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Gaxiola-García MA, Escandón JM, Manrique OJ, Skinner KA, Kushida-Contreras BH. Surgical Treatment for Primary Lymphedema: A Systematic Review of the Literature. Arch Plast Surg 2024; 51:212-233. [PMID: 38596145 PMCID: PMC11001464 DOI: 10.1055/a-2253-9859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 11/30/2023] [Indexed: 04/11/2024] Open
Abstract
This is a retrospective review of surgical management for primary lymphedema. Data were extracted from 55 articles from PubMed MEDLINE, Web of Science, SCOPUS, and Cochrane Central Register of Controlled Trials between the database inception and December 2022 to evaluate the outcomes of lymphaticovenous anastomosis (LVA) and vascularized lymph node transfer (VLNT), and outcomes of soft tissue extirpative procedures such as suction-assisted lipectomy (SAL) and extensive soft tissue excision. Data from 485 patients were compiled; these were treated with LVA ( n = 177), VLNT ( n = 82), SAL ( n = 102), and excisional procedures ( n = 124). Improvement of the lower extremity lymphedema index, the quality of life (QoL), and lymphedema symptoms were reported in most studies. LVA and VLNT led to symptomatic relief and improved QoL, reaching up to 90 and 61% average circumference reduction, respectively. Cellulitis reduction was reported in 25 and 40% of LVA and VLNT papers, respectively. The extirpative procedures, used mainly in patients with advanced disease, also led to clinical improvement from the volume reduction, as well as reduced incidence of cellulitis, although with poor cosmetic results; 87.5% of these reports recommended postoperative compression garments. The overall complication rates were 1% for LVA, 13% for VLNT, 11% for SAL, and 46% for extirpative procedures. Altogether, only one paper lacked some kind of improvement. Primary lymphedema is amenable to surgical treatment; the currently performed procedures have effectively improved symptoms and QoL in this population. Complication rates are related to the invasiveness of the chosen procedure.
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Affiliation(s)
- Miguel Angel Gaxiola-García
- Plastic and Reconstructive Surgery Department, Mexico's Children's Hospital (Hospital Infantil de México “Federico Gómez”), Mexico City, Mexico
| | - 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
| | - Kristin A. Skinner
- Department of Surgical Oncology, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York
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Brouillard P, Witte MH, Erickson RP, Damstra RJ, Becker C, Quéré I, Vikkula M. Primary lymphoedema. Nat Rev Dis Primers 2021; 7:77. [PMID: 34675250 DOI: 10.1038/s41572-021-00309-7] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/17/2021] [Indexed: 11/09/2022]
Abstract
Lymphoedema is the swelling of one or several parts of the body owing to lymph accumulation in the extracellular space. It is often chronic, worsens if untreated, predisposes to infections and causes an important reduction in quality of life. Primary lymphoedema (PLE) is thought to result from abnormal development and/or functioning of the lymphatic system, can present in isolation or as part of a syndrome, and can be present at birth or develop later in life. Mutations in numerous genes involved in the initial formation of lymphatic vessels (including valves) as well as in the growth and expansion of the lymphatic system and associated pathways have been identified in syndromic and non-syndromic forms of PLE. Thus, the current hypothesis is that most cases of PLE have a genetic origin, although a causative mutation is identified in only about one-third of affected individuals. Diagnosis relies on clinical presentation, imaging of the structure and functionality of the lymphatics, and in genetic analyses. Management aims at reducing or preventing swelling by compression therapy (with manual drainage, exercise and compressive garments) and, in carefully selected cases, by various surgical techniques. Individuals with PLE often have a reduced quality of life owing to the psychosocial and lifelong management burden associated with their chronic condition. Improved understanding of the underlying genetic origins of PLE will translate into more accurate diagnosis and prognosis and personalized treatment.
