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Ahmed S, Imeokparia FO, Hassanein AH. Surgical management of lymphedema: prophylactic and therapeutic operations. CURRENT BREAST CANCER REPORTS 2024; 16:185-192. [PMID: 38988994 PMCID: PMC11233112 DOI: 10.1007/s12609-024-00543-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2024] [Indexed: 07/12/2024]
Abstract
Purpose of Review Lymphedema is chronic limb swelling from lymphatic dysfunction and is currently incurable. Breast-cancer related lymphedema (BCRL) affects up to 5 million Americans and occurs in one-third of breast cancer survivors following axillary lymph node dissection. Compression remains the mainstay of therapy. Surgical management of BCRL includes excisional procedures to remove excess tissue and physiologic procedures to attempt improve fluid retention in the limb. The purpose of this review is to highlight surgical management strategies for preventing and treating breast cancer-related lymphedema. Recent findings Immediate lymphatic reconstruction (ILR) is a microsurgical technique that anastomoses disrupted axillary lymphatic vessels to nearby veins at the time of axillary lymph node dissection (ALND) and has been reported to reduce lymphedema rates from 30% to 4-12%. Summary Postsurgical lymphedema remains incurable. Surgical management of lymphedema includes excisional procedures and physiologic procedures using microsurgical technique. Immediate lymphatic reconstruction has emerged as a prophylactic strategy to prevent lymphedema in breast cancer patients.
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Affiliation(s)
- Shahnur Ahmed
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Folasade O Imeokparia
- Division of Surgical Oncology, Indiana University School of Medicine, Indianapolis, IN
| | - Aladdin H Hassanein
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, IN
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Ciudad P, Chen HC, Bustos SS, Manrique OJ, Bolletta A, Forte AJ, Huayllani MT, Agko M, Urbina JA, Date S, Kaya B. The deep inferior epigastric lymphatic cable flap connected to gastroepiploic lymph node flap for treatment of refractory chylous ascites: Report of two cases. Microsurgery 2021; 41:376-383. [PMID: 33864636 DOI: 10.1002/micr.30736] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 02/04/2021] [Accepted: 03/03/2021] [Indexed: 12/23/2022]
Abstract
Chylous ascites is the leakage of lipid-rich lymph into the peritoneal cavity usually due to disruption of lymphatics or increased peritoneal lymphatic pressure. Various surgical options have been proposed to treat chylous ascites but most have shown suboptimal outcomes. The gastroepiploic vascularized lymph node (GE-VLN) flap has been described previously for the treatment of lymphedema. In chylous ascites, this flap could provide an alternate drainage pathway for the intraperitoneal chylous fluid. The purpose of this report is to present another option for the microsurgical treatment of refractory chylous ascites. Herein, we report two patients with refractory chylous ascites secondary to cancer who have undergone deep inferior epigastric-based lymphatic "cable" flap (DIE-LCF) connected to a pedicle GE-VLN flap. Patients were followed-up for a minimum of 2 years. Within the first 3 months following surgery, the patient's nutritional parameters improved along with drastic reduction of ascites. At 2 years follow-up postoperative abdominal circumference decreased significantly. None required further peritoneal paracentesis and all patients were free of chylous ascites symptoms. In conclusion, the DIE-LCF connected to a pedicle GE-VLN flap could be a feasible option for the microsurgical treatment of refractory chylous ascites.
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Affiliation(s)
- Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru.,Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan.,Department of Biotechnology, Experimental Surgery Unit, The Child Health's Institute (Breña), Lima, Peru
| | - Hung-Chi Chen
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Samyd S Bustos
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Oscar J Manrique
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York, USA
| | - Alberto Bolletta
- Department of Translational Research and New Technologies in Medicine and Surgery, Plastic Surgery Unit, University of Pisa, Pisa, Italy
| | - Antonio J Forte
- Department of Plastic and Reconstructive Surgery, Mayo Clinic, Florida, Jacksonville, USA
| | - Maria T Huayllani
- Department of Plastic and Reconstructive Surgery, Mayo Clinic, Florida, Jacksonville, USA
| | - Mouchammed Agko
- Section of Plastic Surgery, Medical College of Georgia, Augusta University, Augusta, Georgia, USA
| | | | - Shivprasad Date
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan.,Padmashree Dr D Y Patil Medical College, Plastic & Reconstructive Surgery, Nerul Navi, Mumbai, India.,China Medical University Hospital, Plastic & Reconstructive Surgery, Taichung, Taiwan
| | - Burak Kaya
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
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Technical Challenges in "Micro" Lymph Node Identification during Vascularized Submental Lymph Node Flap Harvesting. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e3330. [PMID: 33425628 PMCID: PMC7787339 DOI: 10.1097/gox.0000000000003330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 10/21/2020] [Indexed: 11/26/2022]
Abstract
Background: The outcome of autologous lymph node (LN) transfer has depended on the number of LNs in the donor site. Unknown accuracy of the LN counting method has thrown some doubts on the reliability of the previous statistics. This study aimed to assess the accuracy of naked eye (NK) and stereo microscopy (SM) as tools for LN count. Methods: In total, 40 vascularized submental LN flaps were harvested from 23 fresh cadavers. The colored polymer was injected into the external carotid arteries before the harvest. LNs in each flap were counted by NK, SM, and histology in sequential order. Results: An estimated 175 LNs were confirmed, 4.4 ± 1.8 per flap. NK sensitivity was 33.7% compared with that of SM at 63.5%. Both methods missed all micro-lymph nodes (micro-LNs), contributing to 5.1% (9 nodes) of all LNs. Non-LN structures (647 negative counts) were composed of fat lobules, salivary gland lobules, and muscle fibers. NK specificity was 98.0%, compared with that of SM at 96.1%. SM showed a higher false positive rate at 14.3%, compared with NK at 7.4%. False positive counts were located mostly in Ib sublevel. Conclusions: NK and SM are imperfect tools for LN count due to poor sensitivity. If the method needs to be applied, points of considerations are (1) undetectable micro-LNs, (2) interposition of LNs with the digastric muscle and submandibular salivary gland, (3) confusion of LNs with lobules of salivary gland supplied by glandular artery or fat lobules supplied by lobular artery.
