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

Comparing Different Donor Sites After Vascularized Lymph Node Transfer to the Lymphedematous Upper Limb: A Systematic Review and Meta-analysis of Clinical Outcomes

BACKGROUND

Vascularized lymph node transfer (VLNT) involves the microvascular transplantation of functional lymph nodes from a donor site into a limb affected by lymphedema to restore the normal flow of lymphatic fluid. Despite the increasing clinical experience with VLNT, there remains insufficient data to support its routine use in clinical practice. Here, we aim to evaluate the effectiveness and safety of VLNTs for upper limb lymphedema and compare clinical outcomes when using different donor sites.

METHODS

We carried out a systematic search of the literature through PubMed and Scopus databases for studies on VLNT for upper limb lymphedema. Primary and secondary outcomes included circumference reduction rate (CRR) and infection reduction rate by postoperative cellulitis episodes for the efficacy and safety of VLNT. Pooled analysis was performed using the inverse variance weighting meta-analysis of single means using the meta package in R software. Subgroup analyses were performed for donor and recipient sites, age groups, follow-ups, and symptom durations. Quality assessment was performed using the Newcastle-Ottawa Scale for nonrandomized studies.

RESULTS

A total of 1089 studies were retrieved from the literature, and 15 studies with 448 upper limb lymphedema patients who underwent VLNT were included after eligibility assessment. The mean CRR was 34.6 (18.8) and the mean postoperative cellulitis episodes per year was 0.71 (0.7). The pooled analysis of CRR was 28.4% (95% confidence interval, 19.7-41.1) and postoperative cellulitis episodes showed a mean of 0.59 (95% confidence interval, 0.36-0.95) using the random-effect model. Subgroup analyses showed significant group differences in recipient site for CRR and postoperative cellulitis episodes with the wrist comprising the highest weights, and patients younger than 50 years showing a lower postoperative infection.

CONCLUSIONS

Vascularized lymph node transfer using gastroepiploic flaps at the wrists has shown a significant difference in reductions of limb circumference and cellulitis episodes in upper limb lymphedema patients when compared with other donor sites. However, further prospective studies are needed to consolidate this finding.

Decompression of Axillary Vein: An Essential Adjunct for Advanced Lymphedema

BACKGROUND

In advanced lymphedema, lymphovenous anastomosis (LVA) can be a solution based on using the pressure gradient between the high-pressure lymphatics and the low-pressure veins. If the vein pressure is high, the effect of surgery will be less optimal. This study evaluated the effect of axillary vein perivascular scar release on LVA.

METHODS

This is a retrospective study of 40 upper limb stage 2 and 3 lymphedema patients divided into 2 groups with an average follow-up of 33 months (minimum of at least 12 months): the scar release group ( n = 25) and the control group ( n = 15). All patients underwent LVA with or without lymph node transfer. Demographic data, outcome (volumetric change and bioimpedence analysis [BIA]), and major vein (axillary, basilic, and cephalic) diameter changes were evaluated.

RESULTS

Both groups showed significant reduction in volume and BIA parameters after LVA. The scar release group (24 of 25 with lymph node transfer and 1 without) showed statistically higher reduction of BIA analysis compared with the control group at 1, 6, and 12 months after LVA. The changes in the major veins after axilla scar release showed significant changes in all 3 veins. There was a significant correlation between cephalic vein diameter reduction and BIA measurement.

CONCLUSIONS

The release of perivascular scar in the axillary vein may result in better outcome after LVA. This is based on the finding that scar release shows correlation between cephalic vein diameter reduction and BIA measurement suggesting reduction of venous pressure in the peripheral vein increasing the pressure gradient between the lymphatic and venous system allowing better outflow after LVA.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

"No-back-scar" Latissimus Dorsi Muscle Flap and Tissue Expander: A Valuable Strategy for Secondary Breast Reconstructions

