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Desai A, Dahl V, De Castro Silva I, Clark M, Xu KY, Kesmodel SB, Goel N, Rojas KE, Crystal J, Mella-Catinchi JR. Larger recipient vein caliber during lymphatic microsurgical preventive healing approach (LYMPHA) is associated with lower lymphedema rates. Surgery 2024:S0039-6060(24)00547-6. [PMID: 39237435 DOI: 10.1016/j.surg.2024.07.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 06/19/2024] [Accepted: 07/18/2024] [Indexed: 09/07/2024]
Abstract
BACKGROUND The lymphatic microsurgical preventive healing approach reduces the risk of lymphedema after axillary lymph node dissection. We identified surgical factors of Lymphatic Microsurgical Preventive Healing Approach (LYMPHA) that influence lymphedema rates focusing on the vein caliber used. METHODS A single-institution retrospective cohort study included breast cancer patients undergoing axillary lymph node dissection and LYMPHA (April 2021-November 2022) with a follow-up of at least 1 year. Lymphedema was defined as an increase of ≥10 units in the lymphedema index (measured using bioimpedance spectroscopy) from baseline. The primary outcome was the correlation between the lymphedema index of patients with a vein caliber of ≤2 mm vs > 2 mm. RESULTS Forty-eight patients with documented vein caliber were analyzed. The median baseline lymphedema index in patients with a vein caliber ≤2 mm was 2 (SD 3.04) and 2.2 (SD 2.03) for vein caliber >2 mm. (P = .57). After 1-year follow-up, the L-dex was 6.20 (SD 7.48) for vein caliber ≤2 mm and 1.60 (SD 5.85) for vein caliber >2 mm (P = .02). The L-dex difference from baseline was higher for vein caliber ≤2 mm compared to >2 mm (2.9 vs 0.10, P = .02). Larger vein caliber was associated with a lower L-dex at 3 months (P = .04) and a lesser difference from the baseline after 1 year (P = .03). This was maintained on univariate analysis and multivariate analysis controlling for radiation, chemotherapy, and number of lymph nodes excised. CONCLUSION Vein caliber >2 mm during LYMPHA axillary lymph node dissection is associated with a lower postoperative lymphedema index. These results can be enhanced by a multi-institutional study to improve standardization of this technique.
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Affiliation(s)
- Anshumi Desai
- Division of Plastic and Reconstructive Surgery, DeWitt Daughtry Family Department of Surgery, University of Miami, Miami, FL.
| | - Victoria Dahl
- Division of Plastic and Reconstructive Surgery, DeWitt Daughtry Family Department of Surgery, University of Miami, Miami, FL
| | - Iago De Castro Silva
- Department of Surgery, Morsani College of Medicine, University of South Florida, Tampa, FL
| | | | - Kyle Y Xu
- Division of Plastic and Reconstructive Surgery, DeWitt Daughtry Family Department of Surgery, University of Miami, Miami, FL
| | - Susan B Kesmodel
- Division of Surgical Oncology, DeWitt Daughtry Family Department of Surgery, University of Miami, Miami, FL; Sylvester Comprehensive Cancer Center, University of Miami Health System, Miami, FL. https://twitter.com/SueKesmodelMD
| | - Neha Goel
- Division of Surgical Oncology, DeWitt Daughtry Family Department of Surgery, University of Miami, Miami, FL; Sylvester Comprehensive Cancer Center, University of Miami Health System, Miami, FL
| | - Kristin E Rojas
- Division of Surgical Oncology, DeWitt Daughtry Family Department of Surgery, University of Miami, Miami, FL; Sylvester Comprehensive Cancer Center, University of Miami Health System, Miami, FL. https://twitter.com/kristinrojasmd
| | - Jessica Crystal
- Division of Surgical Oncology, DeWitt Daughtry Family Department of Surgery, University of Miami, Miami, FL; Sylvester Comprehensive Cancer Center, University of Miami Health System, Miami, FL
| | - Juan R Mella-Catinchi
- Division of Plastic and Reconstructive Surgery, DeWitt Daughtry Family Department of Surgery, University of Miami, Miami, FL
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McEvoy MP, Feldman S. Prevention and Treatment of Lymphedema in Breast Cancer. Adv Surg 2024; 58:65-77. [PMID: 39089787 DOI: 10.1016/j.yasu.2024.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
Breast cancer related lymphedema (BCRL) affects many breast cancer survivors and drastically affects their quality of life. There are several surveillance methods for BCRL that are critical at early detection. Prevention of BCRL involves knowledge of alternatives to aggressive axillary surgery, avoidance of axillary surgery, and de-escalation of axillary surgery. There are also techniques to better delineate the anatomy in the axilla to avoid taking nodes that drain the upper extremity. A multidisciplinary approach with medical oncology and radiation oncology can also help avoid unnecessary surgery or radiation that can together strongly increase the risk of BCRL.
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Affiliation(s)
- Maureen P McEvoy
- Department of Surgery, Division of Breast Surgery, Montefiore Medical Center, Montefiore Breast Care Center, 1250 Waters Place, Tower 1, 7th Floor, Bronx, NY 10461, USA.
| | - Sheldon Feldman
- Department of Surgery, Division of Breast Surgery, Montefiore Medical Center, Montefiore Breast Care Center, 1250 Waters Place, Tower 1, 7th Floor, Bronx, NY 10461, USA
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Li Y, Tang J, Mao D, Dragomir MP, Li Y, Sun K, Lv Z, Liu X, Meng X, Lu K. MRI-CEUS fusion-guided lymphatic mapping as a preoperative strategy for lymphedema patients undergoing lymphaticovenous anastomosis surgery. J Vasc Surg Venous Lymphat Disord 2024; 12:101907. [PMID: 38759752 DOI: 10.1016/j.jvsv.2024.101907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 04/06/2024] [Accepted: 05/03/2024] [Indexed: 05/19/2024]
Abstract
OBJECTIVE Contrast-enhanced ultrasound (CEUS) is useful in mapping lymphatic vessels in upper limb lymphedema; this study was aimed to evaluate its efficiency in lower limb lymphedema and investigate whether magnetic resonance lymphangiography (MRL) enhance the efficiency of CEUS. METHODS This retrospective study enrolled 48 patients with lymphedema undergoing lymphaticovenous anastomosis (LVA) surgery who received MRL and/or CEUS in addition to conventional indocyanine green (ICG) lymphangiography. The number of anastomotic sites and the duration per site (DPS) for LVA surgery were described and compared. RESULTS Among the 48 patients subjected to analysis, it was observed that 12 (25%), 20 (41.67%), and 16 (33.33%) of them received ICG, ICG+CEUS, and ICG+CEUS+MRL, respectively. The ICG+CEUS group demonstrated a significant increase in the number of LVAs (median, 5; range, 4-7), compared with the ICG group (median, 2; range, 1-4) (P < .001). Moreover, the ICG+CEUS+MRL group exhibited a higher number of LVAs (median, 8; range, 7-8.25) compared with both the ICG+CEUS and ICG groups (P < .001). For lower limb lymphedema, the ICG+CEUS+MRL group displayed an elevated number of LVAs (median, 8; interquartile range, 7-9) (P = .003), in contrast to the ICG group (median, 3; interquartile range, 1.75-4.25). Furthermore, the DPS in the ICG+CEUS+MRL group (median, 50.56; interquartile range, 48.13-59.29) (P = .005) exhibited a remarkable decrease when compared with the ICG group (median, 131.25; interquartile range, 86.75-198.13]). CONCLUSIONS MRL-CEUS fusion demonstrates superior performance in the identification of lymphatic vessels for lymphedema.
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Affiliation(s)
- Yongfeng Li
- Division of General Surgery, Cancer Center, Department of Breast Surgery, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, China
| | - Jinglan Tang
- Cancer Center, Department of Ultrasound Medicine, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, China
| | - Dewang Mao
- Cancer Center, Department of Radiology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, China
| | - Mihnea P Dragomir
- Institute of Pathology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu, Berlin, Germany; German Cancer Consortium (DKTK), Partner Site Berlin, and German Cancer Research Center (DKFZ), Heidelberg, Germany; Berlin Institute of Health, Berlin, Germany
| | - Ying Li
- Division of General Surgery, Cancer Center, Department of Breast Surgery, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, China
| | - Kewang Sun
- Division of General Surgery, Cancer Center, Department of Breast Surgery, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, China
| | - Zhenye Lv
- Division of General Surgery, Cancer Center, Department of Breast Surgery, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, China
| | - Xiaozhen Liu
- Division of General Surgery, Cancer Center, Department of Breast Surgery, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, China
| | - Xuli Meng
- Division of General Surgery, Cancer Center, Department of Breast Surgery, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, China
| | - Kefeng Lu
- Cancer Center, Department of Ultrasound Medicine, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, China.
