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Chu CK, Hanasono MM, Chang EI. Treatment of multiple limb lymphedema with combined supermicrosurgical techniques. Microsurgery 2023; 43:13-19. [PMID: 35244958 DOI: 10.1002/micr.30878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Revised: 01/01/2022] [Accepted: 02/24/2022] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Lymphedema surgery including lymphovenous anastomosis (LVA) and vascularized lymph node transfer (VLNT) are effective treatments for lymphedema; however, treating multiple limbs in a single operation using both approaches has not been described. We hypothesize multiple limb lymphedema can be treated effectively in one operation. PATIENT AND METHODS Retrospective review of seven patients undergoing extreme lymphedema surgery (mean age: 53.2 years; range: 33-66 years) with an average BMI of 34.8 kg/m2 (range: 17.6-53.6 kg/m2 ). Two patients developed bilateral upper extremity (UE) lymphedema secondary to breast cancer treatment, three had bilateral lower extremity (LE) lymphedema, and two suffered from lymphedema of all four extremities due to breast cancer treatment. RESULTS One patient with bilateral UE lymphedema was treated with bilateral inguinal node transfers with LVA and the other with combined bilateral DIEP flaps and inguinal node transfers with LVA. Three patients had bilateral LE lymphedema: two were treated with split omental/gastroepiploic nodes, and one underwent simultaneous supraclavicular and submental node transfers. LVAs were performed in one leg in each patient. Two patients with four-limb lymphedema underwent bilateral inguinal node transfers with DIEP flaps and bilateral LE LVA. In total, there were eight UE and 10 LE treated. Average follow-up was 15.8 months (range: 12.6-28.4 months), all patients reported subjective improvement in symptoms, were able to decrease use of compression garments and pumps, and no patients developed cellulitis. CONCLUSION Patients suffering from lymphedema of multiple extremities can be treated safely and effectively combining both LVA and VLNT in a single operation.
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Affiliation(s)
- Carrie K Chu
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Matthew M Hanasono
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Edward I Chang
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Boccardo F, Santori G, Villa G, Accogli S, Dessalvi S. Long-term patency of multiple lymphatic-venous anastomoses in cancer-related lymphedema: A single center observational study. Microsurgery 2022; 42:668-676. [PMID: 35916247 DOI: 10.1002/micr.30944] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 04/11/2022] [Accepted: 07/11/2022] [Indexed: 01/05/2023]
Abstract
OBJECTIVES Lymphedema is always initially treated by combined decongestive physiotherapy (CDP). Those cases, refractory to CDP, may be managed by surgical therapy. One of the most used microsurgical procedures is represented by the technique of lymphatic-venous anastomosis (LVA). But very few papers report long term results of LVA. The aim of this study is to assess the long-term patency of multiple lymphatic-venous anastomosis (MLVA) for the treatment of secondary lymphedemas. METHODS From January 2014 to December 2014, 101 patients (mean age: 56.94 ± 8.98 years; female/male: 86/15) affected by secondary cancer-related lymphedema (38 lower and 63 upper limbs) were treated by MLVA. All lymphedemas had previously been treated by conservative therapy without sustained results. Many patients (78%) had 1-3 episodes of acute lymphangitis/year. Lymphoscintigraphy, venous duplex-ultrasonography, and abdominal or axillary ultrasound investigation were performed preoperatively. MLVA patency was assessed by the lymphatic transport index (LyTI) and lymphoscintigraphic pattern. RESULTS At 1 year after surgery, excess volume reduction was 75%-90% in the early stage II secondary lymphedemas, and 60%-75% in the late stage II. The decrease in volume maintained stability in the 5-years follow-up period. Two more advanced lower and one upper limb lymphedemas had 45%-60% reduction. LyTI showed a significant decrease between the preoperative mean value (31.7 ± 9.43) and after 18 months from surgery (11.2 ± 1.91) (p < .001). MLVA patency was shown in 98 (97%) patients. No patients had evidence of postoperative lymphangitis. CONCLUSIONS This study demonstrated the long-term patency of MLVA in the treatment of cancer-related lymphedemas.