An overall complication rates for implant-based breast reconstruction (IBBR) have been reported from 29 to 46%, particularly in the setting of adjuvant radiotherapy. Although the majority of the literature describes autologous conversion in such scenario, a microsurgical flap is not always feasible. The aim of the paper is to assess surgical and patient-reported outcomes of breast reconstruction using a Latissimus Dorsi muscle Flap (LDMF), harvested without a back scar, in combination with a tissue expander for a two-staged reconstruction in the setting of a previously failed IBBR. All consecutive patients undergoing a two-stages LDMF IBBR between January 2016 and June 2020 were retrospectively identified. A minimal length vertical incision along the posterior axillary line was used for LD flap harvest. Demographic, clinical and surgical data were collected. Aesthetic outcome was evaluated with the Aesthetic Item Scale, and BREAST-Q was used to assess patients' reported outcomes. Twenty-one patients met the inclusion criteria. Mean age was 45.6 years, and the average follow-up was 41.2 months after tissue expander replacement with definitive implant. All patients completed the secondary reconstructive procedure, without major complications both at reconstructive and donor flap site. All women reported to be very satisfied with the final breast reconstruction. Second-attempt implant-based breast reconstruction for patients with a previously failed IBBR is challenging. A conversion from prosthetic to a mixed breast reconstruction with a "no-back scar" LD flap and tissue expander can be considered as a valuable strategy, especially when an abdominal-based autologous breast reconstruction is not feasible or refused by the patients.Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Leg Lymphoedema After Inguinal and Ilio-Inguinal Lymphadenectomy for Melanoma: Results from a Prospective, Randomised Trial

BACKGROUND

The Evaluation of Groin Lymphadenectomy Extent for Melanoma (EAGLE FM) study sought to address the question of whether to perform inguinal (IL) or ilio-inguinal lymphadenectomy (I-IL) for patients with inguinal nodal metastatic melanoma who have no clinical or imaging evidence of pelvic disease. Primary outcome measure was disease-free survival at 5 years, and secondary endpoints included lymphoedema.

METHODS

EAGLE FM was designed to recruit 634 patients but closed with 88 patients randomised because of slow recruitment and changes in melanoma management. Lymphoedema assessments occurred preoperatively and at 6, 12, 18, and 24 months postoperatively. Lymphoedema was defined as Inter-Limb Volume Difference (ILVD) > 10%, Lymphoedema Index (L-Dex®) > 10 or change of L-Dex® > 10 from baseline.

RESULTS

Prevalence of leg lymphoedema between the two groups was similar but numerically higher for I-IL at all time points in the first 24 months of follow-up; highest at 6 months (45.9% IL [CI 29.9-62.0%], 54.1% I-IL [CI 38.0-70.1%]) and lowest at 18 months (18.8% IL [CI 5.2-32.3%], 41.4% I-IL [CI 23.5-59.3%]). Median ILVD at 24 months for those affected by lymphoedema was 14.5% (IQR 10.6-18.7%) and L-Dex® was 12.6 (IQR 9.0-17.2). There was not enough statistical evidence to support associations between lymphoedema and extent of surgery, radiotherapy, or wound infection.

CONCLUSIONS

Despite a trend for patients who had I-IL to have greater lymphoedema prevalence than IL in the first 24 months after surgery, our study's small sample did not have the statistical evidence to support an overall difference between the surgical groups.

Evaluation of modulation of immunity by lymph node transfer: A preliminary histological evidence in lymphedema patients

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.

Lymph Node Transfer and Neolymphangiogenesis: From Theory to Evidence

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.

Vascularized lymph node flaps can survive on venous blood without an arterial inflow: an experimental model describing the dynamics of venous flow using indocyanine green angiography (With video)

Background

Several surgeons have described studies of free-tissue transfers using veins instead of arteries. These innovative microsurgical techniques can offer several advantages, such as an easier dissection during flap harvesting, and represent an alternative during an accidental surgical mistake or development of new surgical procedures. The purpose of this study was to describe and explore different constructs of vascularized lymph node transfer (VLNT) only based on venous blood flow in a mouse model, evaluate their blood flow microcirculation through indocyanine green (ICG) angiography and investigate the lymphatic drainage function and the lymph nodes' structures.