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El Asmar A, Veys I, Larsimont D, Donckier V, Liberale G. Inferior epigastric artery lymph nodes: A pathway for systemic dissemination from peritoneal carcinomatosis? J Surg Oncol 2020; 123:311-314. [PMID: 33125752 DOI: 10.1002/jso.26269] [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: 09/03/2020] [Revised: 09/23/2020] [Accepted: 10/09/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND OBJECTIVES We report, for the first time in the literature, a metastatic lymphatic pathway along the inferior epigastric vessels, through the inferior epigastric lymph nodes (IELNs), in patients with peritoneal carcinomatosis (PC). Interestingly, these lymph nodes (LNs) in the anterior retroperitoneum were not detectable on preoperative imaging. They may, however, represent a pertinent systemic dissemination pathway for PC. PATIENTS AND METHODS In patients undergoing indocyanine green-fluorescence imaging during cytoreductive surgery for PC, an incidental finding of a hyperfluorescent LN, harboring metastatic tumorous cells, around the inferior epigastric artery was made. RESULTS In three out of five patients with clear fluorescent hotspot, the harvested LN was harboring metastatic cancerous cells. None of these nodes, whether negative or positive, was visible on any preoperative imaging modalities. A protocol to sample, in a systematic manner, the IELN in patients with PC, is currently being devised at our institution. CONCLUSION These lymphatic nodes basin and channels might reveal to be a potential passage from peritoneal metastasis to the extraperitoneal lymphatic compartment, representing an independent pathway for cancerous cell dissemination. This will bring us to further investigate the prevalence and the prognostic significance of these LNs.
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Affiliation(s)
- Antoine El Asmar
- Department of Surgical Oncology, Institut Jules Bordet, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Isabelle Veys
- Department of Surgical Oncology, Institut Jules Bordet, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Denis Larsimont
- Department of Pathology, Institut Jules Bordet, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Vincent Donckier
- Department of Surgical Oncology, Institut Jules Bordet, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Gabriel Liberale
- Department of Surgical Oncology, Institut Jules Bordet, Université Libre de Bruxelles (ULB), Brussels, Belgium
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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.
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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.
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Hassanein AH, Danforth R, DeBrock W, Mailey B, Lester M, Socas J. Deep Inferior Epigastric Artery Vascularized Lymph Node Transfer: A Simple and Safe Option for Lymphedema. J Plast Reconstr Aesthet Surg 2020; 73:1897-1916. [PMID: 32475731 DOI: 10.1016/j.bjps.2020.03.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Accepted: 03/25/2020] [Indexed: 11/16/2022]
Affiliation(s)
- Aladdin H Hassanein
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, IN.
| | - Rachel Danforth
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Will DeBrock
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Brian Mailey
- Institute for Plastic Surgery, Southern Illinois University, Springfield, IL
| | - Mary Lester
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Juan Socas
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, IN
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Scaglioni MF, Meroni M, Franchi A, Fritsche E. Combined lymphovenous anastomosis and deep inferior epigastric perforator flap with lymphatic tissue preservation for defect reconstruction and lymphedema‐lymphocele prevention after medial thigh sarcoma resection: A case report. Microsurgery 2020; 40:598-603. [DOI: 10.1002/micr.30558] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 12/04/2019] [Accepted: 01/03/2020] [Indexed: 11/07/2022]
Affiliation(s)
- Mario F. Scaglioni
- Depatment of Hand‐ and Plastic SurgeryLuzerner Kantonsspital Lucerne Switzerland
| | - Matteo Meroni
- Depatment of Hand‐ and Plastic SurgeryLuzerner Kantonsspital Lucerne Switzerland
| | - Alberto Franchi
- Depatment of Hand‐ and Plastic SurgeryLuzerner Kantonsspital Lucerne Switzerland
| | - Elmar Fritsche
- Depatment of Hand‐ and Plastic SurgeryLuzerner Kantonsspital Lucerne Switzerland
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