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Chao S, Kuan C, Lin Y, Tai H, Cheng N. Lymphovenous Bypass as an Alternative Strategy for Managing Phleboedema and Venous Leg Ulcers: Preliminary Results. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e6064. [PMID: 39148508 PMCID: PMC11326461 DOI: 10.1097/gox.0000000000006064] [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: 02/07/2024] [Accepted: 06/21/2024] [Indexed: 08/17/2024]
Abstract
Background Chronic venous leg ulcers (VLUs) are a common manifestation of chronic venous insufficiency, accounting for up to 70% of all chronic leg ulcers. Patients sustained refractory ulcers and persistent phleboedema even with a combination of different treatment methods. Lymphovenous bypass (LVB) has shown promising results in patients with lymphedema. We hypothesize that LVB could potentially alleviate VLUs and phleboedema, given their symptom similarities with lymphedema. Methods From May 2021 to June 2023, we prospectively deployed LVB in patients with nonhealing stasis ulcers after 4-week traditional care, or in those with persistent phleboedema despite prior surgery for vein etiologies. Demographics, healing course and recurrence, lymphoscintigraphy, and VLU quality of life (QoL) questionnaires were collected. Results Thirty-one patients were treated with LVB and additional skin grafting as necessary. Their mean age was 62.6 ± 14.7 years, with male predominance (20, 64.5%), and most patients sustained clinical, etiologic, anatomic, pathophysiologic classification C6 (25, 80.6%). Postoperatively, wound healing and phleboedema decongestion were observed mostly within 2 months. The VLU QoL questionnaire (39.3% response rate) showed improvement in QoL in activities, and psychological and symptom distress aspects. Conclusions Using LVB for chronic venous insufficiency showed an increase in the success rate of ulcer healing and decompression of the swollen limbs with durable results. Patient-reported outcome measures disclosed the potential benefits of LVB. Large-scale randomized controlled trials and pathophysiological studies are warranted to elucidate its efficacy.
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Affiliation(s)
- Sungchuan Chao
- From the Department of Traumatology, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chenhisang Kuan
- Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Yingsheng Lin
- Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Yunlin, Taiwan
| | - Haochih Tai
- Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Naichen Cheng
- Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
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Engström O, Mani M. Surgical treatments of lymphedema-a literature review on robot-assisted lymphovenous anastomosis (LVA). Gland Surg 2024; 13:1066-1075. [PMID: 39015714 PMCID: PMC11247599 DOI: 10.21037/gs-24-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 05/23/2024] [Indexed: 07/18/2024]
Abstract
Background and Objective Lymphedema is a common issue after surgery and oncologic treatment, affecting millions of people worldwide. A better understanding of the condition has provided an increasing possibility of a tailormade treatment plan, and with improvement in surgical technique, we now have several surgical treatments to offer, including the lymphovenous anastomosis (LVA). Considering the size of lymph vessels used for LVA, sometimes as small as 0.3 mm, there is a need for improvement of the technical aspects of the procedures. This paper explores the potential of robotic assistance in LVA surgery as an innovative approach to overcome the limitations of human dexterity. Methods A literature review was performed on 2023-12-22 using PubMed, Cochrane, and Embase databases to identify all previous publications on robotic LVA surgery, resulting in a total of 65 publications. Original publications in English were considered and after selection, a total of 5 publications were included in the review. Key Content and Findings Two surgical systems used in clinical practice were identified, the MUSA (Microsure) and the Symani Surgical System (Medical Microinstruments). Common topics for discussion include the increased precision the robot assistance provides, clinical outcomes, ergonomics, and the learning curve for aspiring robot surgeons. Anastomosis times were generally found to be longer initially, but several authors note that there is a steep learning curve with rapidly decreasing times with an increasing number of procedures. Overall clinical outcomes were comparable to those using manual anastomosis. Conclusions The use of robotics in LVA surgery, has shown promising results through clinical studies. Robotic assistance can help augment the technical capacity of a surgeon through motion scaling and tremor filtration, facilitating the most delicate steps of the LVA. The learning curve is steep, and the technique can hopefully make microsurgical reconstructions available to a broader number of patients. Further development can include haptic feedback, structured training programs, and cost optimization through dissemination of the technology.
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Affiliation(s)
- Olof Engström
- Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden
| | - Maria Mani
- Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden
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Haidopoulos D, Pergialiotis V, Papageorgiou M, Halaska MJ, Maxova K, Ulrich E, Zapardiel I, Rodolakis A, Gultekin M, Fotopoulou C. Lower Limb Lymphedema Awareness among Gynecological Cancer Patients: An International Survey Supported by the European Network of Gynecological Cancer Advocacy Groups (ENGAGe) Group. Cancers (Basel) 2024; 16:1544. [PMID: 38672626 PMCID: PMC11048365 DOI: 10.3390/cancers16081544] [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: 03/11/2024] [Revised: 04/07/2024] [Accepted: 04/12/2024] [Indexed: 04/28/2024] Open
Abstract
INTRODUCTION Patient awareness of postoperative lymphedema in the field of gynecologic oncology has been poorly documented in the international literature. We wished to capture and document the awareness among gynecological cancer survivors about postoperative lymphedema, including aspects such as the adequacy of perioperative counseling, management, and quality of life. METHODS A web-based survey comprising 25 multiple-choice questions was distributed to gynecological cancer advocacy groups within the European Network of Gynecological Cancer Advocacy Groups (ENGAGe) group. The survey was validated in a pilot group of gynecological patients prior to distribution. RESULTS Overall, 386 women from 20 countries completed the questionnaire. Only half of the patients (n = 211) knew what lymphedema is, whereas 52% of the respondents stated that they were never informed at their pre-operative assessment about the potential risk of developing lymphedema. Fifty-three percent of those women who were informed about the risk and management of lymphedema received information through self-initiative, connecting mainly with patient groups or online. Approximately 84% of patients with lymphedema reported that they informed their doctor about their symptoms. Ninety-four patients (55.3%, which is not 55% of the 386) were treated for lymphedema. Forty-five women out of 136 reported that lymphedema significantly affected their everyday lives. DISCUSSION We report a large lack of awareness and a significant gap of knowledge about the risks and treatment options related to postoperative lymphedema among gynecological cancer survivors. Institutional practice routines and awareness among professionals need to be urgently recalled and adapted to adequately inform and support gynecological cancer patients.
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Affiliation(s)
- Dimitrios Haidopoulos
- First Department of Obstetrics and Gynaecology, Alexandra Hospital, National and Kapodistrian University of Athens, 2 Lour Street, 11522 Athens, Greece; (D.H.); (A.R.)
| | - Vasilios Pergialiotis
- First Department of Obstetrics and Gynaecology, Alexandra Hospital, National and Kapodistrian University of Athens, 2 Lour Street, 11522 Athens, Greece; (D.H.); (A.R.)
| | - Maria Papageorgiou
- "Erifyle" K.E.F.I. Gynecological Cancer Advocacy Group, 11526, Athens, Greece;
| | - Michael J. Halaska
- Department of Obstetrics and Gynaecology, Third Faculty of Medicine, Charles University, Faculty Hospital Kralovske Vinohrady, 11000 Prague, Czech Republic; (M.J.H.); (K.M.)
| | - Katerina Maxova
- Department of Obstetrics and Gynaecology, Third Faculty of Medicine, Charles University, Faculty Hospital Kralovske Vinohrady, 11000 Prague, Czech Republic; (M.J.H.); (K.M.)
| | - Elena Ulrich
- N.N.Petrov Research Institute of Oncology, 197758 St. Petersburg, Russia;
| | - Ignacio Zapardiel
- Gynecologic Oncology Unit, La Paz University Hospital-IdiPAZ, 28046 Madrid, Spain
| | - Alexandros Rodolakis
- First Department of Obstetrics and Gynaecology, Alexandra Hospital, National and Kapodistrian University of Athens, 2 Lour Street, 11522 Athens, Greece; (D.H.); (A.R.)
| | - Murat Gultekin
- Department of Obstetrics and Gynaecology, Hacettepe University Faculty of Medicine, Ankara 06230, Turkey;
| | - Christina Fotopoulou
- Department of Surgery and Cancer, Gynaecologic Oncology, Imperial College London, London W12 0HS, UK;
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Garza RM, Wong D, Chang DW. Optimizing Outcomes in Lymphedema Reconstruction. Plast Reconstr Surg 2023; 152:1131e-1142e. [PMID: 38019691 DOI: 10.1097/prs.0000000000010965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Describe current surgical techniques for treating primary and secondary lymphedema. 2. Optimize the surgical care of patients with lymphedema. SUMMARY Over the past decade, significant advances have been made in the surgical treatment of lymphedema. The most notable changes have been the reintroduction and evolution of physiologic techniques, including lymphovenous bypass-sometimes referred to as lymphovenous anastomosis in the literature-and vascularized lymph node transplant. These surgical modalities are now often used as first-line surgical options or may be combined with nonphysiologic approaches, including direct excision and suction-assisted lipectomy. Surgeons continue to debate the most appropriate sequence and combination of surgical treatment, particularly for patients at both extremes of the severity spectrum. Furthermore, debate remains around the need to apply different treatment approaches for patients with upper versus lower extremity involvement and primary versus secondary cause. In this article, we provide a summary of the surgical techniques currently used for both primary and secondary lymphedema and provide our recommendations for optimizing the surgical care of patients with lymphedema.