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Affiliation(s)
- Pascal Brouillard
- Human Molecular Genetics, de Duve Institute, University of Louvain, Brussels, Belgium
| | - Marlys H Witte
- Department of Surgery, Neurosurgery, and Pediatrics, University of Arizona College of Medicine, Tucson, AZ, USA
| | - Robert P Erickson
- Department of Pediatrics, University of Arizona College of Medicine, Tucson, AZ, USA
| | - Robert J Damstra
- VASCERN PPL European Reference Centre; Department of Dermatology, Phlebology and Lymphology, Nij Smellinghe Hospital, Drachten, Netherlands
| | | | - Isabelle Quéré
- Department of Vascular Medicine, Centre de référence des Maladies Lymphatiques et Vasculaires Rares, Inserm IDESP, CHU Montpellier, Université de Montpellier, Montpellier, France
| | - Miikka Vikkula
- Human Molecular Genetics, de Duve Institute, University of Louvain, Brussels, Belgium. .,VASCERN VASCA European Reference Centre; Center for Vascular Anomalies, Division of Plastic Surgery, University Clinics Saint-Luc, University of Louvain, Brussels, Belgium. .,Walloon Excellence in Lifesciences and Biotechnology (WELBIO), de Duve Institute, University of Louvain, Brussels, Belgium.
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Biological Mechanism of Specific Relationship between Gan (Liver) Meridian of Foot-Jueyin and Genitals. Chin J Integr Med 2021; 27:384-387. [PMID: 33420901 DOI: 10.1007/s11655-020-3483-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/24/2019] [Indexed: 10/22/2022]
Abstract
From the perspective view of Chinese medicine, the Gan (Liver) meridian of Foot-Jueyin starts from the great toe, running upward along the medial side of the thigh to the perineal area, where it curves around the external genitalia and goes up to the lower abdomen. In clinical practice, acupoints in the feet of the Gan meridian of Foot-Jueyin are used to treat the genitourinary and external genitalia diseases. Studies have shown that reproductive system diseases have specific pathological reactions in the places (radial side of tibia and foot) where Gan meridian of Foot-Jueyin passes by. Why does this happen? In this article, we begin by briefly reviewing the evidences linking foot and genitalia. We then explore the potential mechanism of the relationship between genitals and the Gan meridian of Foot-Jueyin. The brain cerebral cortex is characterized by cortical interactions. Numerous studies show that different cerebral cortex function areas (especially the adjacent areas) are overlapping and interact with each other. Finally, we presume that there is a specific connection between the feet and the genitals. Physiologically in the cortical homunculus, the genital area lies adjacent or overlapped to the foot areas, the two areas may interact with each other. The functional reorganization between different areas of the cerebral cortex under pathological conditions may be the underlying mechanism of the relationship between the feet and the genitals.
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Phan R, Seifman MA, Dhillon R, Lim P, Hunter-Smith DJ, Rozen WM. Use of submental and submandibular free vascularized lymph node transfer for treatment of scrotal lymphedema: Report of two cases. Microsurgery 2020; 40:808-813. [PMID: 32985738 DOI: 10.1002/micr.30651] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 08/02/2020] [Accepted: 08/28/2020] [Indexed: 02/05/2023]
Abstract
Genital lymphedema is a rare condition in males that can lead to difficulty in voiding, sexual function, hygiene, and mobility. Only several methods of treatment have been developed and studied, primarily focusing on restoring patency of diseased lymph channels or resection of affected tissue. We are the first to describe the surgical technique and our experience of using free submental and submandibular arterio-venous vascularized lymph node transfer specifically for the treatment of scrotal edema. We report on two patients who have undergone selective neck dissection of submental and submandibular lymph nodes based off the facial artery and vein. These vascularized lymph nodes were then transferred to the groin, with anastomosis to the deep inferior epigastric perforator artery and vein. The first patient, a 63 year old had initial pretreatment measurement of the anal verge to base of penis was 18 cm in length, and maximum circumference of scrotum 27 cm for the first patient, and 31-42 cm, respectively, for the second patient, a 66 year old. At 9-month review for the first patient and 6-month review for the second patient, both donor and recipient site wounds had healed. The anal verge to base of penis length had decreased to 16 cm, while maximum circumference of scrotum had decreased to 23 cm, and 25-38 cm, respectively, for the second patient. We have had good success with reducing the burden on patients using this novel technique, and hence it should be considered as a viable treatment methodology in appropriately selected patients.