Methods

Five types of venous lymph node flaps (LNF) were created and investigated: Types IA, IB, IC, IIA and IIB were developed by ICG intraoperatively (with videos in the article). Seven weeks later, by applying methylene blue, the recanalization of the lymphatic vessels between the LNF and the recipient site was detected. Lymph nodes were collected at the same time and their structures were analyzed by hematoxylin and eosin staining analysis.

Results

All of the venous LNFs developed except Type IC. Seven weeks later, methylene blue flowed into Types IA, IB, IIA and IIB from recipient sites. When comparing with arteriovenous lymph node, the medullary sinus was diffusely distributed in venous lymph nodes. The proportion of cells was significantly reduced (p < 0.05). The artery diameters were significantly smaller (p < 0.05). The veins diameters and lymphatic vessels output in Types IA, IB, IIA and IIB were more dilated (p < 0.05).

Conclusions

This research demonstrated that Type IA, IB, IIA and IIB venous LNFs can retrogradely receive venous blood supply; they can survive, produce a lymphatic recanalization and integrate with the surrounding tissue, despite lymph node structural changes. Our results will improve the understanding of the survival mechanism of venous LNFs and will help researchers to design new studies or lymphatic models and eventually find an alternative procedure for the surgical treatment of lymphedema.

Outcomes after microsurgical treatment of lymphedema: a systematic review and meta-analysis

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.

A comparative study between deep inferior epigastric artery perforator flap breast reconstruction and DIEP flap breast reconstruction coupled with vascularized lymph node transfer: Improving the quality of life of patients with breast cancer related lymphedema without affecting donor site outcomes

BACKGROUND

Despite simultaneous microvascular breast reconstruction (MBR) and vascularized lymph node transfer (VLNT) gaining wide popularity as a potential treatment for breast cancer related lymphedema (BCRL), there is a lack of evidence supporting the procedure. There are few reports in the literature, and no study has compared simple deep inferior epigastric artery perforator (DIEP) to simultaneous DIEP flap and VLNT.

PATIENTS AND METHODS

A retrospective analysis of our series of DIEP flaps was conducted. Patients presenting with BCRL who had delayed MBR and simultaneous VLNT were selected. Thirty-two patients were included and compared with a control group of delayed MBR with DIEP flap alone. Clinical evaluation, circumference reduction rate, and LYMQOL questionnaire were used to compare preoperative and postoperative findings in the study group. A digital version of BREAST Q questionnaire was administered to all patients.

RESULTS

Thirty-two patients were enrolled in the study group, with a mean follow-up of 42.5 ± 25.7 months and mean age of 54.1 ± 7.8 years. The mean circumference reduction rate was 46.1 ± 52.3, 39 ± 42.3, 47.5 ± 53.5, 39.2 ± 52.4, 33.6 ± 50.1 at the deltoid insertion, above the elbow, below the elbow, at the mid-forearm and wrist respectively. Postoperative LYMQOL scores significantly improved (function 1.21, appearance 1.15, symptoms 1.34, mood 1.33, overall QOLscore 8.6) from preoperative baseline (p < .001). There was no significant difference in term of outcomes and complications rate of the donor site between the study and control groups.

CONCLUSIONS

Simultaneous DIEPandVLNT improves the HRQOL of patients with lymphedema. Coupling VLNT with abdominal flap does not increase the morbidity of donor site.

Lymphatic flow through (LyFT) ALT flap: an original solution to reconstruct soft tissue loss with lymphatic leakage or lower limb lymphedema

INTRODUCTION

The lympho-venous shunt using the distal vein of ALT flap pedicle allowed at the same time the coverage of the inguinal defects and to perform lymphovenous shunt into a run-in vein of the descending branch of the lateral circumflex femoral pedicle, draining the lymph through the flap pedicle. Surgical technique, complications and final outcomes (both clinical and lymphoscintigraphic) are reported.