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Affiliation(s)
- Rebecca M Garza
- From the Section of Plastic and Reconstructive Surgery, Department of Surgery, The University of Chicago Medicine & Biological Sciences
| | - Daniel Wong
- From the Section of Plastic and Reconstructive Surgery, Department of Surgery, The University of Chicago Medicine & Biological Sciences
| | - David W Chang
- From the Section of Plastic and Reconstructive Surgery, Department of Surgery, The University of Chicago Medicine & Biological Sciences
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Naoum GE, Taghian AG. Regional Lymph Node Radiation Is Not the Main Risk Factor for Breast Cancer Related Lymphedema: Stop Chasing Radiation Doses, Fractionation or Techniques-Focus on Axillary Surgery De-escalation or Prevention. Int J Radiat Oncol Biol Phys 2023; 117:461-464. [PMID: 37652608 DOI: 10.1016/j.ijrobp.2023.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 04/14/2023] [Accepted: 04/20/2023] [Indexed: 09/02/2023]
Affiliation(s)
- George E Naoum
- Department of Radiation Oncology, Northwestern University Memorial Hospital, Chicago, Illinois.
| | - Alphonse G Taghian
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
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Yim NH, Burns HR, Davis MJ, Selber JC. Robotic Plastic Surgery Education: Developing a Robotic Surgery Training Program Specific to Plastic Surgery Trainees. Semin Plast Surg 2023; 37:157-167. [PMID: 38444955 PMCID: PMC10911909 DOI: 10.1055/s-0043-1771026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2024]
Abstract
Over the past two decades, the surgical community has increasingly embraced robotic-assisted surgery (RAS) due to its potential to enhance accuracy and decrease surgical morbidity. Plastic surgery as a field has been historically slow to incorporate RAS, with lack of adequate training posing as one of the most commonly cited barriers. To date, robot technology has been utilized for various reconstructive procedures including flap elevation and inset, pedicle dissection, and microvascular anastomosis. As RAS continues to integrate within plastic surgery procedures, the need for a structured RAS curriculum designed for plastic surgery trainees is rising. This article delineates the essential components of a plastic surgery-specific RAS curriculum and outlines current training models and assessment tools utilized across surgical subspecialties to date.
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Affiliation(s)
- Nicholas H. Yim
- Michael E. DeBakey Department of Surgery, Division of Plastic Surgery, Baylor College of Medicine, Houston, Texas
- Division of Plastic Surgery, Texas Children's Hospital, Houston, Texas
| | - Heather R. Burns
- Michael E. DeBakey Department of Surgery, Division of Plastic Surgery, Baylor College of Medicine, Houston, Texas
- Division of Plastic Surgery, Texas Children's Hospital, Houston, Texas
| | - Matthew J. Davis
- Michael E. DeBakey Department of Surgery, Division of Plastic Surgery, Baylor College of Medicine, Houston, Texas
- Division of Plastic Surgery, Texas Children's Hospital, Houston, Texas
| | - Jesse C. Selber
- Department of Plastic Surgery, Corewell Health, Grand Rapids, Michigan
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Le NK, Liu L, Jesus Cruz R, Parikh J, Rotatori RM, Wainwright DJ, Weinstein B, Tavares T, Panetta NJ. Efficacy of Immediate Lymphatic Reconstruction in Prevention of Breast Cancer-Related Lymphedema. Ann Plast Surg 2023; 90:S363-S365. [PMID: 36913564 DOI: 10.1097/sap.0000000000003457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
INTRODUCTION Breast cancer-related lymphedema (BCRL) is a chronic condition that can negatively affect the quality of life of breast cancer survivors. Immediate lymphatic reconstruction (ILR) at the time of axillary lymph node dissection is emerging as a technique for the prevention of BCRL. This study compared the incidence of BRCL in patients who received ILR and those who were not amenable to ILR. METHODS Patients were identified through a prospectively maintained database between 2016 and 2021. Some patients were deemed nonamenable to ILR due to a lack of visualized lymphatics or anatomic variability (eg, spatial relationships or size discrepancies). Descriptive statistics, independent t test, and Pearson χ 2 test were used. Multivariable logistic regression models were created to assess the association between lymphedema and ILR. A loose age-matched subsample was created for subanalysis. RESULTS Two hundred eighty-one patients were included in this study (252 patients who underwent ILR and 29 patients who did not). The patients had a mean age of 53 ± 12 years and body mass index of 28.6 ± 6.8 kg/m 2 . The incidence of developing lymphedema in patients with ILR was 4.8% compared with 24.1% in patients who underwent attempted ILR without lymphatic reconstruction ( P = 0.001). Patients who did not undergo ILR had significantly higher odds of developing lymphedema compared with those who had ILR (odds ratio, 10.7 [3.2-36.3], P < 0.001; matched OR, 14.2 [2.6-77.9], P < 0.001). CONCLUSIONS Our study showed that ILR was associated with lower rates of BCRL. Further studies are needed to determine which factors place patients at highest risk of developing BCRL.
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Affiliation(s)
- Nicole K Le
- From the Department of Plastic Surgery, Morsani College of Medicine, University of South Florida
| | - Langfeier Liu
- From the Department of Plastic Surgery, Morsani College of Medicine, University of South Florida
| | - Rachel Jesus Cruz
- From the Department of Plastic Surgery, Morsani College of Medicine, University of South Florida
| | - Jeegan Parikh
- College of Public Health, University of South Florida
| | - Robert M Rotatori
- From the Department of Plastic Surgery, Morsani College of Medicine, University of South Florida
| | - D'Arcy J Wainwright
- From the Department of Plastic Surgery, Morsani College of Medicine, University of South Florida
| | - Brielle Weinstein
- From the Department of Plastic Surgery, Morsani College of Medicine, University of South Florida
| | - Tina Tavares
- Department of Women's Oncology, Breast Program, Moffitt Cancer Center, Tampa, FL
| | - Nicholas J Panetta
- From the Department of Plastic Surgery, Morsani College of Medicine, University of South Florida
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Donahue PMC, MacKenzie A, Filipovic A, Koelmeyer L. Advances in the prevention and treatment of breast cancer-related lymphedema. Breast Cancer Res Treat 2023; 200:1-14. [PMID: 37103598 DOI: 10.1007/s10549-023-06947-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 04/06/2023] [Indexed: 04/28/2023]
Abstract
PURPOSE Breast cancer-related lymphedema (BCRL) represents a lifelong risk for breast cancer survivors and once acquired becomes a lifelong burden. This review summarizes current BCRL prevention and treatment strategies. FINDINGS Risk factors for BCRL have been extensively studied and their identification has affected breast cancer treatment practice, with sentinel lymph node removal now standard of care for patients with early stage breast cancer without sentinel lymph node metastases. Early surveillance and timely management aim to reduce BCRL incidence and progression, and are further facilitated by patient education, which many breast cancer survivors report not having adequately received. Surgical approaches to BCRL prevention include axillary reverse mapping, lymphatic microsurgical preventative healing (LYMPHA) and Simplified LYMPHA (SLYMPHA). Complete decongestive therapy (CDT) remains the standard of care for patients with BCRL. Among CDT components, facilitating manual lymphatic drainage (MLD) using indocyanine green fluorescence lymphography has been proposed. Intermittent pneumatic compression, nonpneumatic active compression devices, and low-level laser therapy appear promising in lymphedema management. Reconstructive microsurgical techniques such as lymphovenous anastomosis and vascular lymph node transfer are growing surgical considerations for patients as well as liposuction-based procedures for addressing fatty fibrosis formation from chronic lymphedema. Long-term self-management adherence remains problematic, and lack of diagnosis and measurement consensus precludes a comparison of outcomes. Currently, no pharmacological approaches have proven successful. CONCLUSION Progress in prevention and treatment of BCRL continues, requiring advances in early diagnosis, patient education, expert consensus and novel treatments designed for lymphatic rehabilitation following insults.
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Affiliation(s)
- Paula M C Donahue
- Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, 2201 21St Children's Way, Suite 1218, Nashville, TN, 37212, USA.
- Dayani Center for Health and Wellness, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Adrien MacKenzie
- Osher Center for Integrative Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Louise Koelmeyer
- Faculty of Medicine, Health, and Human Sciences, Australian Lymphoedema Education, Research, and Treatment (ALERT), Macquarie University, Sydney, Australia
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Salehi BP, Sibley RC, Friedman R, Kim G, Singhal D, Loening AM, Tsai LL. MRI of Lymphedema. J Magn Reson Imaging 2023; 57:977-991. [PMID: 36271779 PMCID: PMC10006319 DOI: 10.1002/jmri.28496] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 10/06/2022] [Accepted: 10/07/2022] [Indexed: 11/09/2022] Open
Abstract
Lymphedema is a devastating disease that has no cure. Management of lymphedema has evolved rapidly over the past two decades with the advent of surgeries that can ameliorate symptoms. MRI has played an increasingly important role in the diagnosis and evaluation of lymphedema, as it provides high spatial resolution of the distribution and severity of soft tissue edema, characterizes diseased lymphatic channels, and assesses secondary effects such as fat hypertrophy. Many different MR techniques have been developed for the evaluation of lymphedema, and the modality can be tailored to suit the needs of a lymphatic clinic. In this review article we provide an overview of lymphedema, current management options, and the current role of MRI in lymphedema diagnosis and management. EVIDENCE LEVEL: 5 TECHNICAL EFFICACY: Stage 5.
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Affiliation(s)
- Betsa Parsai Salehi
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | | | - Rosie Friedman
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | | | - Dhruv Singhal
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | | | - Leo L Tsai
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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Son WC, Kwon JG, Hong JP, Park CS, Kim SA, Do JH, Cheon H, Gelvosa MN, Suh HS, Jeon JY. Clinical Utility of Bioelectrical Impedance Analysis Parameters for Evaluating Patients with Lower Limb Lymphedema after Lymphovenous Anastomosis. J Reconstr Microsurg 2023; 39:171-178. [PMID: 35817050 DOI: 10.1055/s-0042-1750126] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND In lymphedema, lymphatic fluid accumulates in the interstitial space, and localized swelling appears. Lymphovenous anastomosis (LVA) is the most widely used surgery to rebuild a damaged lymphatic system; however, assessing outcome of LVA involves performing volume measurements, which provides limited information on body composition changes. Therefore, we analyzed the bioelectrical impedance analysis (BIA) parameters that can reflect the status of lymphedema patients who underwent LVA. METHODS We retrospectively reviewed records of 42 patients with unilateral lower extremity lymphedema who had LVA. We measured the perioperative BIA parameters such as extracellular water (ECW) ratio and volume as defined by the percentage of excess volume (PEV). We evaluated the relationship between the amount of change in PEV and in BIA parameters before and after surgery. We confirmed the correlation between ΔPEV and BIA parameters using Spearman's correlation. RESULTS Most patients included had secondary lymphedema due to cancer. Average age was 51.76 years and average body mass index was 23.27. PEV and all BIA parameters after surgery showed a significant difference (p < 0.01) compared with preoperative measurements. The ECW ratio aff/unaff showed the strongest correlation with PEV with a correlation coefficient of 0.473 (p < 0.01). CONCLUSION Our findings suggest that BIA parameters, especially ECW ratio aff/unaff could reflect the status of patients with lower limb lymphedema after LVA. Appropriate use of BIA parameters may be useful in the postoperative surveillance of patients.
