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Use of fluorescence imaging during lymphatic surgery: A Delphi survey of experts worldwide. Surgery 2022; 172:S14-S20. [PMID: 36427924 DOI: 10.1016/j.surg.2022.08.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 08/19/2022] [Accepted: 08/23/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Fluorescence imaging with indocyanine green is increasingly used during lymphedema patient management. However, to date, no guidelines exist on when it should and should not be used or how it should be performed. Our objective was to have an international panel of experts identify areas of consensus and nonconsensus in current attitudes and practices in fluorescence imaging with indocyanine green use during lymphedema surgery patient management. METHODS A 2-round Delphi study was conducted involving 18 experts in the use of fluorescence imaging during lymphatic surgery, all asked to vote on 49 statements on patient preparation and contraindications (n = 7 statements), indocyanine green dosing and administration (n = 10), fluorescence imaging uses and potential advantages (n = 16), and potential disadvantages and training needs (n = 16). RESULTS Consensus ultimately was reached on 40/49 statements, including consistent consensus regarding the value of fluorescence imaging with indocyanine green in almost all facets of lymphedema patient management, including early detection, assessing disease extent, preoperative work-up, surgical planning, intraoperative guidance, monitoring short- and longer-term outcomes, quality control, and resident training. All experts felt it was very safe, while 94% felt it should be part of routine care and that indocyanine green was superior to colored dyes and ultrasound. Nonetheless, there also was consensus that limited high-quality evidence remains a barrier to its widespread use and that patients should still be provided with specific information and asked to sign specific consent for both fluorescence imaging and indocyanine green. CONCLUSION Fluorescence imaging with or without indocyanine green appears to have several roles in lymphedema prevention, diagnosis, assessment, and treatment.
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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.
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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
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Abu-Rustum NR, Angioli R, Bailey AE, Broach V, Buda A, Coriddi MR, Dayan JH, Frumovitz M, Kim YM, Kimmig R, Leitao MM, Muallem MZ, McKittrick M, Mehrara B, Montera R, Moukarzel LA, Naik R, Pedra Nobre S, Plante M, Plotti F, Zivanovic O. IGCS Intraoperative Technology Taskforce. Update on near infrared imaging technology: beyond white light and the naked eye, indocyanine green and near infrared technology in the treatment of gynecologic cancers. Int J Gynecol Cancer 2020; 30:670-683. [PMID: 32234846 DOI: 10.1136/ijgc-2019-001127] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 01/29/2020] [Accepted: 02/04/2020] [Indexed: 12/11/2022] Open
Affiliation(s)
- Nadeem R Abu-Rustum
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | | | - Arthur E Bailey
- Research and Development, Stryker Endoscopy, San Jose, California, USA
| | - Vance Broach
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Alessandro Buda
- Department of Obstetrics and Gynecology, Azienda Ospedaliera San Gerardo, Monza, Italy
| | - Michelle R Coriddi
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Joseph H Dayan
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Michael Frumovitz
- Gynecologic Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Yong Man Kim
- Obstetrics and Gynecology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Rainer Kimmig
- Gynecology and Obstetrics, University Hospital of Duisburg-Essen, Essen, Germany
| | - Mario M Leitao
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Mustafa Zelal Muallem
- Department of Gynecology with Center for Oncological Surgery, Charité, Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Virchow Campus Clinic, Charité Medical University, Berlin, Germany
| | - Matt McKittrick
- Research and Development, Stryker Endoscopy, San Jose, California, USA
| | - Babak Mehrara
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Roberto Montera
- Universita Campus Bio-Medico di Roma Facolta di Medicina e Chirurgia, Roma, Lazio, Italy
| | - Lea A Moukarzel
- Gynecology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Raj Naik
- Northern Gynaecological Oncology Centre, Queen Elizabeth Hospital, Gateshead, UK
| | - Silvana Pedra Nobre
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Marie Plante
- Obstetrics and Gynecology, Centre Hospitalier Universitaire de Quebec, Quebec, Quebec, Canada
| | - Francesco Plotti
- Universita Campus Bio-Medico di Roma Facolta di Medicina e Chirurgia, Roma, Lazio, Italy
| | - Oliver Zivanovic
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
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Comprehensive Overview of Available Donor Sites for Vascularized Lymph Node Transfer. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2675. [PMID: 32537339 PMCID: PMC7253262 DOI: 10.1097/gox.0000000000002675] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 12/18/2019] [Indexed: 11/26/2022]
Abstract
The field of lymphedema surgery has grown tremendously in recent years. In particular, the diversity of available donor sites for vascularized lymph node transfer has increased, and new donor sites are emerging. Researchers have explored a number of different donor sites, and their reports have demonstrated promising results with each site. Unfortunately, there are limited studies providing a comprehensive analysis of the available donor sites focusing on both the technical aspects of the harvest, including complications and donor site morbidity, and the efficacy and outcomes following transfer. The present review aims to present a comprehensive analysis of the available donor sites for vascularized lymph node transfer and a summary of the experience from a single center of excellence.
