, Taichung 40447, Taiwan.
| |
Collapse
|
26
|
Marx M, Geßner M, Florek A, Morgenstern S, Passin S, Brucker SY, Wallwiener D, Hahn M. Re-augmentation of the Axilla Using a Turn-Over Flap - a New Approach for the Surgical Treatment of Secondary Lymphedema After Breast Cancer. Geburtshilfe Frauenheilkd 2020; 80:526-531. [PMID: 32435069 PMCID: PMC7234824 DOI: 10.1055/a-1063-6310] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 11/18/2019] [Accepted: 11/18/2019] [Indexed: 11/12/2022] Open
Abstract
Introduction
Scarring and volume reduction of the axillary space resulting in persistent lymphedema is a side effect of axillary treatment in breast cancer patients. The aim of this paper is to describe the reduction of lymphedema achieved with a turnover flap.
Materials and Methods
Between October 2016 and May 2018, five patients with grade 2 lymphedema following breast cancer therapy underwent reconstructive surgery with a turnover flap. Complete excision of the symptomatic axillary scar tissue followed by re-augmentation using a turnover flap was performed. Subsequently, all patients underwent breast reconstruction using a distant flap reconnected to the thoracodorsal vessels. The circumference of both arms, quality of life and pain were measured before and after surgery.
Results
An average reduction in pain in the ipsilateral arm from 6 to 1 on the numerical scale as well as an improvement in quality of life (2.8 vs. 7.0) was observed. A decrease in lymphedema especially in the upper arm was identified. No complications such as secondary bleeding, infections or flap loss were observed.
Conclusion
Complete removal of the axillary scar tissue after breast cancer treatment and re-augmentation of the axilla with a turnover flap results in a reduction in ipsilateral lymphedema and an improvement in pain and quality of life. We interpret these findings as a result of the physiological re-alignment of the lymphatic vessels combined with a lymph node-containing local transposition flap. Therefore, re-augmentation with a turnover flap could be an effective non-microsurgical alternative to lymph node transplantation.
Collapse
Affiliation(s)
- Mario Marx
- Elbland Hospital Radebeul, Department of Plastic, Reconstructive and Breast Surgery, Radebeul, Germany.,Department for Women's Health, University of Tübingen, Tübingen, Germany
| | - Michael Geßner
- Elbland Hospital Radebeul, Department of Plastic, Reconstructive and Breast Surgery, Radebeul, Germany
| | - Alexander Florek
- Elbland Hospital Radebeul, Department of Plastic, Reconstructive and Breast Surgery, Radebeul, Germany
| | - Susanne Morgenstern
- Elbland Hospital Radebeul, Department of Plastic, Reconstructive and Breast Surgery, Radebeul, Germany
| | - Stefan Passin
- Elbland Hospital Radebeul, Department of Plastic, Reconstructive and Breast Surgery, Radebeul, Germany
| | - Sara Y Brucker
- Department for Women's Health, University of Tübingen, Tübingen, Germany
| | | | - Markus Hahn
- Department for Women's Health, University of Tübingen, Tübingen, Germany
| |
Collapse
|
27
|
Ciudad P, Forte AJ, Huayllani MT, Boczar D, Manrique OJ, Bustos SS, Bustamante A, Chen HC. Impact of body mass index on long-term surgical outcomes of vascularized lymph node transfer in lymphedema patients. Gland Surg 2020; 9:603-613. [PMID: 32420296 DOI: 10.21037/gs.2020.03.13] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Background Vascularized lymph node transfer (VLNT) is a surgical procedure with high interest to treat lymphedema. Body mass index (BMI) is a well-described factor that increases the risk of lymphedema, but little is known about its influence on the surgical outcomes of lymphedema patients who undergo VLNT. The aim of this study was to analyze the impact of preoperative BMI on the long-term surgical outcomes after VLNT in lymphedema patients. Methods We retrospectively compiled data of patients with International Society of Lymphology (ISL) stage II or III lymphedema who were treated with VLNT from July 2010 to July 2016 at China Medical University Hospital. Preoperative and postoperative demographic and clinical data, such as limb circumference and number of infection episodes were reviewed. Statistical analyses compared circumference reduction rates and infection episode reduction between preoperative BMI categories was done. In addition, prediction of outcomes based on quantitative preoperative BMI was analyzed. Results A total of 83 patients met the inclusion criteria. Nine patients (10.8%) were normal weight, 43 (51.8%) were overweight, and 31 (37.3%) were obese. Compared with normal-weight patients, mean circumference reduction rates were significantly lower in overweight (P=0.005) and obese patients (P=0.02), but quantitative BMI was not correlated with circumference reduction rate (P=0.96). However, obese patients had a significantly greater reduction in infection episodes than normal-weight patients (P=0.03). In addition, greater BMI predicted greater reduction in infection episodes after VLNT (P=0.02). Conclusions VLNT is an effective surgical treatment, especially for lymphedema patients with higher preoperative BMIs. The results of our study suggest that this procedure considerably decreases the number of postoperative infection episodes per year in obese patients, even though preoperative BMI does not influence circumference reduction rate.