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Affiliation(s)
- Woo Chul Son
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin Geun Kwon
- Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Joon Pio Hong
- Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chang Sik Park
- Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang Ah Kim
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung Hwa Do
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hwayeong Cheon
- Biomedical Engineering Research Center, Asan Institute for Life Sciences, Asan Medical Center, Seoul, Korea
| | - Ma Nessa Gelvosa
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyun Suk Suh
- Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Yong Jeon
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Lin CH, Yamamoto T. Identification of lymph vessels using an indocyanine green camera-integrated operative microscope for lymphovenous anastomosis in the treatment of secondary lymphedema. J Vasc Surg Venous Lymphat Disord 2023; 11:161-166. [PMID: 35940447 DOI: 10.1016/j.jvsv.2022.06.012] [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: 02/28/2022] [Revised: 06/21/2022] [Accepted: 06/30/2022] [Indexed: 10/16/2022]
Abstract
OBJECTIVE Lymphedema is a debilitating disease that impairs a patient's quality of life. Although lymphovenous anastomosis (LVA) can cure lymphedema, successful LVAs rely on the precise identification of the lymph vessels. In the present study, we assessed the use of a near-infrared camera-integrated operating microscope for preoperative mapping of the lymphatic vessels and evaluated the outcome of LVAs in patients with secondary lymphedema of a limb. METHODS We retrospectively reviewed patients with secondary unilateral lymphedema who had undergone LVA surgery with the lymph vessels identified using a near-infrared camera-integrated operating microscope (Moller 3-1000; Möller-Wedel Optical GmbH, Wedel, Germany) between 2020 and 2021. The lymph vessels identified using near-infrared fluorescence lymphography, diameter of the vessels used for anastomosis, anastomosis configuration, and perioperative limb circumference were recorded. RESULTS Overall, 35 LVAs were performed in six patients with secondary lymphedema, with a mean number of 5.8 LVAs per limb. The anastomotic configurations were end-to-end in 26 LVAs, side-to-end in 2 LVAs, and end-to-side in 7 LVAs. The diameter of the lymph vessels ranged from 0.3 to 0.9 mm (mean, 0.62 ± 0.18 mm) and that of the vein from 0.4 to 1.2 mm (mean, 0.75 ± 0.21 mm). The changes in the lymphedema index and estimated limb volume indicated a postoperative decrease in edema. CONCLUSIONS We found a near-infrared camera-integrated operating microscope useful for the preoperative identification of functional lymph vessels. Our results have shown that microsurgical LVAs can be performed using an integrated indocyanine green camera without an independent indocyanine green detector.
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Affiliation(s)
- Chih-Hsun Lin
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Surgery, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
| | - Takumi Yamamoto
- Department of Plastic and Reconstructive Surgery, Center Hospital of National Center for Global Health and Medicine, Tokyo, Japan
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Lampejo AO, Ghavimi SAA, Hägerling R, Agarwal S, Murfee WL. Lymphatic/blood vessel plasticity: motivation for a future research area based on present and past observations. Am J Physiol Heart Circ Physiol 2023; 324:H109-H121. [PMID: 36459445 PMCID: PMC9829479 DOI: 10.1152/ajpheart.00612.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 11/23/2022] [Accepted: 11/23/2022] [Indexed: 12/04/2022]
Abstract
The lymphatic system plays a significant role in homeostasis and drainage of excess fluid back into venous circulation. Lymphatics are also associated with a number of diseases including lymphedema, tumor metastasis, and various lymphatic malformations. Emerging evidence suggests that lymphatics might have a bigger connection to the blood vascular system than originally presumed. As these two systems are often studied in isolation, several knowledge gaps exist surrounding what constitutes lymphatic vascular plasticity, under what conditions it arises, and where structures characteristic of plasticity can form. The objective of this review is to overview current structural, cell lineage-based, and cell identity-based evidence for lymphatic plasticity. These examples of plasticity will then be considered in the context of potential clinical and surgical implications of this evolving research area. This review details our current understanding of lymphatic plasticity, highlights key unanswered questions in the field, and motivates future research aimed at clarifying the role and therapeutic potential of lymphatic plasticity in disease.
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Affiliation(s)
- Arinola O Lampejo
- J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, Florida
| | | | - René Hägerling
- Institute of Medical and Human Genetics, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Berlin Institute of Health Center for Regenerative Therapies, Berlin Institute of Health at Charité-Universitätsmedizin Berlin, Berlin, Germany
- Clinician Scientist Program, Berlin Institute of Health Academy, Berlin Institute of Health at Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Shailesh Agarwal
- Division of Plastic and Reconstructive Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Walter L Murfee
- J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, Florida
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Lampejo AO, Jo M, Murfee WL, Breslin JW. The Microvascular-Lymphatic Interface and Tissue Homeostasis: Critical Questions That Challenge Current Understanding. J Vasc Res 2022; 59:327-342. [PMID: 36315992 PMCID: PMC9780194 DOI: 10.1159/000525787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 06/20/2022] [Indexed: 11/07/2022] Open
Abstract
Lymphatic and blood microvascular networks play critical roles in the clearance of excess fluid from local tissue spaces. Given the importance of these dynamics in inflammation, tumor metastasis, and lymphedema, understanding the coordinated function and remodeling between lymphatic and blood vessels in adult tissues is necessary. Knowledge gaps exist because the functions of these two systems are typically considered separately. The objective of this review was to highlight the coordinated functional relationships between blood and lymphatic vessels in adult microvascular networks. Structural, functional, temporal, and spatial relationships will be framed in the context of maintaining tissue homeostasis, vessel permeability, and system remodeling. The integration across systems will emphasize the influence of the local environment on cellular and molecular dynamics involved in fluid flow from blood capillaries to initial lymphatic vessels in microvascular networks.
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Affiliation(s)
- Arinola O. Lampejo
- J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, FL, 32611, USA
| | - Michiko Jo
- Division of Presymptomatic Disease, Institute of Natural Medicine, University of Toyama, Toyama, Japan
| | - Walter L. Murfee
- J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, FL, 32611, USA
| | - Jerome W. Breslin
- Department of Molecular Pharmacology and Physiology, Morsani College of Medicine, University of South Florida, Tampa, FL, 33612, USA
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17
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Physical and Functional Outcomes of Simultaneous Vascularized Lymph Node Transplant and Lymphovenous Bypass in the Treatment of Lymphedema. Plast Reconstr Surg 2022; 150:169-180. [PMID: 35583944 DOI: 10.1097/prs.0000000000009247] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The authors analyze the outcomes of simultaneous vascularized lymph node transplant and lymphovenous bypass for treatment of primary and secondary lymphedema. To the best of their knowledge, this is the largest study to date with long-term outcome data of this novel approach. METHODS Three hundred twenty-eight patients who underwent physiologic surgical treatment over a 5.5-year period were evaluated using a prospective database and chart review. Preoperative characteristics, operative details, and postoperative outcomes (volume difference change, Lymphedema Life Impact Scale score) were assessed. Statistical analysis including multivariate regression was performed. RESULTS Two hundred twenty patients (67.1 percent) underwent simultaneous vascularized lymph node transplant and lymphovenous bypass. Mean body mass index was 26.9 ± 4.7 kg/m 2 . Ninety-two patients (41.8 percent) had lymphedema of the lower extremity, 121 (55.0 percent) had upper extremity involvement, and seven had lymphedema of upper and lower extremities (3.2 percent). Average duration of lymphedema was 95.4 ± 103.6 months. Thirty patients (13.6 percent) had primary lymphedema and 190 patients (86.4 percent) had secondary lymphedema. The majority improved and experienced volume reduction of an average 21.4 percent at 1 year ( p < 0.0001), 36.2 percent at 2 years ( p < 0.0001), 25.5 percent at 3 years ( p = 0.1), and 19.6 percent at 4 years. Median Lymphedema Life Impact Scale scores were 7.0 points lower ( p < 0.0001) at 3 months and improved progressively over time to 27.5 points lower at 3 years postoperatively ( p < 0.005). CONCLUSIONS Simultaneous vascularized lymph node transplant and lymphovenous bypass is an appropriate and effective approach for both early and advanced stages of primary and secondary lymphedema, with significant objective and subjective improvements. Volume reduction in the affected limb was observed at all time points postoperatively, with significant improvement in Lymphedema Life Impact Scale scores. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Wainwright D, Weinstein B, Tavares T, Panetta NJ. Relationship of Adjuvant Radiation and the Lymphedema Index: A Valuable Trend to Follow Subclinical Lymphedema in Patients After Immediate Lymphatic Reconstruction. Ann Plast Surg 2022; 88:S512-S516. [PMID: 35690948 DOI: 10.1097/sap.0000000000003252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Immediate lymphaticovenular bypass (immediate lymphatic reconstruction [ILR]) at the time of axillary lymph node dissection has emerged as a preventative paradigm to decrease the incidence of breast cancer-related lymphedema in high-risk patients. These patients are often treated with adjuvant therapies, including radiation. Bioimpedance spectroscopy is a validated tool for trending breast cancer-related lymphedema and identifying subclinical disease. Lymphedema Index (LDEX) values are commonly obtained in ILR patients; however, postoperative trends and relationships with adjuvant treatments are yet to be reported in the literature. METHODS After International Review Board approval, 100 consecutive patients underwent axillary lymph node dissection with axillary reverse lymphatic mapping and ILR at a tertiary cancer center. These patients were then followed prospectively in a multidisciplinary lymphedema clinic at 3-month intervals with clinical examination, circumferential limb girth measurements and bioimpedance spectroscopy (LDEX). RESULTS Seventy-two patients met inclusion for analysis at 3 months, 60 at 6 months, 51 at 9 months, 45 at 12 months, 41 at 15 months, and 22 at 18 months. A majority of the patients included underwent adjuvant radiation. Average LDEX score for patients who developed lymphedema was 3.02 at 3 months, at 29.1 months, 17.8 at 9 months, 15.05 at 12 months, 18.75 at 15 months, and 7.7 at 18 months. Patients who went on to develop lymphedema had a higher LDEX score at 6 months (29.1 vs 3.20, P = 0.1329), which reached a significant difference beginning at 9 months (17.8 vs 3.19, P = 0.0004). All patients who went on to develop lymphedema received adjuvant radiation. CONCLUSIONS These data provide valuable insight guiding follow-up after ILR. Six-month LDEX is much higher in patients who developed lymphedema, all of which underwent adjuvant radiation therapy, which correlates with the time of completion of their treatment. Average LDEX value after this remains significantly higher in this population. Patients who demonstrate this increase in LDEX and received adjuvant radiation are at highest risk to develop lymphedema despite ILR. All patients who developed lymphedema despite ILR had adjuvant radiation, and this is likely a contributing factor. Injury from adjuvant radiation and its impact after ILR is not insignificant and warrants further studies.