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Affiliation(s)
- Francesco Boccardo
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy.,Department of Cardio-Thoracic-Vascular and Endovascular Surgery, San Martino Polyclinic Hospital, Genoa, Italy
| | - Gregorio Santori
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Giuseppe Villa
- Department of Diagnostics and Radiotherapy - Nuclear Medicine, San Martino Polyclinic Hospital, Genoa, Italy
| | - Susanna Accogli
- Department of Neuro-Science-Rehabilitation Unit, San Martino Polyclinic Hospital, Genoa, Italy
| | - Sara Dessalvi
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
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3
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Flores T, Bergmeister KD, Staudenherz A, Pieber K, Schrögendorfer KF. [Diagnosis, prevention and therapy of lymphedema]. Wien Klin Wochenschr 2020; 133:855-868. [PMID: 33226525 PMCID: PMC8452052 DOI: 10.1007/s00508-020-01766-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Tonatiuh Flores
- Karl Landsteiner Privatuniversität für Gesundheitswissenschaften, Dr. Karl-Dorrek-Straße 30, 3500, Krems, Österreich. .,Klinische Abteilung für Plastische, Ästhetische und Rekonstruktive Chirurgie, Universitätsklinikum St. Pölten, Dunant-Platz 1, 3100, St. Pölten, Österreich.
| | - Konstantin D Bergmeister
- Karl Landsteiner Privatuniversität für Gesundheitswissenschaften, Dr. Karl-Dorrek-Straße 30, 3500, Krems, Österreich.,Klinische Abteilung für Plastische, Ästhetische und Rekonstruktive Chirurgie, Universitätsklinikum St. Pölten, Dunant-Platz 1, 3100, St. Pölten, Österreich
| | - Anton Staudenherz
- Karl Landsteiner Privatuniversität für Gesundheitswissenschaften, Dr. Karl-Dorrek-Straße 30, 3500, Krems, Österreich.,Klinisches Institut für Nuklearmedizin, molekulare Bildgebung und spezielle Endokrinologie, Universitätsklinikum St. Pölten, Dunant-Platz 1, 3100, St. Pölten, Österreich
| | - Karin Pieber
- Karl Landsteiner Privatuniversität für Gesundheitswissenschaften, Dr. Karl-Dorrek-Straße 30, 3500, Krems, Österreich.,Klinisches Institut für Physikalische Medizin und Rehabilitation, Universitätsklinikum St. Pölten, Dunant-Platz 1, 3100, St. Pölten, Österreich
| | - Klaus F Schrögendorfer
- Karl Landsteiner Privatuniversität für Gesundheitswissenschaften, Dr. Karl-Dorrek-Straße 30, 3500, Krems, Österreich.,Klinische Abteilung für Plastische, Ästhetische und Rekonstruktive Chirurgie, Universitätsklinikum St. Pölten, Dunant-Platz 1, 3100, St. Pölten, Österreich
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Doscher ME, Schreiber JE, Weichman KE, Garfein ES. Update on Post-mastectomy Lymphedema Management. Breast J 2016; 22:553-60. [DOI: 10.1111/tbj.12625] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Matthew E. Doscher
- Division of Plastic and Reconstructive Surgery; Montefiore Medical Center; Albert Einstein College of Medicine; Bronx New York
| | - Jillian E. Schreiber
- Division of Plastic and Reconstructive Surgery; Montefiore Medical Center; Albert Einstein College of Medicine; Bronx New York
| | - Katie E. Weichman
- Division of Plastic and Reconstructive Surgery; Montefiore Medical Center; Albert Einstein College of Medicine; Bronx New York
| | - Evan S. Garfein
- Division of Plastic and Reconstructive Surgery; Montefiore Medical Center; Albert Einstein College of Medicine; Bronx New York
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Cormier JN, Rourke L, Crosby M, Chang D, Armer J. The surgical treatment of lymphedema: a systematic review of the contemporary literature (2004-2010). Ann Surg Oncol 2011; 19:642-51. [PMID: 21863361 DOI: 10.1245/s10434-011-2017-4] [Citation(s) in RCA: 94] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2011] [Indexed: 12/24/2022]
Abstract