Collapse
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
| | - Antonio J Forte
- Division of Plastic Surgery, and Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Jacksonville, FL, USA
| | - Maria T Huayllani
- Division of Plastic Surgery, and Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Jacksonville, FL, USA
| | - Daniel Boczar
- Division of Plastic Surgery, and Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Jacksonville, FL, USA
| | - Oscar J Manrique
- Department of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, MN, USA
| | - Samyd S Bustos
- Department of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, MN, USA
| | - Atenas Bustamante
- 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
| |
Collapse
|
28
|
Manrique OJ, Bustos SS, Kapoor T, Lin J, Ciudad P, Forte AJ, Del Corral G, Mani M, Maruccia M, Terzic A. Gastroepiploic vascularized lymph node transfer for the treatment of extremity lymphedema: comparison between middle and distal inset. Gland Surg 2020; 9:528-538. [PMID: 32420288 PMCID: PMC7225493 DOI: 10.21037/gs.2020.02.10] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Accepted: 12/12/2019] [Indexed: 11/06/2022]
Abstract
BACKGROUND Middle and distal insets of gastroepiploic vascularized lymph node transfer (GE-VLNT) for extremity lymphedema have been described. However, there has been no prior comparison of surgical or patient-reported outcomes between these techniques. We analyzed the outcomes between both insets in patients with extremity lymphedema. METHODS Retrospective review of patients with extremity-lymphedema who underwent GE-VLNT. Two groups were analyzed: middle and distal recipient inset. We analyzed 6-month surgical and patient-reported outcomes using the Lymphedema Life Impact Scale-v2 (LLISv2) and scar satisfaction utilizing the Patient Scar Assessment Questionnaire (PSAQ). RESULTS Between 2017 and 2019, 26 patients with stage II unilateral extremity lymphedema underwent laparoscopically-harvested GE-VLNT (13 distal and 13 middle inset). There were no differences in patient demographics between groups. Mean hospital stay for patients with upper extremity lymphedema was 1.3 vs. 4.0 days (P<0.05), and for lower extremity lymphedema was 1.0 vs. 4.5 days (P<0.05), middle vs. distal inset, respectively. Mean return to daily activities for patients with upper extremity lymphedema was 13.4 vs. 33.4 days (P<0.05), and for lower extremity lymphedema was 16.0 vs. 29.5 days (P<0.05), middle vs. distal inset, respectively. Both middle and distal inset showed significant mean excess volume reduction at 6 months postoperatively for both upper and lower extremity lymphedema (upper extremity: middle inset 23.3%, distal inset: 22.0%; lower extremity: middle inset 23.3% and distal inset 13.3%). LLISv2 scores showed improved functional outcomes postoperatively in both upper and lower extremity lymphedema with both insets. Scar satisfaction with appearance and symptoms was higher with middle inset (P<0.05). CONCLUSIONS GE-VLNT is an effective surgical treatment for extremity lymphedema. The middle placement showed shorter hospital stay, early return to work and higher patient satisfaction.
Collapse
Affiliation(s)
- Oscar J. Manrique
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, MN, USA
- Center for Regenerative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Samyd Said Bustos
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, MN, USA
- Center for Regenerative Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Jason Lin
- Mayo Clinic Alix School of Medicine, Rochester, MN, USA
| | - Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Antonio J. Forte
- Center for Regenerative Medicine, Mayo Clinic, Rochester, MN, USA
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Gabriel Del Corral
- MedStar Plastic and Reconstructive Surgery, Georgetown University Hospital, Washington D.C., USA
| | - Maria Mani
- Department of Plastic Surgery, Uppsala Universitet, Uppsala, Sweden
| | - Michele Maruccia
- Division of Plastic and Reconstructive Surgery, Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Bari, Italy
| | - Andre Terzic
- Center for Regenerative Medicine, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
29
|
Ciudad P, Manrique OJ, Bustos SS, Vargas MI, Reynaga C, Agko M, Huang TCT, Benites EF, Mayer HF, Forte AJ. Combined microvascular breast and lymphatic reconstruction with deep inferior epigastric perforator flap and gastroepiploic vascularized lymph node transfer for postmastectomy lymphedema patients. Gland Surg 2020; 9:512-520. [PMID: 32420286 PMCID: PMC7225469 DOI: 10.21037/gs.2020.01.14] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 12/12/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND The combination of microvascular breast reconstruction (MBR) and vascularized lymph node transfer (VLNT) in a single-stage procedure is a surgical option for women who desire breast reconstruction and postmastectomy lymphedema surgery. In this study, we present a series of patients who underwent simultaneous lymphatic and MBR with the gastroepiploic VLNT (GE-VLNT) and the deep inferior epigastric perforator (DIEP) flap respectively. METHODS Between 2018 and 2019, all consecutive patients diagnosed with lymphedema stage IIb-III International Society of Lymphology who opted to pursue simultaneous MBR with DIEP flap and GE-VLNT were included in this study. Patient demographics, comorbidities, prior radiation therapy, operative characteristics, surgical outcomes and complications were collected and analyzed. RESULTS Six patients underwent simultaneous unilateral MBR with DIEP flap and GE-VLNT. The mean age was 48±10.5 years and mean body mass index was 28.2±4.5 kg/m2. The flap survival rate was 100%. One patient required re-exploration due to venous congestion of the lymph node flap but was successfully salvaged. There was no donor site morbidity at the donor or recipient site for the DIEP flap were seen. The mean circumference reduction rate was 30.0%±5.1% (P<0.001). One patient stage III underwent additional liposuction at 12 months postoperative to improve final results. CONCLUSIONS The combined use of DIEP flap and GE-VLNT flaps in a single-stage procedure is a safe and reliable surgical option for patients with postmastectomy lymphedema who desire and are suitable for autologous microvascular breast and lymphatic reconstruction.