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Affiliation(s)
- D'Arcy Wainwright
- From the Department of Plastic and Reconstructive Surgery, University of South Florida, Morsani College of Medicine
| | - Brielle Weinstein
- From the Department of Plastic and Reconstructive Surgery, University of South Florida, Morsani College of Medicine
| | - Tina Tavares
- Department of Surgery, Moffitt Cancer Center, Tampa, FL
| | - Nicholas J Panetta
- From the Department of Plastic and Reconstructive Surgery, University of South Florida, Morsani College of Medicine
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19
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Park JKH, Seo J, Yang EJ, Kang Y, Heo CY, Myung Y. Association of lymphatic flow velocity with surgical outcomes in patients undergoing lymphovenous anastomosis for breast cancer-related lymphedema. Breast Cancer 2022; 29:835-843. [PMID: 35553019 DOI: 10.1007/s12282-022-01363-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 04/20/2022] [Indexed: 01/09/2023]
Abstract
PURPOSE Lymphovenous anastomosis (LVA) is primarily used for treating early-stage lymphedema. Here, we aimed to investigate the relationship between lymphatic flow velocity and the efficacy of LVA in breast cancer-related lymphedema patients. To this end, we assessed the transit velocity of lymphatic fluid using indocyanine green (ICG) lymphography and radioisotope lymphoscintigraphy. METHODS We retrospectively examined patients diagnosed with breast cancer-related lymphedema who underwent LVA from January to December 2020. Patient data, including demographics, clinical stage, and postoperative surgical outcomes, were collected from electronic medical records. ICG lymphography results and dynamic lymphoscintigrams were analyzed to measure the lymphatic flow velocity and to determine the grade of the limb lymphedemas. RESULTS Eighty patients (all female, mean age of 53.6 years) were included. The lymphatic flow velocity ranged between 0.58 and 21.5 cm/min (average, 7.61 cm/min); 37 (46.3%), 18 (22.5%), 15 (18.8%), and 10 (12.5%) arm lymphedemas were classified as lymphoscintigraphy grade 0, 1, 2, and 3, respectively. A significant association was observed between lymphatic flow velocity and lymphedema grade determined using lymphoscintigraphy and between the amount of volume reduction after LVA and preoperative lymphatic flow velocity (P < 0.05). CONCLUSIONS Our findings suggest that lymphatic flow velocity is positively correlated with surgical outcomes in patients undergoing LVA. Therefore, surgical treatment plans for lymphedema should not be based only on the International Society of Lymphedema stage, because advanced-stage lymphedema patients with high ICG velocities can benefit from LVA alone.
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Affiliation(s)
- Joseph Kyu-Hyung Park
- Department of Plastic and Reconstructive Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 300 Gumi-dong, Bundang-gu, Seongnam-si, Gyeonggi-do, South Korea
| | - Junggyo Seo
- Department of Plastic and Reconstructive Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 300 Gumi-dong, Bundang-gu, Seongnam-si, Gyeonggi-do, South Korea
| | - Eun Joo Yang
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 300 Gumi-dong, Bundang-gu, Seongnam-si, South Korea
| | - Yusuhn Kang
- Department of Diagnostic Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 300 Gumi-dong, Bundang-gu, Seongnam-si, South Korea
| | - Chan Yeong Heo
- Department of Plastic and Reconstructive Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 300 Gumi-dong, Bundang-gu, Seongnam-si, Gyeonggi-do, South Korea
| | - Yujin Myung
- Department of Plastic and Reconstructive Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 300 Gumi-dong, Bundang-gu, Seongnam-si, Gyeonggi-do, South Korea.
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20
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Chang EI. Optimizing Treatment of Breast Cancer Related Lymphedema Using Combined DIEP Flap and Lymphedema Surgery. Arch Plast Surg 2022; 49:150-157. [PMID: 35832680 PMCID: PMC9045539 DOI: 10.1055/s-0042-1744414] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Patients undergoing treatment for breast cancer who undergo an axillary dissection and require adjuvant therapies such as radiation and chemotherapy are at high risk of developing lymphedema of the associated extremity. Historically, patients with lymphedema were treated with ablative procedures aimed simply to remove excess fluid and adiposity; however, the field of lymphatic surgery employing super-microsurgery techniques has witnessed tremendous advances in a relatively short period of time. Advancements in surgical instruments, microscope magnification and optics, imaging technology, and surgeon experience have ushered in a new era of hope to treat patients suffering from breast cancer–related lymphedema (BCRL). Here we aim to present the available options for patients suffering from BCRL, and the pinnacle in reconstruction and restoration for these patients.
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Affiliation(s)
- Edward I. Chang
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
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21
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Jang S, Lee CU, Hesley GK, Knudsen JM, Brinkman NJ, Tran NV. Lymphatic Mapping Using US Microbubbles before Lymphaticovenous Anastomosis Surgery for Lymphedema. Radiology 2022; 304:218-224. [PMID: 35380494 DOI: 10.1148/radiol.212351] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Background Lymphaticovenous anastomosis (LVA) surgery is an effective surgical treatment of secondary lymphedema in the extremities, but indocyanine green (ICG) fluorescent lymphography, the reference standard for imaging target lymphatic vessels, has several limitations. More effective methods are needed for preoperative planning. Purpose To evaluate whether contrast-enhanced US (CEUS) can be used to identify target lymphatic vessels for LVA surgery in patients with secondary upper extremity lymphedema and compare the results with those from ICG fluorescent lymphography. Materials and Methods In this single-center retrospective review, CEUS with intradermal injection of microbubbles was performed in patients before LVA surgery in the upper extremities between October 2019 and September 2021. All patients had secondary upper extremity lymphedema from breast cancer treatment. Technical success rate was defined as lymphatic vessels identified with use of CEUS that led to successful LVAs. Descriptive statistics were used. Results All 11 patients were women (mean age, 56 years ± 8 [SD]). The median number of microbubble injection sites was 11 (range, 8-14). CEUS helped identify lymphatic vessels in all 11 women, including in six women in whom ICG fluorescent lymphography could not be performed or failed to help identify any targets. Thirty-five explorations (median, three per patient; range, two to four) were performed, and 24 LVAs (median, three per patient; range, zero to four) were created. Of the anastomoses, 33% (eight of 24) were mapped with use of both CEUS and ICG fluorescent lymphography, 58% (14 of 24) with CEUS only, and 8% (two of 24) with ICG fluorescent lymphography only. Among the 33 explorations on targets mapped with CEUS, an anastomosis could be made at 22 sites, for a technical success rate of 67%. Seven women had at least one additional LVA created from the use of CEUS. Conclusion Contrast-enhanced US is a promising tool for identifying lymphatic vessels in the upper extremities, especially when indocyanine green fluorescent lymphography fails to depict targets or cannot be used. Published under a CC BY 4.0 license.