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Ngo QD, Munot S, Mackie H, Czerniec S, Koelmeyer LA, Lam T, Heydon-White A, Suami H, Boyages J. Vascularized Lymph Node Transfer for Patients with Breast Cancer-Related Lymphedema Can Potentially Reduce the Burden of Ongoing Conservative Management. Lymphat Res Biol 2020; 18:357-364. [PMID: 31944882 DOI: 10.1089/lrb.2019.0048] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Vascularized lymph node transfer (VLNT) microsurgery is conducted in selected specialist lymphatic programs as a surgical treatment option for breast cancer-related lymphedema (BCRL) with variation in treatment outcomes. Methods and Results: Ten patients with BCRL underwent VLNT from 2012 to 2015. Donor sites were the inguinal (n = 6) or supraclavicular fossa/neck (n = 4) regions and recipient sites were the axilla (n = 6) or elbow regions (n = 4). Outcomes included changes in limb volume and extracellular fluid ratios, postoperative garment use, number of cellulitis episodes, and self-reported symptom improvement. At a mean follow-up of 46 months from surgery (range: 28-66 months), the excess volume in the affected arm had reduced (n = 4) or remained stable (n = 1) for 5 of 10 patients (50%) (mean change: -106.4 mL, range: -515.5 to +69.6 mL). Four of these five patients had also reduced (n = 3) or discontinued (n = 1) wearing compression garments and three reported a reduction in episodes of cellulitis. The remaining five patients had an increase of over 100 mL in postoperative excess volume (mean change: 295.8 mL, range: 142.1-382.8 mL). Three of these five patients reported noncompliance with compression garments. Despite the increase in limb volume, some patients reported softness in swelling (n = 3) and better response to conservative treatment (n = 1). Conclusion: Our results warrant continuation of VLNT as a surgical treatment option for patients with BCRL and show that the burden of conservative management such as wearing garments can be reduced over time for some patients. Longer term follow-up with standardized measures across all centers is required to further investigate VLNT.