METHODS

Five patients (45.8 y.o.[22-70]) with groin soft tissue loss with lymphatic leakage or lower limb lymphedema, benefited of the described technique. The ALT flap was used to cover the defect and, at the same time, we could perform a lymphovenous shunt between afferent lymphatics to the thigh and the descending branch of the lateral circumflex femoral pedicle, distal to the perforator nourishing the flap. Clinical and lymphoscintigraphic assessment of the limbs, cease of lymphorrhea or cellulitis/lymphangitis episodes, eventual downstaging of physiologic/physical therapy were recorded. LYMphatic Quality Of Life in leg (LYMQoLLeg) and patient satisfaction were evaluated.

RESULTS

Average flap size was 88.8cm² (range 84-126). The mean number of multi-lymphovenous anastomosis (MLVA) performed was 1.8 (range 1-3) per patient with 1-3 lymphatics shunted into each vein. Only one hemato-seroma requiring surgical revision. Mean improvement of perometer values was 48.2% (range 27.7-67.7) with an average follow-up of 13.6 months (range 12-17). Lymphoscintigraphy showed disappearing of the lymphatic leak and lymphedema with a high satisfaction of LYMQoL score.

DISCUSSION

The combination of pedicle flap with lympho-venous bypass as lymphatic derivation concept, improving the chronic morbidity scenarios of lymphatic complications.

A Prospective Study on the Safety and Efficacy of Vascularized Lymph Node Transplant

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.

[Autologous Breast Reconstruction in Conjuction with Lymphatic Microsurgery in Breast Cancer-Related Lymphedema]

Breast cancer-related lymphedema of the upper extremity is the most significant non-oncological complication of tumour therapy, leading to functional impairment and impacting patients' quality of life. Autologous breast reconstruction per se effectively reduces incidence and stage of lymphedema after breast cancer treatment by surgical angiogenesis. In addition, modern surgical techniques for treating lymphedema are effective in reducing limb volume, circumference and functional impairment, and improving patients' quality of life, body image, integrity and local immunocompetence. Reconstructive surgery, including lymphovenous anastomoses (LVA) and vascularised lymph node transfer (VLNT), have been shown to rearrange or restore lymphatic flow and prevent stage progression. For patients with breast cancer-related lymphedema after mastectomy, autologous breast reconstruction in conjunction with lymphatic microsurgery using VLNT, LVA or a combination of these procedures offers the option of holistic and single-stage restoration in modern senology. Extensive scar release in the axilla is a crucial component of the surgical technique, aiming to prepare the recipient bed for the VLN transplant and to allow for the functional recruitment of remaining lymph vessels of the upper extremity. This article presents the indications, preoperative diagnostic evaluation, surgical techniques and precautions, complications and results of combined lymphatic and breast restoration.

Emerging Anti-Inflammatory Pharmacotherapy and Cell-Based Therapy for Lymphedema

Secondary lymphedema is a common complication of lymph node dissection or radiation therapy for cancer treatment. Conventional therapies such as compression sleeve therapy, complete decongestive physiotherapy, and surgical therapies decrease edema; however, they are not curative because they cannot modulate the pathophysiology of lymphedema. Recent advances reveal that the activation and accumulation of CD4+ T cells are key in the development of lymphedema. Based on this pathophysiology, the efficacy of pharmacotherapy (tacrolimus, anti-IL-4/IL-13 antibody, or fingolimod) and cell-based therapy for lymphedema has been demonstrated in animal models and pilot studies. In addition, mesenchymal stem/stromal cells (MSCs) have attracted attention as candidates for cell-based lymphedema therapy because they improve symptoms and decrease edema volume in the long term with no serious adverse effects in pilot studies. Furthermore, MSC transplantation promotes functional lymphatic regeneration and improves the microenvironment in animal models. In this review, we focus on inflammatory cells involved in the pathogenesis of lymphedema and discuss the efficacy and challenges of pharmacotherapy and cell-based therapies for lymphedema.