Collapse
Affiliation(s)
- Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
- Department of Plastic and Reconstructive Surgery, Ciruesthetic Clinic, Lima, Peru
| | - Oscar J. Manrique
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, MN, USA
- Center for Regenerative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Samyd S. Bustos
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, MN, USA
- Center for Regenerative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Maria I. Vargas
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - César Reynaga
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Mouchammed Agko
- Section of Plastic Surgery, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Tony C. T. Huang
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Horacio F. Mayer
- Plastic Surgery Department, Hospital Italiano de Buenos Aires, University of Buenos Aires Medical School, Buenos Aires, Argentina
| | - Antonio J. Forte
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Jacksonville, FL, USA
| |
Collapse
|
30
|
Controversies in Surgical Management of Lymphedema. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2671. [PMID: 32537335 PMCID: PMC7253258 DOI: 10.1097/gox.0000000000002671] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 12/18/2019] [Indexed: 12/01/2022]
Abstract
Surgical treatment of lymphedema has expanded in recent years. Lymphovenous bypass and vascularized lymph node transfer are both modern techniques to address the physiologic dysfunction associated with secondary lymphedema. While efficacy of both techniques has been demonstrated in numerous studies, there are several questions that remain. Here, the authors discuss the most pertinent controversies in our practice as well as the current state of surgical management of lymphedema.
Collapse
|
31
|
Ciudad P, Vargas MI, Bustamante A, Agko M, Manrique OJ, Ludeña J, Castro J, Wiegering G, Navarro W, Reynaga C. Combined radical reduction with preservation of perforators and distal lymphaticovenular anastomosis for advanced lower extremity lymphedema. Microsurgery 2020; 40:417-418. [PMID: 32073166 DOI: 10.1002/micr.30569] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 01/10/2020] [Accepted: 01/31/2020] [Indexed: 11/06/2022]
Affiliation(s)
- Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Maria I Vargas
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Atenas Bustamante
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Mouchammed Agko
- Section of Plastic Surgery, Medical College of Georgia, Augusta University, Augusta, Georgia
| | - Oscar J Manrique
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester
| | - Juan Ludeña
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Jorge Castro
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Guillermo Wiegering
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Walter Navarro
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - César Reynaga
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| |
Collapse
|
32
|
Ciudad P, Manrique OJ, Bustos SS, Coca JJP, Chang C, Shih P, Nicoli F, Lo Torto F, Agko M, Huang TC, Maruccia M, Chen H. Comparisons in long‐term clinical outcomes among patients with upper or lower extremity lymphedema treated with diverse vascularized lymph node transfer. Microsurgery 2020; 40:130-136. [DOI: 10.1002/micr.30508] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 08/08/2019] [Accepted: 08/16/2019] [Indexed: 11/09/2022]
Affiliation(s)
- Pedro Ciudad
- Department of Plastic, Reconstructive and Burn SurgeryArzobispo Loayza National Hospital Lima Peru
- Department of Plastic and Reconstructive SurgeryChina Medical University Taichung Taiwan
| | - Oscar J. Manrique
- Department of Plastic and Reconstructive SurgeryMayo Clinic Rochester Minnesota
| | - Samyd S. Bustos
- Department of Plastic and Reconstructive SurgeryMayo Clinic Rochester Minnesota
| | - John J. P. Coca
- Department of Plastic, Reconstructive and Burn SurgeryArzobispo Loayza National Hospital Lima Peru
| | - Chang‐Cheng Chang
- Department of Plastic and Reconstructive SurgeryChina Medical University Taichung Taiwan
| | - Pin‐Keng Shih
- Department of Plastic and Reconstructive SurgeryChina Medical University Taichung Taiwan
| | - Fabio Nicoli
- Department of Plastic and Reconstructive SurgeryUniversity of Rome “Tor Vergata” Rome Italy
| | - Federico Lo Torto
- Sapienza Università di Roma, Policlinico Umberto I, Department of Surgery “P. Valdoni”Unit of Plastic Reconstructive and Aesthetic Surgery Rome Italy
| | - Mouchammed Agko
- Section of Plastic Surgery, Medical College of GeorgiaAugusta University Augusta Georgia
| | - Tony C.‐T. Huang
- Department of Plastic and Reconstructive SurgeryMayo Clinic Rochester Minnesota
| | - Michele Maruccia
- Division of Plastic and Reconstructive Surgery, Department of Emergency and Organ TransplantationUniversity of Bari Bari Italy
| | - Hung‐Chi Chen
- Department of Plastic and Reconstructive SurgeryChina Medical University Taichung Taiwan
| |
Collapse
|
33
|
Forte AJ, Cinotto G, Boczar D, Huayllani MT, McLaughlin SA. Omental Lymph Node Transfer for Lymphedema Patients: A Systematic Review. Cureus 2019; 11:e6227. [PMID: 31807393 PMCID: PMC6881079 DOI: 10.7759/cureus.6227] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 11/24/2019] [Indexed: 11/16/2022] Open
Abstract
Lymph node transfer is a surgical treatment that is becoming more prevalent. The lymph nodes from the groin and neck are most frequently used. Iatrogenic lymphedema can be a consequence of the dissection of the groin nodes; thus, some surgeons prefer to use the neck as a donor site. Literature reporting surgical algorithms for the treatment of lymphedema is scarce. Thus, we conducted a systematic review of vascularized omentum lymph node transfer (VOLT) in patients with lymphedema to provide more information about this increasingly common procedure. We hypothesize that the analyzed studies will show that VOLT has positive outcomes. Two reviewers (G.J.C., D.B.) performed independent searches using the PubMed database without timeframe limitations initially through title and abstract descriptions and then by full-text review. The search was done using the following keywords: Breast cancer lymphedema OR lymphedema AND lymph node transfer OR lymph node flap OR lymph node graft AND omental OR omentum OR gastroepiploic. Eligibility criteria included publications evaluating patients with lymphedema in the upper extremity and lower extremity, who underwent VOLT. Our search yielded 35 potential papers in the literature, but only six studies fulfilled the study eligibility criteria. The total number of patients was 137. Three studies described single VOLT, two studies described double VOLT and one study described two cohort patients, one that was treated with single VOLT and another one that was treated with double VOLT. Postoperative reduction of arm circumference, arm volume, and symptoms of the upper extremity were reported in all patients. Nonetheless, in one study, seven patients did not notice any extremity circumference reduction during the follow-up period and four patients noticed an increase in arm volume. Flap loss was reported by two authors in a total of two patients. Overall, patients experienced successful lymphedema treatment with VOLT. All authors presented results with reduced circumferential size of the affected upper and lower limbs, as well as reduction of the infectious intercurrences, such as cellulitis, with a small incidence of associated complications.