PURPOSE A systematic review of the literature was performed to examine contemporary peer-reviewed literature (2004-2010) evaluating the surgical treatment of lymphedema. METHODS A comprehensive search of 11 major medical indices was performed. Selected articles were sorted to identify those related to the surgical treatment of lymphedema. Extracted data included the number of patients, specific surgical procedure performed, length of follow-up, criteria for defining lymphedema, measurement methods, volume or circumference reduction, and reported complications. RESULTS A total of 20 studies met inclusion criteria; procedures were categorized as excisional procedures (n = 8), lymphatic reconstruction (n = 8), and tissue transfer (n = 4). The reported incidence of volume reduction of lymphedema in these studies varied from 118% reduction to a 13% increase over the follow-up intervals ranging from 6 months to 15 years. The largest reported reductions were noted after excisional procedures (91.1%), lymphatic reconstruction (54.9%), and tissue transfer procedures (47.6%). Procedure complications were rarely reported. CONCLUSIONS A number of surgical approaches have demonstrated beneficial effects for select patients with lymphedema. Most of these reports, however, are based on small numbers of patients, use nonstandardized or inconsistent measurement techniques, and lack long-term follow-up. The proposed benefits of any surgical approach should be evaluated in the context of the potential morbidity to the individual patient and the availability of surgical expertise. In addition, although these surgical techniques have shown promising results, nearly all note that the procedures do not obviate the need for continued use of conventional therapies, including compression, for long-term maintenance.
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Affiliation(s)
- Janice N Cormier
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Kawase T, Takeda A, Kunieda E, Kokubo M, Kamikubo Y, Ishibashi R, Nagaoka T, Shigematsu N, Kubo A. Extrapulmonary Soft-Tissue Fibrosis Resulting From Hypofractionated Stereotactic Body Radiotherapy for Pulmonary Nodular Lesions. Int J Radiat Oncol Biol Phys 2009; 74:349-54. [PMID: 19427551 DOI: 10.1016/j.ijrobp.2008.08.072] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2008] [Revised: 08/13/2008] [Accepted: 08/14/2008] [Indexed: 12/25/2022]
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Wallmichrath J, Baumeister RGH, Deglmann CJ, Greiner A, Heim S, Frick A. Technique and proof of patency of microsurgical lympho-lymphonodular anastomoses: A study in the rat model. Microsurgery 2009; 29:303-9. [DOI: 10.1002/micr.20629] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Salgado CJ, Mardini S, Spanio S, Tang WR, Sassu P, Chen HC. Radical Reduction of Lymphedema With Preservation of Perforators. Ann Plast Surg 2007; 59:173-9. [PMID: 17667412 DOI: 10.1097/sap.0b013e31802ca54c] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Surgical management of lymphedema of the lower extremity is indicated in select patients when conservative measures have failed. The excisional approach has traditionally consisted of a staged excision procedure or total excision of diseased tissue. Based on an improved knowledge of vascular anatomy and understanding of perforator flap surgery, radical reduction of lymphedema with preservation of perforators (RRPP) applies an excisional approach and microsurgical principles to the radical reduction of lymphedema. METHODS Fifteen patients underwent RRPP during the period of June 1993 to February 2002 and were included in this study. Medial and lateral skin flaps were raised through incisions on the anterior and posterior leg, preserving a 4-cm skin bridge in the central portion of the incisions. The skin flaps were reduced to 5 mm in thickness, except in the vicinity of the lateral and medial septae, which contain perforators from the posterior tibial and peroneal arteries. RESULTS At an average follow-up period of 13 months, a statistically significant reduction in lymphedema was achieved (P < 0.05). The average percentage in reduction above the knee was 51%, below the knee 66%, at the ankle 44%, and at the level of the foot 41%. The average overall lymphedema reduction for the patients was 52%. There were no cases of wound breakdown or skin flap necrosis. Complications consisted of cellulitis in 3 patients and seroma and hematoma in 1 patient. CONCLUSIONS Based on angiosome principles and application of perforator principles to the surgical reduction of lymphedema, effective, long-lasting, and cosmetically appealing results are achieved in a single-stage procedure.