Prevention of Secondary Lymphedema after Complete Lymph Node Dissection in Melanoma Patients: The Role of Preventive Multiple Lymphatic-Venous Anastomosis in Observational Era

Background and Objectives: Current guidelines have limited the performance of complete lymph node dissection (CLND) for patients with clinically detectable lymphatic metastases. Despite the limitations of this surgical procedure, secondary lymphedema (SL) is an unsolved problem that affects approximately 20% of patients undergoing CLND. Preventive lymphatic–venous micro-anastomoses (PMLVA) has already demonstrated its efficacy in the prevention of SL in melanoma patients with a positive sentinel lymph node biopsy (SLNB), but the efficacy of this procedure is not demonstrated in patients with clinically detectable lymphatic metastases. Materials and Methods: This retrospective cohort study, was performed in two observation periods. Until March 2018, CLND was proposed to all subjects with positive-SLNB andPMLVA was performed in a subgroup of patients with risk factors for SL (Group 1). From April 2018, according to the modification of melanoma guidelines, all patients with detectable metastatic lymph nodes underwent PMLVA during CLND (Group 2). The frequency of lymphedema in subjects undergoing PMLVA was compared with the control group. Results: Database evaluation revealed 172 patients with melanoma of the trunk with follow-up information for at least 6 mounts. Twenty-three patients underwent PMLVA during CLND until March 2018, 29 from April 2018, and 120 subjects underwent CLND without any preventive surgery (control Group). The frequency of SL was significantly lower in both Group 1 (4.3% vs. 24.2%, p = 0.03) and Group 2 (3.5%, p = 0.01). Patients undergoing PMLVA showed a similar recurrence-free periods and overall survival when compared to the control group. Conclusions: PMLVA significantly reduces the frequency of SL both in immediate and delayed CLND. This procedure is safe and does not lead to an increase in length of hospitalization.

Combined lymph node transfer and suction-assisted lipectomy in lymphedema treatment: A prospective study

BACKGROUND

Recent studies have analyzed the combination of suction-assisted lipectomy (SAL) and vascularized lymph node transfer (VLNT) in lymphedema treatment, reporting positive outcomes. However, it is difficult to draw conclusions due to the heterogeneity of the studies. Aim of this prospective study is to evaluate the effectiveness of the combination of VLNT and SAL in lymphedema treatment.

PATIENTS AND METHODS

Between January 2016 and May 2019, 94 patients with upper or lower limb stage IIb-III lymphedema were enrolled and treated with the gastroepiploic VLNT followed by SAL. Patients were prospectively evaluated through circumference measurement and clinical examination, including number of episodes of cellulitis.

RESULTS

Among patients enrolled in the study 83 were affected by lower limb lymphedema (LLL) and 11 were affected by upper limb lymphedema (ULL). Average follow-up was 3 ± 0.8 years. In the LLL group, the mean circumference reduction rates (CRR) were 60.4, 56.9, 29.6, and 55.4% above and below the knee, above the ankle, and at the foot level, respectively. A statistically significant difference was noted at all the levels (p < .05), but above the ankle (p = .059). Regarding the ULL group, the mean CRR were 80.7, 60.7, 65.0 and 49.6% above and below the elbow, at wrist and at mid-hand, respectively. CRR were reported at all the levels but no statistical difference was noted. The number of episodes of cellulitis dropped significantly (p < .05).

CONCLUSION

This study supports the use of VLNT+SAL in lymphedema grades IIb-III, with important implications for the clinical practice.

Axilla versus Wrist as the Recipient Site in Vascularized Lymph Node Transfer for Breast Cancer-Related Lymphedema: A Systematic Review and Meta-Analysis

BACKGROUND

 Vascularized lymph node transfers (VLNT) are being used with increasing frequency for the treatment of breast cancer-related lymphedema (BCRL). However, there is a lack of consensus in the surgical field as to which recipient site should be utilized. We, therefore, aim to assess the evidence comparing the wrist and axilla as recipient sites for VLNT in BCRL.