Collapse
Affiliation(s)
- Antonio J Forte
- Plastic Surgery, Mayo Clinic Florida - Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Jacksonville, USA
| | - Gabriela Cinotto
- Plastic Surgery, Mayo Clinic Florida - Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Jacksonville, USA
| | - Daniel Boczar
- Plastic Surgery, Mayo Clinic Florida - Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Jacksonville, USA
| | - Maria T Huayllani
- Plastic Surgery, Mayo Clinic Florida - Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Jacksonville, USA
| | - Sarah A McLaughlin
- Surgery, Mayo Clinic Florida - Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Jacksonville, USA
| |
Collapse
|
34
|
Maruccia M, Pezzolla A, Nacchiero E, Dicillo P, Macchia L, Fiore P, Giudice G, Elia R. Efficacy and early results after combining laparoscopic harvest of double gastroepiploic lymph node flap and active physiotherapy for lower extremity lymphedema. Microsurgery 2019; 39:679-687. [DOI: 10.1002/micr.30511] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 08/20/2019] [Accepted: 08/23/2019] [Indexed: 01/14/2023]
Affiliation(s)
- Michele Maruccia
- Division of Plastic and Reconstructive Surgery, Department of Emergency and Organ TransplantationUniversity of Bari Aldo Moro Bari Italy
| | - Angela Pezzolla
- Division of Videolaparoscopic Surgery, Department of Emergency and Organ TransplantationUniversity of Bari Bari Italy
| | - Eleonora Nacchiero
- Division of Plastic and Reconstructive Surgery, Department of Emergency and Organ TransplantationUniversity of Bari Aldo Moro Bari Italy
| | - Patrizia Dicillo
- Department of Basic Medical Sciences, Neuroscience and Sensory OrgansUniversity of Bari "Aldo Moro" Bari Italy
| | - Laura Macchia
- Department of Basic Medical Sciences, Neuroscience and Sensory OrgansUniversity of Bari "Aldo Moro" Bari Italy
| | - Piero Fiore
- Department of Basic Medical Sciences, Neuroscience and Sensory OrgansUniversity of Bari "Aldo Moro" Bari Italy
| | - Giuseppe Giudice
- Division of Plastic and Reconstructive Surgery, Department of Emergency and Organ TransplantationUniversity of Bari Aldo Moro Bari Italy
| | - Rossella Elia
- Division of Plastic and Reconstructive Surgery, Department of Emergency and Organ TransplantationUniversity of Bari Aldo Moro Bari Italy
| |
Collapse
|
35
|
|
36
|
Fan KL, Black CK, Song DH, Del Corral GA. The "String of Pearls" technique for increased surface area and lymphedematous fluid drainage in right gastroepiploic-vascularized lymph node transfer: A report of two cases. Microsurgery 2019; 39:548-552. [PMID: 31225685 DOI: 10.1002/micr.30484] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Revised: 05/28/2019] [Accepted: 06/11/2019] [Indexed: 11/09/2022]
Abstract
We present our "String of Pearls" technique for upper and lower extremity lymphedema based off the right gastroepiploic artery. The entire laprascopically harvested omentum is placed through a longitudinal incision at the lymphedematous area, and anastomosed proximally, with additional distal venous outflow. This approach preserves the native lymphaticovenous architecture, distributes free lymphatic tissue along the axis of the extremity, and allows for scar release. The additional vein serves to restore bidirectional physiologic drainage inherent in the omentum and providing further lymphaticovenous drainage. We present two cases of upper and lower extremity lymphedema as a result of malignancy treated using this method. The first case was a result of breast cancer in a 55-year-old female with orthotopically placed omentum, and the second case a result of malignant nodular fasciitis in the distal lower extremity in a 56-year-old female with distally placed omentum. No complications occurred. At 3 months follow up, there is a 25% and 28% reduction in lower and upper extremity volume, respectively, with no recurrent cellulitis episodes. The safety and feasibility of placement of the entire omentum longitudinally with additional venous anastomosis are apparent. However, long-term studies are required.