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Affiliation(s)
- Samuel Jang
- From the Departments of Radiology (S.J., C.U.L., G.K.H., J.M.K.), Pharmacy (N.J.B.), and Plastic Surgery (N.V.T.), Mayo Clinic, 200 First St SW, Rochester, MN 55905
| | - Christine U Lee
- From the Departments of Radiology (S.J., C.U.L., G.K.H., J.M.K.), Pharmacy (N.J.B.), and Plastic Surgery (N.V.T.), Mayo Clinic, 200 First St SW, Rochester, MN 55905
| | - Gina K Hesley
- From the Departments of Radiology (S.J., C.U.L., G.K.H., J.M.K.), Pharmacy (N.J.B.), and Plastic Surgery (N.V.T.), Mayo Clinic, 200 First St SW, Rochester, MN 55905
| | - John M Knudsen
- From the Departments of Radiology (S.J., C.U.L., G.K.H., J.M.K.), Pharmacy (N.J.B.), and Plastic Surgery (N.V.T.), Mayo Clinic, 200 First St SW, Rochester, MN 55905
| | - Nathan J Brinkman
- From the Departments of Radiology (S.J., C.U.L., G.K.H., J.M.K.), Pharmacy (N.J.B.), and Plastic Surgery (N.V.T.), Mayo Clinic, 200 First St SW, Rochester, MN 55905
| | - Nho V Tran
- From the Departments of Radiology (S.J., C.U.L., G.K.H., J.M.K.), Pharmacy (N.J.B.), and Plastic Surgery (N.V.T.), Mayo Clinic, 200 First St SW, Rochester, MN 55905
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22
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Goldman C, Lee H, Tom L, Krasnow R. Microsurgical treatment of lower extremity lymphedema: A multidisciplinary approach to improve morbidity in advanced penile cancer patients. Urol Oncol 2022; 40:113.e1-113.e8. [PMID: 35042662 DOI: 10.1016/j.urolonc.2021.11.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 10/13/2021] [Accepted: 11/08/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Lower extremity lymphedema is a major source of morbidity in up to 70% of penile cancer patients. Lymphedema is often thought to be incurable, though surgical treatments have started to emerge. This study is the first to apply lymphovenous bypass specifically to penile cancer patients status post lymphadenectomy. METHODS We performed microsurgical lymphovenous bypass in 3 patients who underwent inguinal lymphadenectomy for advanced penile cancer, and later lymph node transplant in 1 patient. RESULTS The lymphovenous bypass was performed by a trained microsurgeon: Two patients were treated as outpatients for lymphedema, and 1 patient underwent prophylactic lymphovenous bypass simultaneously with initial lymphadenectomy. We saw significant improvement in patient's clinical lymphedema as well as lymphatic drainage on infared imaging for 2 of 3 patients at 12 months, however 1 of these patients did require later lymph node transfer at 24 months. CONCLUSION This early proof of concept study shows that these procedures should be considered and studied further in the treatment and prevention of debilitating lymphedema in the penile cancer population.
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Affiliation(s)
- Charlotte Goldman
- MedStar Georgetown University Hospital Department of Urology, Washington, DC.
| | - Harry Lee
- Georgetown University School of Medicine, Washington, DC
| | - Laura Tom
- MedStar Washington Hospital Center Department of Plastic Surgery, Washington, DC
| | - Ross Krasnow
- MedStar Washington Hospital Center Department of Urology, Washington, DC
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ICG lymphographic findings following immediate lymphatic reconstruction in breast cancer patients. J Plast Reconstr Aesthet Surg 2022; 75:2164-2171. [PMID: 35370119 DOI: 10.1016/j.bjps.2022.02.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 01/15/2022] [Accepted: 02/12/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Immediate lymphatic reconstruction (ILR), performed at the time of axillary lymph node dissection (ALND), has demonstrated promising reductions in breast cancer-associated lymphedema. However, questions remain over the effects of adjuvant therapies on the continued patency of the lymphaticovenous anastomosis. Our study aimed to assess lymphographic outcomes, including ICG pattern and LVB patency, in patients at high risk for breast cancer-associated lymphedema following axillary ILR. METHODS Baseline ICG lymphography studies performed during ILR of 15 patients were compared to repeat ICG studies obtained during second-stage breast reconstructive procedures to assess for changes in lymphatic flow patterns through the at-risk arm and transit into the axilla. RESULTS All 15 patients in this study demonstrated linear lymphatic flow in baseline lymphography. Repeat lymphographic studies showed linear lymphatic transit in 12/15 patients. Of these 12 patients, 10 received chemotherapy, and all 12 received post-mastectomy radiation (PMRT). Dermal backflow patterns were recorded in 3/15 patients. All 3 patients received chemotherapy and 2/3 underwent PMRT. Additionally, repeat ICG studies of 7/12 lymphedema-free patients demonstrated clear visualization of linear ICG flow from the lymphatics of the arm into the axilla. CONCLUSION We have demonstrated that ICG lymphography can be implemented as a postoperative tool to assess lymphatic function in patients who have undergone ILR in the axilla. Repeat ICG studies in the majority of patients demonstrated linear ICG flow similar to baseline studies. Additionally, ICG flow patterns through the axilla in repeat lymphography provided visual evidence supporting sustained LVB patency, despite axillary irradiation.
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Hosokawa T, Uchiyama M, Tanami Y, Sato Y, Wakabayashi Y, Oguma E. Insufficient hepatic uptake in pediatric patients on lymphoscintigraphy. Pediatr Int 2022; 64:e15156. [PMID: 35510682 DOI: 10.1111/ped.15156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 01/03/2022] [Accepted: 02/03/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND To demonstrate the association between pediatric outcomes and tracer hepatic uptake as a marker of systemic circulation in lymphoscintigraphy. METHODS We included 31 initial lymphoscintigraphic studies. We compared the presence or absence of hepatic uptake between deceased and survived patients in both early and delayed images using Fisher's exact test. Kaplan-Meier survival analysis was performed based on imaging results, and these curves were compared using the log-rank test. The primary endpoint was death and the survival period was defined from the day of examination to the day of the last visit or death. RESULTS Of 31 patients, six died. Hepatic uptake was significantly different in both early and delayed images (early images, died [with/without visualization] vs. survived [with/without visualization], 0/6 vs. 13/12, P = 0.028; delayed images, died [with/without visualization] vs. survived [with/without visualization], 2/4 vs. 22/3, P = 0.014) between deceased and survived patients. Survival periods were significantly different between the two groups with and without hepatic uptake in early and delayed images (with/without visualization in early imags = 1,177.1 ± 773.8 days/426.7 ± 419.8 days, P = 0.008 and with/without visualization in delayed images = 821.3 ± 738.0 days/467.4 ± 452.4 days, P = 0.003). CONCLUSIONS Visualization of hepatic uptake in both early and delayed lymphoscintigraphy is associated with patient outcomes. Hepatic uptake could represent tracer inflow into the systemic circulation, indicating preservation of the connection between the lymphatic system and the systemic circulation. Physicians should evaluate these findings carefully on lymphoscintigraphy.
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Affiliation(s)
- Takahiro Hosokawa
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
| | - Mayuki Uchiyama
- Department of Radiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Yutaka Tanami
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
| | - Yumiko Sato
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
| | - Yasuharu Wakabayashi
- Division of Radiological Technology, Saitama Prefectural Children's Medical Center, Saitama, Saitama, Japan
| | - Eiji Oguma
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
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Discussion: Selection of Optimal Functional Lymphatic Vessel Cutoff Size in Supermicrosurgical Lymphaticovenous Anastomosis in Lower Extremity Lymphedema. Plast Reconstr Surg 2022; 149:247-248. [PMID: 34936628 DOI: 10.1097/prs.0000000000008675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Subramanyam P, Janarthanan R, Palaniswamy SS. Early Demonstration of Spontaneous Perinodal Lymphangiogenesis by Lymphoscintigraphy after Vascularized Lymph Node Transplantation - A Pilot Study. Indian J Nucl Med 2022; 37:1-6. [PMID: 35478675 PMCID: PMC9037873 DOI: 10.4103/ijnm.ijnm_123_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 09/27/2021] [Accepted: 11/22/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Despite the lymphatic system being so important and extensive, the field of lymphatic diseases, research is still very young. Lymphedema is a progressively debilitating condition with no known "cure." Specific pathologies that could benefit from improved lymphatic drainage by advanced super surgical techniques or engineered tissue transfer are being sought. Microsurgical techniques like lymphovenous bypass and anastomosis have spurred interest as they tend to physiologically restore the damaged lymphatic channels and may be a key to permanent cure. The latest in the field is vascularized lymph node transfer (VLNT), indicated in post mastectomy or other post operative settings producing disruption of regional lymphatic channels and draining lymph nodes. Autologous healthy lymph nodes are transferred along with surrounding fat and vascular pedicle to the affected limb in a bid to promote lymphangiogenesis. Lymphoscintigraphy (LS) is a simple, noninvasive nuclear technique used in identifying upper or lower limb lymphatic dysfunction and obstruction with a high degree of sensitivity. Quantitative LS is extremely useful in follow-up assessment of lymphedema postmanual lymphatic drainage (MLD) or other forms of medical management. AIM We hypothesize that LS can document perinodal lymphangiogenesis post VLNT. MATERIAL AND METHODS Three cases of acquired lymphedema (suspected filariasis and postmastectomy conditions) who underwent VLNT in our institute were prospectively studied with LS. The imaging findings highlight the subtle lymphatic regeneration along with the vascularized graft in all three patients during the early postoperative period. CONCLUSION This is the first (pilot) study documenting early spontaneous perinodal lymphangiogenesis after VLNT in human subjects.99mTc Nanocolloid LS has been found to be incremental in demonstrating early lymphangiogenesis.