METHODS

 We conducted a systematic literature review to compare the wrist and axilla as recipient sites for VLNT in BCRL. Demographic data, as well as circumference reduction rate (CRR), excess volume reduction (EVR), postoperative decrease in infections per year, postoperative discontinuation of compression garments, and overall pooled complication rate were extracted from included studies. These were compared through a meta-analysis.

RESULTS

 A total of 37 studies met the inclusion criteria for a total of 689 patients. VLNTs to the wrist and axilla resulted in a decrease in CRR of 42.1 and 51.5%, and a decrease in EVR of 35.6 and 48.8%, respectively. However, our meta-analysis showed no significant differences between CRR or EVR and between wrist and axilla as recipient sites. Similarly, we found no differences in postoperative decrease in infections per year, postoperative discontinuation of compression garments, and overall pooled complication rate.

CONCLUSION

 These data suggest noninferiority between the wrist and axilla as recipient sites for VLNT in the context of BCRL. In the absence of randomized, prospective data, we hope these results can be used as an evidence-based reference and facilitate future studies.

Intra-abdominal vascularized lymph node transfer for treatment of lymphedema: A systematic literature review and meta-analysis

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.

Surgical Treatment of Lymphedema: A Systematic Review and Meta-Analysis of Controlled Trials. Results of a Consensus Conference

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.

A Systematic Review and Meta-Analysis of Vascularised Lymph Node Transfer for Breast Cancer Related Lymphedema

INTRODUCTION

Vascularized lymph node transfer (VLNT) is an increasingly popular technique for treating lymphedema. However, while many studies have been performed, its efficacy to increase patients' quality of life and reduce lymphedema in the affected body part are still controversial. In this systematic review we summarize the evidence on VLNT for treating breast cancer related lymphedema (BCRL).

MATERIAL AND METHODS

MEDLINE, EMBASE and Cochrane CENTRAL were searched for studies including patients with BCRL who received VLNT. Methodology was assessed by the MINORS tool. Primary outcomes were change in volume difference between arms and quality of life. Secondary outcomes were skin infections, complications and discontinuation of compression garment use.

RESULTS

17 Studies were included for qualitative synthesis and eight studies for meta-analysis. The average reduction rate between the healthy and affected arm for studies included in the meta-analysis was 40.31%. Five studies evaluated QoL and in all of these studies QoL was significantly increased. Eight studies evaluated skin infections of which three provided yearly infection rates before and after surgery. In these studies infection rate was significantly decreased. Three studies described usage of compression garment. When patients are pooled 27 out of 60 were able to discontinue compression garment. Donor and recipient complication rates were 12.1 and 7.3% respectively.

CONCLUSIONS

Current evidence indicates that VLNT can improve volume difference between arms in unilateral lymphedema patients by about 40%. In addition, although based on few studies, it is likely that VLNT has a positive effect on patients QoL, the number of skin infections and compression garment usage while coinciding with a low complication rate.

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

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 [CRR_P] = 42.7% [95% confidence interval (CI): 36.5-48.8]; below elbow CRR_P = 34.1% [95% CI: 33.0-35.1]) and LL (above knee CRR_P = 46.8% [95% CI: 43.2-50.4]; below knee CRR_P = 54.6% [95% CI: 39.0-70.2]) CTRL. VLNT flaps from extra-abdominal donor sites were associated with greater volume reductions (CRR_P = 49.5% [95% CI: 46.5-52.5]) than those from intra-abdominal donor sites (CRR_P = 39.6% [95% CI: 37.2-42.0]) and synchronous autologous breast reconstruction/VLNT flaps (CRR_P = 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.

"To Pre or Not to Pre": Introduction of a Prepectoral Breast Reconstruction Assessment Score to Help Surgeons Solving the Decision-Making Dilemma. Retrospective Results of a Multicenter Experience

BACKGROUND

Implant-based reconstruction is the most performed breast reconstruction, and both subpectoral and prepectoral approaches can lead to excellent results. Choosing the best procedure requires a thorough understanding of every single technique, and proper patient selection is critical to achieve surgical success, in particular when dealing with prepectoral breast reconstruction.