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Affiliation(s)
- Quan D Ngo
- Australian Lymphoedema Education Research and Treatment (ALERT), Macquarie University Faculty of Medicine and Health Sciences, Sydney, Australia
| | - Sonali Munot
- Australian Lymphoedema Education Research and Treatment (ALERT), Macquarie University Faculty of Medicine and Health Sciences, Sydney, Australia
| | - Helen Mackie
- Australian Lymphoedema Education Research and Treatment (ALERT), Macquarie University Faculty of Medicine and Health Sciences, Sydney, Australia.,Mt. Wilga Rehabilitation Hospital, Hornsby, Australia
| | - Sharon Czerniec
- Australian Lymphoedema Education Research and Treatment (ALERT), Macquarie University Faculty of Medicine and Health Sciences, Sydney, Australia
| | - Louise A Koelmeyer
- Australian Lymphoedema Education Research and Treatment (ALERT), Macquarie University Faculty of Medicine and Health Sciences, Sydney, Australia
| | - Thomas Lam
- Australian Lymphoedema Education Research and Treatment (ALERT), Macquarie University Faculty of Medicine and Health Sciences, Sydney, Australia
| | - Asha Heydon-White
- Australian Lymphoedema Education Research and Treatment (ALERT), Macquarie University Faculty of Medicine and Health Sciences, Sydney, Australia
| | - Hiroo Suami
- Australian Lymphoedema Education Research and Treatment (ALERT), Macquarie University Faculty of Medicine and Health Sciences, Sydney, Australia
| | - John Boyages
- Australian Lymphoedema Education Research and Treatment (ALERT), Macquarie University Faculty of Medicine and Health Sciences, Sydney, Australia
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Frontiers in Oncologic Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2181. [PMID: 31624664 PMCID: PMC6635183 DOI: 10.1097/gox.0000000000002181] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 01/15/2019] [Indexed: 11/25/2022]
Abstract
Objectives: The authors seek to highlight some of the ongoing challenges related to complex oncologic reconstruction and the current solutions to these problems. Summary: The standard of care in reconstruction following oncologic resection is continually evolving. Current frontiers in breast reconstruction include addressing animation deformity through prepectoral reconstruction, offering autologous reconstruction to patients with limited donor sites, and improving postoperative sensation with innervation of free tissue transfer. Facial nerve reconstruction and contour defects pose an ongoing challenge in patients undergoing parotidectomy requiring complex nerve transfers and autologous reconstruction. Lymphedema is not a monolithic disease, and as our understanding of the pathophysiology improves, our surgical algorithms continue to evolve.
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Slooter MD, Blok RD, Wisselink DD, Buskens CJ, Bemelman WA, Tanis PJ, Hompes R. Near-infrared fluorescence angiography for intra-operative assessment of pedicled omentoplasty for filling of a pelvic cavity: a pilot study. Tech Coloproctol 2019; 23:723-728. [PMID: 31432336 PMCID: PMC6736781 DOI: 10.1007/s10151-019-02048-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 07/19/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND During creation of a pedicled omentoplasty, blood flow to segments of the omentum might become compromised. If unrecognized, this can lead to omental necrosis. The purpose of this study was to investigate the potential added intra-operative value of the use of fluorescence angiography (FA) with indocyanine green (ICG) to assess omental perfusion. METHODS All consecutive patients undergoing a pedicled omentoplasty in a 6-month period (April 1 2018-October 1 2018) in a University hospital were included. The primary outcome was change in management due to FA. Secondary outcomes included the amount of additionally resected omentum, added surgical time, and quantitative fluorescent values (time to fluorescent enhancement, contrast quantification). RESULTS Fifteen patients had pelvic surgery with omentoplasty and FA. Change in management occurred in 12 patients (80%) and consisted of resecting a median of 44 g (range 12-198 g) of poorly perfused omental areas that were not visible by conventional white light. The median added surgical time for the use of FA and subsequent management was 8 min (range 3-39 min). The first fluorescent signal in the omental tissue appeared after a median of 20 s (range 9-37 s) after injection of ICG. The median signal-to-baseline ratio was 23.7 (interquartile range 12.2-29.7) in well perfused and 2.5 (interquartile range 1.7-4.0) in poorly perfused tissue. CONCLUSIONS FA of a pedicled omentoplasty allows a real-time assessment of omental perfusion and leads to change in management in 80% of the cases in this pilot study. These findings support the conduct of larger studies to determine the impact on patient outcome in this setting.
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Affiliation(s)
- M D Slooter
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - R D Blok
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.,LEXOR, Center for Experimental and Molecular Medicine, Oncode Institute, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - D D Wisselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - C J Buskens
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - W A Bemelman
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - P J Tanis
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - R Hompes
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands. .,Department of Surgery, Amsterdam UMC, University of Amsterdam, G4, Post box 22660, 1100 DD, Amsterdam, The Netherlands.
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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.
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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
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