Collapse
Affiliation(s)
- Kenneth L Fan
- MedStar Plastic and Reconstructive Surgery, MedStar Health, Washington, District of Columbia
| | - Cara K Black
- MedStar Plastic and Reconstructive Surgery, MedStar Health, Washington, District of Columbia
| | - David H Song
- MedStar Plastic and Reconstructive Surgery, MedStar Health, Washington, District of Columbia
| | - Gabriel A Del Corral
- MedStar Plastic and Reconstructive Surgery, MedStar Health, Washington, District of Columbia
| |
Collapse
|
37
|
Di Taranto G, Chen S, Elia R, Bolletta A, Amorosi V, Sitpahul N, Chan JCY, Ribuffo D, Chen H. Free gastroepiploic lymph nodes and omentum flap for treatment of lower limb ulcers in severe lymphedema: Killing two birds with one stone. J Surg Oncol 2019; 121:168-174. [DOI: 10.1002/jso.25581] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 05/09/2019] [Accepted: 05/20/2019] [Indexed: 01/27/2023]
Affiliation(s)
- Giuseppe Di Taranto
- Department of Plastic SurgeryChina Medical University HospitalTaichung Taiwan
- Department of Plastic and Reconstructive SurgeryUmberto I University HospitalSapienza University of RomeRome Italy
| | - Shih‐Heng Chen
- Department of Plastic SurgeryChang Gung Memorial HospitalTaipei Taiwan
| | - Rossella Elia
- Department of Plastic SurgeryChina Medical University HospitalTaichung Taiwan
- Division of Plastic and Reconstructive Surgery, Department of Emergency and Organ TransplantationUniversity of BariBari Italy
| | - Alberto Bolletta
- Department of Plastic SurgeryChina Medical University HospitalTaichung Taiwan
- Department of Medical, Surgical, and Experimental SciencesPlastic Surgery UnitUniversity of SassariSassari Italy
| | - Vittoria Amorosi
- Department of Plastic SurgeryChina Medical University HospitalTaichung Taiwan
- Plastic Surgery DepartmentSapienza University of RomeRome Italy
| | - Ngamcherd Sitpahul
- Department of Plastic SurgeryChina Medical University HospitalTaichung Taiwan
- Department of Plastic and Maxillofacial Surgery, Faculty of Medicine, Ramathibodi HospitalMahidol UniversityBangkok Thailand
| | - Jeffrey CY Chan
- Department of Plastic SurgeryChina Medical University HospitalTaichung Taiwan
| | - Diego Ribuffo
- Department of Plastic and Reconstructive SurgeryUmberto I University HospitalSapienza University of RomeRome Italy
| | - Hung‐Chi Chen
- Department of Plastic SurgeryChina Medical University HospitalTaichung Taiwan
| |
Collapse
|
38
|
Bolletta A, Di Taranto G, Chen SH, Elia R, Amorosi V, Chan JCY, Chen HC. Surgical treatment of Milroy disease. J Surg Oncol 2019; 121:175-181. [DOI: 10.1002/jso.25583] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 05/21/2019] [Accepted: 05/21/2019] [Indexed: 12/21/2022]
Affiliation(s)
- A Bolletta
- Department of Plastic SurgeryChina Medical University Hospital Taichung Taiwan
- Department of Medical, Surgical, and Experimental SciencesPlastic Surgery Unit, University of SassariSassari Italy
| | - G Di Taranto
- Department of Plastic SurgeryChina Medical University Hospital Taichung Taiwan
- Department of Plastic and Reconstructive SurgerySapienza University of Rome, Umberto I University HospitalRome Italy
| | - SH Chen
- Department of Plastic SurgeryChang Gung Memorial HospitalTaipei Taiwan
| | - R Elia
- Department of Plastic SurgeryChina Medical University Hospital Taichung Taiwan
- Division of Plastic and Reconstructive Surgery, Department of Emergency and Organ TransplantationUniversity of BariBari Italy
| | - V Amorosi
- Department of Plastic SurgeryChina Medical University Hospital Taichung Taiwan
- Plastic Surgery Unit, Sant'Andrea Hospital, School of Medicine and PsychologySapienza University of RomeRome Italy
| | - J CY Chan
- Department of Plastic SurgeryChina Medical University Hospital Taichung Taiwan
| | - HC Chen
- Department of Plastic SurgeryChina Medical University Hospital Taichung Taiwan
| |
Collapse
|
39
|
Chilgar RM, Khade S, Chen HC, Ciudad P, Yeo MSW, Kiranantawat K, Maruccia M, Li K, Zhang YX, Nicoli F. Surgical Treatment of Advanced Lymphatic Filariasis of Lower Extremity Combining Vascularized Lymph Node Transfer and Excisional Procedures. Lymphat Res Biol 2019; 17:637-646. [PMID: 31038386 DOI: 10.1089/lrb.2018.0058] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Lymphatic filariasis (LF) in advanced stage is a clinically challenging disability resulting in poor quality of life. In advanced stage of filariasis, medical management is seldom effective and few surgical procedures are beneficial. In this study, we assessed clinical efficacy of a surgical technique combining vascularized lymph node transfer (VLNT) and serial excision for patients affected by advanced LF. Patients and Methods: A total of 17 patients with grades 2 and 3 lower limb lymphedema after three consecutive humanitarian missions in India between 2014 and 2018 underwent excision of excessive soft tissue of leg and supraclavicular lymph node flap transferred to dorsum of foot. Recipient vessels were prepared and microanastomosis was performed. Lymphedema was assessed by measuring leg circumferences at different levels, episodes of infectious lymphangitis, and lymphoscintigraphy. Results: A significant decrease of lower limb circumference measurements at all levels was noted postoperatively. Postoperative lymphoscintigraphy revealed reduced lymph stasis. One patient suffered of a seroma on donor site. Six patients had partial loss of skin graft over the flap at recipient site and it was managed by regrafting. Data analysis observed statistically significant reduction in feeling of heaviness (p < 0.005) and episodes of acute lymphangitis after surgery. Conclusion: Advanced LF of leg is difficult to manage using traditional medical treatment. The combination of VLNT and surgical excision provided a safe and reliable approach to treat this debilitating disease.