METHODS

Between January of 2014 and December of 2018, patients undergoing mastectomy and eligible for immediate prepectoral breast reconstruction with tissue expander or definitive implant, were selected. The Prepectoral Breast Reconstruction Assessment score was applied to evaluate patient-related preoperative and intraoperative risk factors that could influence the success of prepectoral breast reconstruction. All patients were scored retrospectively, and the results obtained through this assessment tool were compared to the records of the surgical procedures actually performed.

RESULTS

Three hundred fifty-two patients were included; 112 of them underwent direct-to-implant immediate reconstruction, and 240 underwent the two-stage procedure with temporary tissue expander. According to the Prepectoral Breast Reconstruction Assessment score, direct-to-implant reconstruction should have been performed 6.2 percent times less, leading to an increase of 1.4 percent in two-stage reconstruction and 4.8 percent in submuscular implant placement.

CONCLUSIONS

To date, there is no validated system to guide surgeons in identifying the ideal patient for subcutaneous or retropectoral breast reconstruction and eventually whether she is a good candidate for direct-to-implant or two-stage reconstruction. The authors processed a simple risk-assessment score to objectively evaluate the patient's risk factors, to standardize the decision-making process, and to identify the safest and most reliable breast reconstructive procedure.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Quality-of-life outcomes after operative management of primary and secondary lymphoedema: a systematic review

BACKGROUND

Lymphoedema is an incurable and progressive disease that affects not only physical function but overall quality of life. Surgical treatment options for the management of lymphoedema are being increasingly performed. This study aims to review post-operative health-related quality of life (HRQOL) following surgical treatment of lymphoedema.

METHODS

A systematic search of the PubMed and Medline databases was performed from the date of their inception until September 2018 to evaluate HRQOL following different surgical options for the treatment of lymphoedema.

RESULTS

One hundred and thirteen articles were identified. Twenty-one articles were included in the final review, comprising a total of 736 patients. HRQOL improvements appear to be sustained for at least 6-12 months post-operatively. In particular, major benefits were noted in the domains based around physical functioning. Patient satisfaction similarly mirrors HRQOL improvements, following an initial dip in the immediate post-operative period.

CONCLUSION

All surgical treatment modalities for the management of lymphoedema confer significant HRQOL improvements across a diverse range of health domains, with this critical outcome of surgery an important pre-operative consideration. Recommendations for ongoing research are suggested.

Adipose-derived regenerative cells and lipotransfer in alleviating breast cancer-related lymphedema: An open-label phase I trial with 4 years of follow-up

Patients with breast cancer‐related lymphedema (BCRL) have reduced quality of life and arm function. Current treatments are palliative, and treatments improving lymphedema are lacking. Preclinical studies have suggested that adipose‐derived regenerative cells (ADRCs) can alleviate lymphedema. We, therefore, aimed to assess whether ADRCs can alleviate lymphedema in clinical reality with long‐term follow‐up. We treated 10 patients with BCRL using ADRCs and a scar‐releasing lipotransfer to the axillary region, and all patients were followed 1, 3, 6, 12, and 48 months after treatment. The primary endpoint was change in arm volume. Secondary endpoints were safety, change in lymphedema symptoms, quality of life, lymphedema‐associated cellulitis, and conservative treatment use. There was no significant decrease in BCRL volume after treatment. However, self‐reported upper extremity disability and arm heaviness and tension improved. Six patients reduced their use of conservative BCRL treatment. Five patients felt that their BCRL had improved substantially, and four of these would redo the treatment. We did not observe any cases of locoregional breast cancer recurrence. In this phase I study with 4 years of follow‐up, axillary delivered ADRCs and lipotransfer were safe and feasible and improved BCRL symptoms and upper extremity function. Randomized controlled trials are needed to confirm the results of this study.