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Affiliation(s)
- Christopher J Salgado
- Department of Plastic Surgery, E-Da Hospital/I-Shou University, 1 E-Da Road, Jiau-shu Tsuen, Yan-chau Shiang, Kaohsiung County, Taiwan 824, ROC
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Campisi C, Davini D, Bellini C, Taddei G, Villa G, Fulcheri E, Zilli A, Da Rin E, Eretta C, Boccardo F. Lymphatic microsurgery for the treatment of lymphedema. Microsurgery 2006; 26:65-9. [PMID: 16444753 DOI: 10.1002/micr.20214] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
One of the main problems of microsurgery for lymphedema consists of the discrepancy between the excellent technical possibilities and the subsequently insufficient reduction of the lymphoedematous tissue fibrosis and sclerosis. Appropriate treatment based on pathologic study and surgical outcome have not been adequately documented. Over the past 25 years, more than 1000 patients with peripheral lymphedema have been treated with microsurgical techniques. Derivative lymphatic micro-vascular procedures has today its most exemplary application in multiple lymphatic-venous anastomoses (LVA). For those cases where a venous disease is associated to more or less latent or manifest lymphostatic pathology of such severity to contraindicate a lymphatic-venous shunt, reconstructive lymphatic microsurgery techniques have been developed (autologous venous grafts or lymphatic-venous-Iymphatic-plasty - LVLA). Objective assessment was undertaken by water volumetry and lymphoscintigraphy. Subjective improvement was noted in 87% of patients. Objectively, volume changes showed a significant improvement in 83%, with an average reduction of 67% of the excess volume. Of those patients followed-up, 85% have been able to discontinue the use of conservative measures, with an average follow-up of more than 7 years and average reduction in excess volume of 69%. There was a 87% reduction in the incidence of cellulitis after microsurgery. Microsurgical lymphatic-venous anastomoses have a place in the treatment of peripheral lymphedema and should be the therapy of choice in patients who are not sufficiently responsive to nonsurgical treatment. Improved results can be expected with operations performed earlier at the very first stages of lymphedema.
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Affiliation(s)
- C Campisi
- Section of Lymphatic Surgery and Microsurgery, Department of Surgery, S. Martino Hospital, University of Genoa, Genoa, Italy.
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Campisi C, Boccardo F, Zilli A, Macciò A, Gariglio A, Schenone F. Peripheral lymphedema: New advances in microsurgical treatment and long-term outcome. Microsurgery 2003; 23:522-5. [PMID: 14558015 DOI: 10.1002/micr.10185] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
We report on the modern surgical management of peripheral lymphedema. An adequate diagnostic route is essential: it has to include patient history and clinical examination, an isotopic lymphography, an accurate study of the venous circulation, and in cases of angiodysplasia, an accurate study of the artery circulation. Based on over 25 years of clinical experience (more than 1,000 patients), the role of derivative and (in those cases where a venous disease is associated with lymphostatic pathology) reconstructive lymphatic microsurgery is particularly underlined, in comparison with conservative medico-physical treatment, to which it is complementary. "Debulking" surgery can be used just in properly selected patients for minor operations with only cosmethic-reductive purposes. With a follow-up even over 15 years after surgery, positive results from lymphatic microsurgery can be achieved in more than 80% of cases, especially in patients at precocious stages.
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Affiliation(s)
- Corradino Campisi
- Department of Surgery, Lymphology and Microsurgery Center, S. Martino Hospital, University of Genoa, Genoa, Italy.