Collapse
Affiliation(s)
- Ram M Chilgar
- Department of Plastic and Reconstructive Surgery, Elrevo Clinic, Aurangabad, India.,Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Sujit Khade
- Department of Plastic and Reconstructive Surgery, Elrevo Clinic, Aurangabad, India
| | - Hung-Chi Chen
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Pedro Ciudad
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Matthew Sze-Wei Yeo
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Kidakorn Kiranantawat
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan.,Department of Plastic and Maxillofacial Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Michele Maruccia
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Ke Li
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Yi Xin Zhang
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Fabio Nicoli
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan.,Department of Plastic and Reconstructive Surgery, University of Rome "Tor Vergata", Rome, Italy.,Department of Plastic and Reconstructive Surgery, Newcastle Upon Tyne Hospitals, Newcastle Upon Tyne, United Kingdom
| |
Collapse
|
40
|
Maruccia M, Elia R, Ciudad P, Nacchiero E, Nicoli F, Vestita M, Chen HC, Giudice G. Postmastectomy upper limb lymphedema: Combined vascularized lymph node transfer and scar release with fat graft expedites surgical and patients' related outcomes. A retrospective comparative study. J Plast Reconstr Aesthet Surg 2019; 72:892-901. [PMID: 30819649 DOI: 10.1016/j.bjps.2019.01.029] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 12/15/2018] [Accepted: 01/18/2019] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Lymphedema resulting from breast cancer treatment is a chronic condition that can significantly compromise quality of life. Several works have documented the efficacy of vascularized lymph node flap transfer (VLNT) for the treatment of advanced-stage lymphedema. Given that the axillary scar may contribute to the patient's existing lymphedema, the authors assumed that combining VLNT and scar release with fat graft could be an effective strategy of treatment. The purpose of this study is to compare the efficacy in the reduction of limb circumference and health-related quality of life between a combined strategy, namely, VLN transfer (VLNT) and axillary scar release with fat grafting, and only VLNT for patients affected by postmastectomy upper limb lymphedema. The idea. MATERIALS AND METHODS All patients with stage II and III breast cancer-related lymphedema operated between January 2012 and January 2016 were retrospectively identified, and only those treated by combined VLNT and scar release (Group A) or only VLNT (Group B) were included. The outcomes were assessed clinically by limb circumference measurement and radiologically by lymphoscintigraphy. Lymphedema-related quality of life was evaluated preoperatively and at 1 year follow-up through the LYMQOL questionnaire. RESULTS Thirty-nine patients met inclusion criteria (Group A = 18; Group B = 21). Mean follow-up was 29 months for Group A and 32 months for Group B. Flap survival rate was 100%, with no donor site morbidity in all patients. A statistically significant difference between the circumference reduction rates (RR) at above elbow level was observed at 3 and 6 months of follow-up comparing the two groups (p<0.00001), with higher values in Group A than in Group B. No significant difference was detected comparing RR values at above and below elbow at 12 and 24 months postoperatively. LYMQOL metrics showed significantly better scores (p<0.0001) in all domains at all follow-up appointments in Group A. CONCLUSIONS Patients with postmastectomy upper limb lymphedema can benefit from combined lymph node transfer and axillary scar release with fat graft, as this approach seems to fasten the onset of improvement and to have a positive impact on patients' quality of life.
Collapse
Affiliation(s)
- M Maruccia
- Division of Plastic and Reconstructive Surgery, Department of Emergency and Organ Transplantation, University of Bari, 11, Piazza Giulio Cesare, Bari 70124, Italy
| | - R Elia
- Division of Plastic and Reconstructive Surgery, Department of Emergency and Organ Transplantation, University of Bari, 11, Piazza Giulio Cesare, Bari 70124, Italy.
| | - P Ciudad
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - E Nacchiero
- Division of Plastic and Reconstructive Surgery, Department of Emergency and Organ Transplantation, University of Bari, 11, Piazza Giulio Cesare, Bari 70124, Italy
| | - F Nicoli
- Department of Plastic and Reconstructive Surgery, University of Rome ``Tor Vergata'', Rome, Italy
| | - M Vestita
- Division of Plastic and Reconstructive Surgery, Department of Emergency and Organ Transplantation, University of Bari, 11, Piazza Giulio Cesare, Bari 70124, Italy
| | - H C Chen
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - G Giudice
- Division of Plastic and Reconstructive Surgery, Department of Emergency and Organ Transplantation, University of Bari, 11, Piazza Giulio Cesare, Bari 70124, Italy
| |
Collapse
|
41
|
Elia R, Clemente ET, Vestita M, Nacchiero E. Letter to editor: Surgical-site infection following lymph node excision indicates susceptibility for lymphedema: A retrospective cohort study of malignant melanoma patients. J Plast Reconstr Aesthet Surg 2019; 72:685-710. [PMID: 30733079 DOI: 10.1016/j.bjps.2018.12.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Accepted: 12/02/2018] [Indexed: 10/27/2022]
Abstract
Following the reading of the original article "Surgical-site infection following lymph node excision indicates susceptibility for lymphedema: A retrospective cohort study of malignant melanoma patients", the authors reviewed the literature for the discussed therapeutic value of complete lymph node dissection (CLND), the major complications and the current treatment for lymphedema. The authors also share their experience and protocol for CLND, and treating lymphedema using lymph node flap transfer and multiple lymphatic-venous anastomoses.
Collapse
Affiliation(s)
- R Elia
- Division of Plastic and Reconstructive Surgery, Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Piazza Giulio Cesare 11, Bari 70124, Italy
| | - E Tedone Clemente
- Division of Plastic and Reconstructive Surgery, Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Piazza Giulio Cesare 11, Bari 70124, Italy.