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Affiliation(s)
- Robert Phan
- Peninsula Clinical School, Central Clinical School, Faculty of Medicine, Monash University, Frankston, Victoria, Australia
| | - Marc A Seifman
- Peninsula Clinical School, Central Clinical School, Faculty of Medicine, Monash University, Frankston, Victoria, Australia
| | - Raminder Dhillon
- Peninsula Clinical School, Central Clinical School, Faculty of Medicine, Monash University, Frankston, Victoria, Australia
| | - Pelicia Lim
- Peninsula Clinical School, Central Clinical School, Faculty of Medicine, Monash University, Frankston, Victoria, Australia
| | - David J Hunter-Smith
- Peninsula Clinical School, Central Clinical School, Faculty of Medicine, Monash University, Frankston, Victoria, Australia
| | - Warren M Rozen
- Peninsula Clinical School, Central Clinical School, Faculty of Medicine, Monash University, Frankston, Victoria, Australia
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Forte AJ, Khan N, Huayllani MT, Boczar D, Saleem HY, Lu X, Manrique OJ, Ciudad P, McLaughlin SA. Lymphaticovenous Anastomosis for Lower Extremity Lymphedema: A Systematic Review. Indian J Plast Surg 2020; 53:17-24. [PMID: 32367914 PMCID: PMC7192660 DOI: 10.1055/s-0040-1709372] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Background Lymphedema is an accumulation of protein-rich fluid in the interstitial spaces resulting from impairment in the lymphatic circulation that can impair quality of life and cause considerable morbidity. Lower extremity lymphedema (LEL) has an overall incidence rate of 20%. Conservative therapies are the first step in treatment of LEL; however, they do not provide a cure because they fail to address the underlying physiologic dysfunction of the lymphatic system. Among several surgical alternatives, lymphaticovenous anastomosis (LVA) has gained popularity due to its improved outcomes and less invasive approach. This study aims to review the published literature on LVA for LEL treatment and to analyze the surgical outcomes. Methods PubMed database was used to perform a comprehensive literature review of all articles describing LVA for treatment of LEL from Novemeber 1985 to June 2019. Search terms included "lymphovenous" OR "lymphaticovenous" AND "bypass" OR "anastomosis" OR "shunt" AND "lower extremity lymphedema." Results A total of 95 articles were identified in the initial query, out of which 58 individual articles were deemed eligible. The studies included in this review describe notable variations in surgical techniques, number of anastomoses, and supplementary interventions. All, except one study, reported positive outcomes based on limb circumference and volume changes or subjective clinical improvement. The largest reduction rate in limb circumference and volume was 63.8%. Conclusion LVA demonstrated a considerable reduction in limb volume and improvement in subjective findings of lymphedema in the majority of patients. The maintained effectiveness of this treatment modality in long-term follow-up suggests great efficacy of LVA in LEL treatment.