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Affiliation(s)
- Padma Subramanyam
- Department of Nuclear Medicine and Molecular Imaging, Amrita Institute of Medical Sciences, Cochin, Kerala, India,Address for correspondence: Dr. Padma Subramanyam, Department of Nuclear Medicine and Molecular Imaging, Amrita Institute of Medical Sciences, Amrita Viswavidyapeetham, Cochin - 682 041, Kerala, India. E-mail:
| | - R Janarthanan
- Department of Plastic and Reconstructive Surgery, Amrita Institute of Medical Sciences, Cochin, Kerala, India
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Mohos B, Czedik-Eysenberg M, Steinbacher J, Tinhofer I, Meng S, Tzou CHJ. Long-term Use of Ultrasound for Locating Optimal LVA Sites: A Descriptive Data Analysis. J Reconstr Microsurg 2021; 38:238-244. [PMID: 34820800 DOI: 10.1055/s-0041-1740124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Preoperative mapping of lymphatic vessels for lymphovenous anastomosis (LVA) surgery is frequently performed by indocyanine green (ICG) lymphography solely; however, other imaging modalities, such as ultrasound (US), might be more efficient, particularly for Caucasian patients. We present our preoperative assessment protocol, experience, and approach of using US for locating optimal LVA sites. MATERIAL AND METHODS Fifty-six (16 males) lymphedema patients who underwent LVA surgery were included in this study, 5 of whom received two LVA operations. In total, 61 LVA procedures with 233 dissected lymphatic vessels were evaluated. Preoperative US was performed by the author S.M. 2 days before intraoperative ICG lymphography. Fluid-predominant lymphedema regions were scanned more profoundly. Skin incisions followed preoperative US and ICG lymphography markings. Detection of lymphatic vessels was compared between ICG lymphography and the US by using the intraoperative verification under the microscope with 20 to 50x magnification as the reference standard. RESULTS Among the dissected lymphatic vessels, 83.3% could be localized by US, and 70% were detectable exclusively by it. In all, 7.2% of US-detected lymphatic vessels could not be found and verified intraoperatively. Among the lymphatic vessels found by US, only 16% were apparent with ICG before skin incision. In total, 23.2% of the dissected lymphatic vessels could be visualized with ICG lymphography preoperatively. Only 9.9% of the lymphatic vessels could be found by ICG alone. CONCLUSION High-frequency US mapping accurately finds functional lymphatic vessels and matching veins. It locates fluid-predominant regions for targeted LVA surgeries. It reveals 3.6 times as many lymphatic vessels as ICG lymphography. In our practice, it has an integral role in planning LVA procedures.
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Affiliation(s)
- Balazs Mohos
- Plastic and Reconstructive Surgery, Department of Surgery, Hospital of Divine Savior (Krankenhaus Goettlicher Heiland Wien), Vienna, Austria
| | - Manon Czedik-Eysenberg
- Plastic and Reconstructive Surgery, Department of Surgery, Hospital of Divine Savior (Krankenhaus Goettlicher Heiland Wien), Vienna, Austria
| | - Johannes Steinbacher
- Plastic and Reconstructive Surgery, Department of Surgery, Hospital of Divine Savior (Krankenhaus Goettlicher Heiland Wien), Vienna, Austria
| | - Ines Tinhofer
- Plastic and Reconstructive Surgery, Department of Surgery, Hospital of Divine Savior (Krankenhaus Goettlicher Heiland Wien), Vienna, Austria
| | - Stefan Meng
- Department of Radiology, Hanusch Hospital, Vienna, Austria
| | - Chieh-Han John Tzou
- Plastic and Reconstructive Surgery, Department of Surgery, Hospital of Divine Savior (Krankenhaus Goettlicher Heiland Wien), Vienna, Austria.,Medical Faculty, Sigmund Freud University, Vienna, Austria.,TZOU MEDICAL, Lymphedema Center, Vienna, Austria
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Bamba R, Chu A, Gallegos J, Herrera FA, Hassanein AH. Outcomes analysis of microsurgical physiologic lymphatic procedures for the upper extremity from the United States National Surgical Quality Improvement Program. Microsurgery 2021; 42:305-311. [PMID: 34812535 DOI: 10.1002/micr.30844] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 08/21/2021] [Accepted: 10/28/2021] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Physiologic microsurgical procedures to treat lymphedema include vascularized lymph node transfer (VLNT) and lymphovenous bypass (LVB). The purpose of this study was to assess 30-day outcomes of VLNT and LVB using the National Surgical Quality Improvement Program (NSQIP) database. METHODS NSQIP was queried (2012-2018) for lymphatic procedures for upper extremity lymphedema after mastectomy. Prophylactic lymphatic procedures and those for lower extremity lymphedema were excluded. Outcomes were assessed for three groups: LVB, VLNT, and patients who had procedures simultaneously (VLNA+LVB). Primary outcomes measured were operative time, 30-day morbidities, and hospital length of stay. RESULTS The study included 199 patients who had LVB (n = 43), VLNT (n = 145), or VLNT+LVB (n = 11). There was no difference in co-morbidities between the groups (p = 0.26). 30-day complication rates including unplanned reoperation (6.9% VLNT vs. 2.3% LVB) and readmission (0.69% VLNT vs. none in LVB) were not statistically significant (p = 0.54). Surgical site infection, wound complications, deep vein thromboembolism, and cardiac arrest was also similar among the three groups. Postoperative length of stay for VLNT (2.5 days± 2.3), LVB (1.9 days± 1.9), and VLNT+LVB (2.8 days± 0.3) did not differ significantly (p = 0.20). Operative time for LVB (305.4 min ± 186.7), VLNT (254 min ± 164.4), and VLNT+LVB (295.3 min ± 43.2) was not significantly different (p = 0.21). CONCLUSIONS Our analysis of the NSQIP data revealed that VLNT and LVB are procedures with no significant difference in perioperative morbidity. Our results support that choice of VLNT versus LVB can be justifiably made per the surgeon's preference and experience as the operations have similar complication rates.
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Affiliation(s)
- Ravinder Bamba
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Amanda Chu
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jose Gallegos
- Division of Plastic Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Fernando A Herrera
- Division of Plastic Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Aladdin H Hassanein
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Yoshida S, Koshima I, Imai H, Roh S, Mese T, Uchiki T, Sasaki A, Nagamatsu S. Lymphaticovenous Anastomosis for Age-Related Lymphedema. J Clin Med 2021; 10:jcm10215129. [PMID: 34768657 PMCID: PMC8584733 DOI: 10.3390/jcm10215129] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 10/26/2021] [Accepted: 10/30/2021] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Primary lymphedema is usually caused by intrinsic disruption or genetic damage to the lymphatics but may also be the result of age-related deterioration of the lymphatics. The aims of this study were to determine the characteristics of age-related lymphedema and to assess the effectiveness of lymphaticovenous anastomosis (LVA) in its treatment. METHODS Eighty-six patients with primary lymphedema affecting 150 lower limbs were divided into three groups according to whether the age of onset was younger than 35 years, 35-64 years, or 65 years or older. Indocyanine green (ICG) lymphography was performed, followed by LVA surgery. ICG lymphography images were visually classified according to whether the pattern was linear, low enhancement (LE), distal dermal backflow (dDB), or extended dermal backflow (eDB). The lower extremity lymphedema (LEL) index score was calculated before and after LVA. Lymphatic vessel diameter and detection rates were also recorded. RESULTS In the ≥65 group, the lymphedema was bilateral in 54 patients and unilateral in 1 patient. There was statistically significant deterioration in the LEL index score with progression from the linear, LE, dDB through to the eDB pattern in the ≥65 group. The lymphatic vessel diameter was significantly greater in the ≥65 group. The rate of improvement was highest in the ≥65 group. CONCLUSION Age-related lymphedema was bilateral and deterioration started distally. The lymphatic vessels in patients with age-related lymphedema tended to be ectatic, which is advantageous for LVA and may increase the improvement rate.
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Affiliation(s)
- Shuhei Yoshida
- The International Center for Lymphedema, Hiroshima University Hospital, 1-2-3, Kasumi, Minami-ku, Hiroshima 734-8551, Japan; (I.K.); (H.I.); (S.R.); (T.M.)
- Correspondence: ; Tel.: +81-82-257-5555
| | - Isao Koshima
- The International Center for Lymphedema, Hiroshima University Hospital, 1-2-3, Kasumi, Minami-ku, Hiroshima 734-8551, Japan; (I.K.); (H.I.); (S.R.); (T.M.)
| | - Hirofumi Imai
- The International Center for Lymphedema, Hiroshima University Hospital, 1-2-3, Kasumi, Minami-ku, Hiroshima 734-8551, Japan; (I.K.); (H.I.); (S.R.); (T.M.)
| | - Solji Roh
- The International Center for Lymphedema, Hiroshima University Hospital, 1-2-3, Kasumi, Minami-ku, Hiroshima 734-8551, Japan; (I.K.); (H.I.); (S.R.); (T.M.)
| | - Toshiro Mese
- The International Center for Lymphedema, Hiroshima University Hospital, 1-2-3, Kasumi, Minami-ku, Hiroshima 734-8551, Japan; (I.K.); (H.I.); (S.R.); (T.M.)
| | - Toshio Uchiki
- Department of Plastic and Reconstructive Surgery, Hiroshima University, 1-2-3, Kasumi, Minami-ku, Hiroshima 739-8551, Japan; (T.U.); (A.S.); (S.N.)
| | - Ayano Sasaki
- Department of Plastic and Reconstructive Surgery, Hiroshima University, 1-2-3, Kasumi, Minami-ku, Hiroshima 739-8551, Japan; (T.U.); (A.S.); (S.N.)
| | - Shogo Nagamatsu
- Department of Plastic and Reconstructive Surgery, Hiroshima University, 1-2-3, Kasumi, Minami-ku, Hiroshima 739-8551, Japan; (T.U.); (A.S.); (S.N.)