| | - M Vestita
- Division of Plastic and Reconstructive Surgery, Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Piazza Giulio Cesare 11, Bari 70124, Italy; Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - E Nacchiero
- Division of Plastic and Reconstructive Surgery, Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Piazza Giulio Cesare 11, Bari 70124, Italy
| |
Collapse
|
42
|
Anatomical Basis of the Gastroepiploic Vascularized Lymph Node Transfer: A Radiographic Evaluation Using Computed Tomographic Angiography. Plast Reconstr Surg 2019; 142:1046-1052. [PMID: 30020230 DOI: 10.1097/prs.0000000000004772] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND The omentum, nourished by the gastroepiploic vessels, has gained popularity as an option for vascularized lymph node transfer. The anatomy of the gastroepiploic vessels, omentum, and lymph nodes has not been investigated. The purpose of this article is to describe the right gastroepiploic artery and related structures by using computed tomographic angiography. METHODS A retrospective analysis was conducted on 34 patients who underwent computed tomographic angiography. Statistical models were applied to identify right gastroepiploic artery and lymph node anatomical characteristics. RESULTS The right gastroepiploic artery was identified in 33 of 34 patients. It was found to have a diameter of 2.49 ± 0.66 mm at its origin. The gastroduodenal artery length before right gastroepiploic artery takeoff was 3.09 ± 1.31 cm. Twenty-five patients had lymph nodes in the right gastroepiploic artery lymphosome. There were 2.7 ± 2.12 lymph nodes identified per patient. The distance from the right gastroepiploic artery origin to the most proximal lymph node was 3.99 ± 2.21 cm. The distance from the gastroepiploic artery origin to the third lymph node was 9.12 ± 5.06 cm. Each lymph node was within 7.00 ± 6.2 mm of the right gastroepiploic artery. CONCLUSIONS When using the right gastroepiploic artery donor site for vascularized lymph node transfer, the plastic surgeon should anticipate using a pedicle length of 4 cm, a total flap length of 9 cm, and 3 cm of surrounding tissue to obtain at least three lymph nodes for transfer. Computed tomographic angiography is an effective imaging modality that can be used for patient-specific surgical navigation before vascularized lymph node transfer.
Collapse
|
43
|
Ciudad P, Agko M, Huang TCT, Manrique OJ, Chang WL, Nicoli F, Maruccia M, Lo Torto F, Chen HC. Comprehensive multimodal surgical treatment of end-stage lower extremity lymphedema with toe management: The combined Charles,’ Homan’s, and vascularized lymph node transfer (CHAHOVA) procedures. J Surg Oncol 2019; 119:430-438. [PMID: 30613978 DOI: 10.1002/jso.25356] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 12/16/2018] [Indexed: 11/12/2022]
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 Hospital; Taichung Taiwan
| | - Mouchammed Agko
- Section of Plastic Surgery; Medical College of Georgia, Augusta University; Augusta Georgia
| | - Tony C. T. Huang
- Department of Plastic and Reconstructive Surgery; Mayo Clinic; Rochester Minnesota
| | - Oscar J Manrique
- Department of Plastic and Reconstructive Surgery; Mayo Clinic; Rochester Minnesota
| | - Wei-Ling Chang
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - Fabio Nicoli
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - Michele Maruccia
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - Federico Lo Torto
- Department of Plastic and Reconstructive Surgery; National Cancer Institute of Peru (INEN); Lima Peru
| | - Hung-Chi Chen
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| |
Collapse
|
44
|
Elia R, Tedone Clemente E, Vestita M, Nacchiero E. Robotic inguinal lymph node dissection for melanoma: a novel approach to a complicated problem. J Robot Surg 2019; 13:361-362. [PMID: 30607692 DOI: 10.1007/s11701-018-00906-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 12/02/2018] [Indexed: 10/27/2022]
Abstract
Following the interesting reading of the article "Robotic inguinal lymph node dissection for melanoma: a novel approach to a complicated problem", the authors review the pros and cons of a minimally invasive technique for lymph node dissection, the consequences of complete lymph node dissection and the possible treatments for lymphedema, such as lymph node flap transfer and multiple lymphatic-venous anastomoses. The authors also review the possible benefits of applying the robotic technique to anatomical sites other than the inguinal one.
Collapse
Affiliation(s)
- R Elia
- Division of Plastic and Reconstructive Surgery, Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Piazza Giulio Cesare 11, 70124, Bari, Italy
| | - Erica Tedone Clemente
- Division of Plastic and Reconstructive Surgery, Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Piazza Giulio Cesare 11, 70124, Bari, Italy.
| | - M Vestita
- Division of Plastic and Reconstructive Surgery, Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Piazza Giulio Cesare 11, 70124, Bari, Italy.,Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - E Nacchiero
- Division of Plastic and Reconstructive Surgery, Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Piazza Giulio Cesare 11, 70124, Bari, Italy
| |
Collapse
|
45
|
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: 6.4] [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
| |
Collapse
|
46
|
Ochoa O, Metzner M, Theoharis C, Chrysopoulo M, Pisano S, Nastala C, Ledoux P, Arishita G, Garza R, Snider T. Deep inferior epigastric lymph node basin: Analysis of novel donor site for vascularized lymph node transfer among 10 consecutive patients. Microsurgery 2018; 39:215-220. [DOI: 10.1002/micr.30372] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 07/11/2018] [Accepted: 08/07/2018] [Indexed: 11/09/2022]
Affiliation(s)
- Oscar Ochoa
- Plastic Reconstructive and Microsurgical Associates (PRMA) San Antonio Texas
| | | | | | - Minas Chrysopoulo
- Plastic Reconstructive and Microsurgical Associates (PRMA) San Antonio Texas
| | - Steven Pisano
- Plastic Reconstructive and Microsurgical Associates (PRMA) San Antonio Texas
| | - Chet Nastala
- Plastic Reconstructive and Microsurgical Associates (PRMA) San Antonio Texas
| | - Peter Ledoux
- Plastic Reconstructive and Microsurgical Associates (PRMA) San Antonio Texas
| | - Gary Arishita
- Plastic Reconstructive and Microsurgical Associates (PRMA) San Antonio Texas
| | - Ramon Garza
- Plastic Reconstructive and Microsurgical Associates (PRMA) San Antonio Texas
| | - Ted Snider
- South Texas Pathology Associates San Antonio Texas
| |
Collapse
|
47
|
Schaverien MV, Badash I, Patel KM, Selber JC, Cheng MH. Vascularized Lymph Node Transfer for Lymphedema. Semin Plast Surg 2018; 32:28-35. [PMID: 29636651 DOI: 10.1055/s-0038-1632401] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Advances in our understanding of the lymphatic system and the pathogenesis of lymphedema have resulted in the development of effective surgical treatments. Vascularized lymph node transfer (VLNT) involves the microvascular transplantation of functional lymph nodes into an extremity to restore physiological lymphatic function. It is most commonly performed by transferring combined deep inferior epigastric artery perforator and superficial inguinal lymph node flaps for postmastectomy breast reconstruction. For patients who do not require or are unable to undergo free abdominal breast reconstruction or have lymphedema affecting the lower extremity, several other VLNT options are available. These include flaps harvested from within the axillary, inguinal, or cervical lymph node basins, and lymph node flaps from within the abdominal cavity. This article reviews the lymph node flap options and techniques available for VLNT for lymphedema.