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Affiliation(s)
- Antonio J. Forte
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, Florida, United States
| | | | - Maria T. Huayllani
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, Florida, United States
| | - Daniel Boczar
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, Florida, United States
| | - Humza Y. Saleem
- Department of Surgery, Mayo Clinic, Jacksonville, Florida, United States
| | - Xiaona Lu
- Division of Plastic and Reconstructive Surgery, Yale School of Medicine, New Haven, Connecticut, United States
| | - Oscar J. Manrique
- Division of Plastic Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
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Hara H, Mihara M. Treating and preventing recurrence of recurrent genital acquired lymphangiectasia using lymphaticovenous anastomosis at genital area: A case report. Microsurgery 2020; 40:399-403. [DOI: 10.1002/micr.30552] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 11/23/2019] [Accepted: 12/26/2019] [Indexed: 01/23/2023]
Affiliation(s)
- Hisako Hara
- Department of Lymphatic and Reconstructive Surgery JR Tokyo General Hospital Tokyo Japan
| | - Makoto Mihara
- Department of Lymphatic and Reconstructive Surgery JR Tokyo General Hospital Tokyo Japan
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A Systematic Review of Outcomes After Genital Lymphedema Surgery: Microsurgical Reconstruction Versus Excisional Procedures. Ann Plast Surg 2019; 83:e85-e91. [PMID: 31135508 DOI: 10.1097/sap.0000000000001875] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Genital lymphedema (GL) surgery can be either palliative or functional. Palliative procedures involve excision of the affected tissue and reconstruction by either local flaps or skin grafts. Reconstructive procedures aim to restore lymphatic flow through microsurgical lymphaticovenous anastomoses (LVAs). This systematic analysis of outcomes and complication rates aims to compare outcomes between these surgical treatment options for GL. METHODS A systematic review of the PubMed database was performed with the following search algorithm: (lymphorrhea or lymphedema) and (genital or scrotal or vulvar) and (microsurgery or "surgical treatment"), evaluating outcomes, and complications after surgical treatment of GL. RESULTS Twenty studies published between 1980 and 2016 met the inclusion criteria (total, 151 patients). Three main surgical treatments for GL were identified. Surgical resection and primary closure or skin graft was the most common procedure (46.4%) with a total complication rate of 10%. Surgical resection and flap reconstruction accounted for 39.1% of the procedures with an overall complication rate of 54.2%. Lympho venous shunt (LVA) procedures (14.5%) had a total complication rate of 9%. CONCLUSIONS This review demonstrates a lack of consensus in both the preoperative assessment and surgical management of GL. Patients receiving excisional procedures tended to be later stage lymphedema. Patients in the excision and flap reconstruction group seemed to have the highest complication rates. Microsurgical LVAs may represent an alternative approach to GL, either alone or in combination with traditional procedures.
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Romics M, Tasnadi G, Sulya B, Kiss A, Merksz M, Nyirady P. Congenital lymphovascular malformations with urological symptoms: a report of two cases and review of the literature. Int Urol Nephrol 2016; 48:1771-1775. [DOI: 10.1007/s11255-016-1365-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Accepted: 06/30/2016] [Indexed: 01/30/2023]
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Mok ZR, Yew YW, Chong WS. Scrotal cutaneous chylous reflux: a scrotum with a white coat. Int J Dermatol 2015; 54:e557-8. [PMID: 26341840 DOI: 10.1111/ijd.12978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Accepted: 01/13/2015] [Indexed: 11/28/2022]
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Re-evaluation of qualitative lymphangioscintigraphic findings in secondary lower extremity lymphedema. Surg Today 2013; 44:1048-55. [PMID: 24374366 DOI: 10.1007/s00595-013-0819-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Accepted: 05/13/2013] [Indexed: 10/25/2022]
Abstract
PURPOSE To re-evaluate whether qualitative lymphangioscintigraphy (LAS) findings are sensitive enough to diagnose or classify the clinical severity of lower extremity lymphedema. METHODS LAS was performed in 78 extremities with lymphedema and 24 extremities without lymphedema between April, 2009 and March, 2012. We assessed the proportion of extremities in which there was no visual evidence of the ilioinguinal lymph nodes (LN-60) or the lymphatic trunk (Tr-60) 60 min after tracer injection, the number of visualized ilioinguinal lymph nodes (#LN), and the proportion of extremities with dermal backflow (pDBF) and lymph stasis (pLS). These were associated with the International Society of Lymphology (ISL) clinical stage. RESULTS LN-60, Tr-60, #LN, pDBF, and pLS, especially when extending into both the thigh and lower leg, were significantly associated with the ISL stage. The sensitivity of LN-60, Tr-60, and #LN <2 for diagnosing lymphedema was 49, 47, and 59 %, respectively, with no significant difference among these parameters for consecutive ISL stages. CONCLUSIONS None of the above measures was sufficiently sensitive to diagnose lymphedema or classify the severity of the disease; however, each of these criteria can aid in diagnosis, by excluding other diseases and assessing disease pathophysiology.
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