Surgical versus Nonsurgical Management of Postmastectomy Lymphedema: A Prospective Quality of Life Investigation

Background Postmastectomy secondary lymphedema can cause substantial morbidity. However, few studies have investigated longitudinal quality of life (QoL) outcomes in patients with postmastectomy lymphedema, especially with regard to surgical versus nonoperative management. This study prospectively investigated QoL in surgically versus nonsurgically managed patients with postmastectomy upper extremity lymphedema.

Methods This was a longitudinal cohort study of breast cancer-related lymphedema patients at a single institution, between February 2017 and January 2020. Lymphedema Quality of Life Instrument (LyQLI) and RAND-36 QoL instrument were used. Mann–Whitney U and Fisher's exact tests were used for descriptive statistics. Wilcoxon's signed-rank testing and linear modeling were used to analyze longitudinal changes in QoL.

Results Thirty-two lymphedema patients were recruited to the study (20 surgical and 12 nonsurgical). Surgical and nonsurgical cohorts did not significantly differ in clinical/demographic characteristics or baseline QoL scores, but at the 12-month time point surgical patients had significantly greater LyQLI overall health scores than nonsurgical patients (79.3 vs. 58.3, p = 0.02), as well as higher composite RAND-36 physical (68.5 vs. 38.3, p = 0.04), and mental (77.0 vs. 52.7, p = 0.02) scores. Furthermore, LyQLI overall health scores significantly improved over time in surgical patients (60.0 at baseline vs. 79.3 at 12 months, p = 0.04). Besides surgical treatment, race, and age were also found to significantly impact QoL on multivariable analysis.

Conclusion Our results suggest that when compared with nonoperative management, surgery improved QoL for chronic, secondary upper extremity lymphedema patients within 12-month postoperatively. Our results also suggested that insurance status may have influenced decisions to undergo lymphedema surgery. Further study is needed to investigate the various sociodemographic factors that were also found to impact QoL outcomes in these lymphedema patients.

Impact of body mass index on long-term surgical outcomes of vascularized lymph node transfer in lymphedema patients

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.

Combined microvascular breast and lymphatic reconstruction with deep inferior epigastric perforator flap and gastroepiploic vascularized lymph node transfer for postmastectomy lymphedema patients

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.

Systematic Review of Patient-Reported Outcomes following Surgical Treatment of Lymphedema

INTRODUCTION

Analysis of quality of life (QOL) outcomes is an important aspect of lymphedema treatment since this disease can substantially impact QOL in affected individuals. There are a growing number of studies reporting patient-reported outcomes (PROMs) for patients with lymphedema. The purpose of this study was to conduct a systematic review of outcomes and utilization of PROMs following surgical treatment of lymphedema.

METHODS

A literature search of four databases was performed up to and including March, 2019. Studies included reported on QOL outcomes after physiologic procedures, defined as either lymphovenous bypass (LVB) or vascularized lymph node transplant (VLNT), to treat upper and/or lower extremity primary or secondary lymphedema.

RESULTS

In total, 850 studies were screened-of which, 32 studies were included in this review. Lymphovenous bypass was the surgical intervention in 16 studies, VLNT in 11 studies, and both in 5 studies. Of the 32 total studies, 16 used validated survey tools. The most commonly used PROM was the lymph quality of life measure for limb lymphedema (LYMQOL) (12 studies). In the remaining four studies, the upper limb lymphedema 27 scale (ULL27), the short form 36 questionnaire (SF-36), the lymphedema functioning, disability and health questionnaire (Lymph-ICF), and lymphedema life impact scale (LLIS) were each used once. QOL improvement following surgical treatment was noted in all studies.

CONCLUSIONS

Physiologic surgical treatment of lymphedema results in improved QOL outcomes in most patients. The use of validated PROM tools is increasing but there is no current consensus on use. Future research to evaluate the psychometric properties of PROMs in lymphedema is needed to guide the development and use of lymphedema-specific tools.

Surgical Treatment of Advanced Lymphatic Filariasis of Lower Extremity Combining Vascularized Lymph Node Transfer and Excisional Procedures

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.