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Abstract
Lymphedema is often diagnosed by its characteristic clinical presentation. In some cases, however, instrumental investigations are necessary to establish the diagnosis, particularly in early stages of the disease. One of the primary problems for microsurgery in treating lymphedema consists of the discrepancy between the excellent technical possibilities and the insufficient results in reduction of lymphedematous tissue fibrosis and sclerosis. Long-term results indicate that microsurgical operations have a valuable place in the treatment of obstructive lymphedema (primary or secondary) and should be the treatment of choice in these patients. Improved results can be expected with earlier microsurgical operations because patients referred earlier usually have less lymphatic disruption and fibrotic tissue. Advanced diagnostic methods and improvements in operation techniques have modified indications for surgical therapy of lymphedema. This article systematically reviews the published literature on the microsurgical treatment of lymphedema to the present.
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Affiliation(s)
- C Campisi
- Department of Specialist Surgical Sciences, Anesthesiology and Organ Transplants, Lymphology and Microsurgery Center, St. Martino's Hospital, University of Genoa, Largo Rosanna Venzi 8, 16132 Genoa, Italy.
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Campisi C, Boccardo F, Zilli A, Macciò A, Napoli F. Long-term results after lymphatic-venous anastomoses for the treatment of obstructive lymphedema. Microsurgery 2001; 21:135-9. [PMID: 11494379 DOI: 10.1002/micr.1025] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Over the past 25 years, 665 patients with obstructive lymphedema have been treated with microsurgical lymphatic-venous anastomoses; of these, 446 patients were available for long-term follow-up study. Objective assessment was undertaken by water volumetry and lymphoscintigraphy. Lymphangioscintigraphy, lymphangiography (in patients with gravitational reflux pathology), and echo-Doppler were used preoperatively. Subjective improvement was noted in 578 patients (87%). Objectively, volume changes showed a significant improvement in 552 patients (83%), with an average reduction of 67% of the excess volume. Of those patients followed up, 379 patients (85%) have been able to discontinue the use of conservative measures, with an average follow-up of more than 7 years and average reduction in excess volume of 69%. There was a 87% reduction in the incidence of cellulitis after microsurgery. In those patients who improved, drainage resulted in increased softness of the limbs. Peripheral edema (hand and foot) diminished considerably in most patients. These long-term results indicate that lymphatic-venous anastomoses have a place in the treatment of obstructive lymphedema and should be the therapy of choice in patients who are not sufficiently responsive to nonsurgical treatment. Improved results can be expected with earlier operations because patients referred earlier usually have fewer lymphatic alterations.
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Affiliation(s)
- C Campisi
- Department of Specialistic Surgical Sciences, Anaesthesiology and Organ Transplants (DISCAT), Emergency Surgical Clinic Section, Lymphology and Microsurgery Center, S. Martino Hospital, University of Genoa, 16122 Genoa, Italy.
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Campisi C, Boccardo F, Zilli A, Macció A, Napoli F. The use of vein grafts in the treatment of peripheral lymphedemas: long-term results. Microsurgery 2001; 21:143-7. [PMID: 11494381 DOI: 10.1002/micr.1027] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
This study evaluates long-term results of the treatment of peripheral lymphedemas by the microsurgical reconstructive technique of interposed vein grafts. The technique consists of the use of autologous vein grafts to reconstruct lymphatic pathways where there is a block to the lymphatic circulation of the limb, whether of congenital or acquired etiology. The venous segment represents a sort of "bridge" between afferent and efferent lymphatic collectors (lymphatic-venous-lymphatic plasty [LVLA]). The results also proved to have positive long-term effects after microsurgical operation. Follow-up evaluation was performed clinically by water volumetry and instrumentally by lymphangioscintigraphy. With this LVLA technique, peripheral lymphedemas can be treated when derivative lymphovenous shunts cannot be used because of impaired venous circulation in the same lymphedematous limb. The new aspect of the study is that we report long-term clinical and instrumental results.
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Affiliation(s)
- C Campisi
- Department of Specialistic Surgical Sciences, Anaesthesiology and Organ Transplants (DISCAT), Emergency Surgical Clinic Section, Lymphology and Microsurgery Center, S. Martino Hospital, University of Genoa, 16122 Genoa, Italy.
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