Collapse
Affiliation(s)
- Mark V Schaverien
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ido Badash
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Ketan M Patel
- Division of Plastic and Reconstructive Surgery, Keck Medical Center of USC, University of Southern California, Los Angeles, California
| | - Jesse C Selber
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ming-Huei Cheng
- Department of Plastic Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| |
Collapse
|
48
|
Kenworthy EO, Nelson JA, Verma R, Mbabuike J, Mehrara BJ, Dayan JH. Double vascularized omentum lymphatic transplant (VOLT) for the treatment of lymphedema. J Surg Oncol 2018. [PMID: 29518822 DOI: 10.1002/jso.25033] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND AND OBJECTIVES Orthotopic vascularized lymph node transplant has been successfully used to treat lymphedema. A second, heterotopic lymph node transplant in the distal extremity may provide further improvement. The vascularized omentum lymphatic transplant (VOLT) provides adequate tissue for two simultaneous flap transfers to one limb. The purpose of this study was to review our experience with this technique. METHODS We conducted a retrospective study of patients who underwent VOLT, with a subgroup analysis of patients who underwent double VOLT. Technical aspects of the procedure, complications, and early outcomes were reviewed. RESULTS From May 2015 to August 2017, 54 VOLTs were performed in 38 patients, of whom 16 received double VOLT. Among patients in the double VOLT group with postoperative imaging at 1 year, uptake into the transplanted omentum was seen in three of six (50%) patients on lymphoscintigraphy and in one of five (20%) patients on indocyanine green lymphangiography. One patient (3.1%) in the double VOLT group required a return to the operating room. There were no donor site complications in the double VOLT group. The overall complication rate was 15.8%. CONCLUSIONS Double VOLT to the mid-level and proximal extremity is a safe and viable option.
Collapse
Affiliation(s)
- Elizabeth O Kenworthy
- Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, New York
| | - Jonas A Nelson
- Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, New York
| | - Richa Verma
- Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, New York
| | - JeanJacques Mbabuike
- Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, New York
| | - Babak J Mehrara
- Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, New York
| | - Joseph H Dayan
- Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, New York
| |
Collapse
|
49
|
Maruccia M, Pezzolla A, Elia R, Vestita M, Nacchiero E, Giudice G. LETTER TO THE EDITOR. J Surg Oncol 2018; 117:1344-1345. [DOI: 10.1002/jso.24958] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 11/10/2017] [Indexed: 11/06/2022]
Affiliation(s)
- Michele Maruccia
- Section of Plastic and Reconstructive Surgery, Department of Emergency and Organ Transplantation; University of Bari; Bari Italy
| | - Angela Pezzolla
- Section of Videolaparoscopic Surgery, Department of Emergency and Organ Transplantation; University of Bari; Bari Italy
| | - Rossella Elia
- Section of Plastic and Reconstructive Surgery, Department of Emergency and Organ Transplantation; University of Bari; Bari Italy
| | - Michelangelo Vestita
- Section of Plastic and Reconstructive Surgery, Department of Emergency and Organ Transplantation; University of Bari; Bari Italy
| | - Eleonora Nacchiero
- Section of Plastic and Reconstructive Surgery, Department of Emergency and Organ Transplantation; University of Bari; Bari Italy
| | - Giuseppe Giudice
- Section of Plastic and Reconstructive Surgery, Department of Emergency and Organ Transplantation; University of Bari; Bari Italy
| |
Collapse
|
50
|
Chang CC, Su CL, Xu DR, Lin BS, Chen HC. A quantitative evaluation with an innovative wireless bio-impedance device to check improvement of limb lymphedema after receiving two-site vascularized lymph node transfer simultaneously in a patient. Microsurgery 2018; 38:347-348. [PMID: 29446479 DOI: 10.1002/micr.30299] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 12/12/2017] [Accepted: 01/24/2018] [Indexed: 11/10/2022]
Affiliation(s)
- Chang-Cheng Chang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, China Medical University Hospital, Taichung, Taiwan.,School of Medicine, China Medical University, Taichung, Taiwan.,Institute of Imaging and Biomedical Photonics, National Chiao Tung University, Tainan, Taiwan
| | - Chun-Lin Su
- Department of Surgery, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
| | - Dai-Ru Xu
- Institute of Imaging and Biomedical Photonics, National Chiao Tung University, Tainan, Taiwan
| | - Bor-Shyh Lin
- Institute of Imaging and Biomedical Photonics, National Chiao Tung University, Tainan, Taiwan
| | - Hung-Chi Chen
- Division of Plastic and Reconstructive Surgery, Department of Surgery, China Medical University Hospital, Taichung, Taiwan
| |
Collapse
|