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30
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Evaluating the Impact of Immediate Lymphatic Reconstruction for the Surgical Prevention of Lymphedema. Plast Reconstr Surg 2021; 147:373e-381e. [PMID: 33620920 DOI: 10.1097/prs.0000000000007636] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Breast cancer-related lymphedema affects one in five patients. Its risk is increased by axillary lymph node dissection and regional lymph node radiotherapy. The purpose of this study was to evaluate the impact of immediate lymphatic reconstruction or the lymphatic microsurgical preventative healing approach on postoperative lymphedema incidence. METHODS The authors performed a retrospective review of all patients referred for immediate lymphatic reconstruction at the authors' institution from September of 2016 through February of 2019. Patients with preoperative measurements and a minimum of 6 months' follow-up data were identified. Medical records were reviewed for demographics, cancer treatment data, intraoperative management, and lymphedema incidence. RESULTS A total of 97 women with unilateral node-positive breast cancer underwent axillary nodal surgery and attempt at immediate lymphatic reconstruction over the study period. Thirty-two patients underwent successful immediate lymphatic reconstruction with a mean patient age of 54 years and body mass index of 28 ± 6 kg/m2. The median number of lymph nodes removed was 14 and the median follow-up time was 11.4 months (range, 6.2 to 26.9 months). Eighty-eight percent of patients underwent adjuvant radiotherapy of which 93 percent received regional lymph node radiotherapy. Mean L-Dex change was 2.9 units and mean change in volumetry by circumferential measurements and perometry was -1.7 percent and 1.3 percent, respectively. At the end of the study period, we found an overall 3.1 percent rate of lymphedema. CONCLUSION Using multiple measurement modalities and strict follow-up guidelines, the authors' findings support that immediate lymphatic reconstruction at the time of axillary surgery is a promising, safe approach for lymphedema prevention in a high-risk patient population. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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31
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Bianchi A, Salgarello M, Akitatsu H, Visconti G. Breast Cancer related upper limb lymphedema: approach and surgical management. Minerva Surg 2021; 76:575-579. [PMID: 34338471 DOI: 10.23736/s2724-5691.21.09013-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Lymphedema of the upper extremities in a common, chronic, progressive and debilitating disease, that affects the increasing population of cancer survivors. The gold standard is nowadays an integrated approach, including conservative and surgical treatment. Lymphatic surgery, particularly the physiologic procedures including lymphaticovenous anastomosis and vascularised lymph node transfer, should be offered to lymphedema patients as soon as possible, aimed to ameliorate the subjective symptoms and also to interrupt the degeneration cascade that makes this condition progressive over time. Indications for surgery, patient selection, and diagnostic tools will be discussed.
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Affiliation(s)
- Alessandro Bianchi
- UOC Chirurgia Plastica, Dipartimento per la Salute della Donna, del Bambino e di Sanità Pubblica - Fondazione Policlinico Universitario Agostino Gemelli IRCCS - Università Cattolica del Sacro Cuore, Rome, Italy
| | - Marzia Salgarello
- UOC Chirurgia Plastica, Dipartimento per la Salute della Donna, del Bambino e di Sanità Pubblica - Fondazione Policlinico Universitario Agostino Gemelli IRCCS - Università Cattolica del Sacro Cuore, Rome, Italy
| | - Hayashi Akitatsu
- Department of Plastic Surgery, Asahi General Hospital, Chiba, Japan
| | - Giuseppe Visconti
- UOC Chirurgia Plastica, Dipartimento per la Salute della Donna, del Bambino e di Sanità Pubblica - Fondazione Policlinico Universitario Agostino Gemelli IRCCS - Università Cattolica del Sacro Cuore, Rome, Italy -
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Gupta N, Verhey EM, Torres-Guzman RA, Avila FR, Jorge Forte A, Rebecca AM, Teven CM. Outcomes of Lymphovenous Anastomosis for Upper Extremity Lymphedema: A Systematic Review. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3770. [PMID: 34476159 PMCID: PMC8386908 DOI: 10.1097/gox.0000000000003770] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 06/21/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Lymphovenous anastomosis (LVA) is an accepted microsurgical treatment for lymphedema of the upper extremity (UE). This study summarizes and analyzes recent data on the outcomes associated with LVA for UE lymphedema at varying degrees of severity. METHODS A literature search was conducted in the PubMed database to extract articles published through June 19, 2020. Studies reporting data on postoperative improvement in limb circumference/volume or subjective improvement in quality of life for patients with primary or secondary lymphedema of the UE were included. Extracted data consisted of demographic data, number of patients and upper limbs, duration of symptoms before LVA, surgical technique, follow-up, and objective and subjective outcomes. RESULTS A total of 92 articles were identified, of which 16 studies were eligible for final inclusion comprising a total of 349 patients and 244 upper limbs. The average age of patients ranged from 38.4 to 64 years. The duration of lymphedema before LVA ranged from 9 months to 7 years. The mean length of follow-up ranged from 6 months to 8 years. Fourteen studies reported an objective improvement in limb circumference or volume measurements following LVA, ranging from 0% to 100%. Patients included had varying severity of lymphedema, ranging from Campisi stage I to IV. The maximal improvement in objective measurements was found in patients with lower stage lymphedema. CONCLUSION LVA is a safe, effective technique for the treatment of UE lymphedema refractory to decompressive treatment. Results of LVA indicate greater efficacy in earlier stages of lymphedema before advanced lymphatic sclerosis.
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Affiliation(s)
- Nikita Gupta
- From the Mayo Clinic Alix School of Medicine, Scottsdale, Ariz
| | - Erik M. Verhey
- University of Notre Dame, Department of Biological Sciences, Notre Dame, Ind
| | - Ricardo A. Torres-Guzman
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Mayo Clinic, Jacksonville, Fla
| | - Francisco R. Avila
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Mayo Clinic, Jacksonville, Fla
| | - Antonio Jorge Forte
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Mayo Clinic, Jacksonville, Fla
| | - Alanna M. Rebecca
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Mayo Clinic, Jacksonville, Fla
| | - Chad M. Teven
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Mayo Clinic, Phoenix, Ariz
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Choi YJ, Park JH, Ko HH, Suh YJ. Surgical technique for lymphovenous bypass in patients with advanced lymphedema: Initial experience in a tertiary care center. Asian J Surg 2021; 44:1110-1111. [PMID: 34154939 DOI: 10.1016/j.asjsur.2021.05.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 05/19/2021] [Indexed: 10/21/2022] Open
Affiliation(s)
- Yeon Ju Choi
- Research Cooperation Center, Hallym University, Chuncheon, 24252, South Korea
| | - Jung Ho Park
- Department of Breast and Endocrine Surgery, Hallym University Sacred Heart Hospital, Anyang, 14068, South Korea
| | - Ho Hyun Ko
- Department of Thoracic and Cardiovascular Surgery, Hallym University Sacred Heart Hospital, Anyang, 14068, South Korea
| | - Yong Joon Suh
- Department of Breast and Endocrine Surgery, Hallym University Sacred Heart Hospital, Anyang, 14068, South Korea.
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Forte AJ, Boczar D, Huayllani MT, Avila FR, Guliyeva G, Lu X, Mash WR, Kung TA. Use of magnetic resonance imaging lymphangiography for preoperative planning in lymphedema surgery: A systematic review. Microsurgery 2021; 41:384-390. [PMID: 33710683 DOI: 10.1002/micr.30731] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 01/04/2021] [Accepted: 03/03/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND In recent years, magnetic resonance imaging lymphangiography (MRL) has emerged as a way to predict if patients are candidates for lymphedema surgery, particularly lymphovenous anastomosis (LVA). Our goal was to conduct a systematic review of the literature on the use of MRL for preoperative planning in lymphedema surgery. We hypothesized that MRL could add valuable information to the standard preoperative evaluation of lymphedema patients. METHODS On February 17, 2020, we conducted a systematic review of the PubMed/MEDLINE, Cochrane Clinical Answers, and Embase databases, without time frame or language limitations, to identify articles on the use of MRL for preoperative planning of lymphedema surgery. We excluded studies that investigated other applications of magnetic resonance imaging, such as lymphedema diagnosis and treatment evaluation. The primary outcome was the examination capacity to identify lymphatic anatomy and the secondary outcome was the presence of adverse effects. RESULTS Of 372 potential articles identified with the search, nine studies fulfilled the eligibility criteria. A total of 334 lymphedema patients were enrolled in these studies. Two studies compared MRL findings with those of other standard examinations (indocyanine green lymphography [ICG-L] or lymphoscintigraphy). No adverse effects due to MRL were reported. A study shown that MRL had higher sensitivity to detect lymphatic vessel abnormalities compared with lymphoscintigraphy and a statistically higher chance of successful LVA was observed when the results of MRL agreed with those of ICG-L (p < .001). CONCLUSIONS MRL could be useful for preoperative planning in lymphedema surgery. The scientific evidence has been limited, so further studies with greater numbers of patients and cost analysis are necessary to justify the addition of MRL to current preoperative protocols.
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Affiliation(s)
- Antonio J Forte
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Daniel Boczar
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Maria T Huayllani
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Francisco R Avila
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Gunel Guliyeva
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Xiaona Lu
- Division of Plastic and Reconstructive Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - William R Mash
- Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Theodore A Kung
- Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, Michigan, USA
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Yoshida S, Koshima I, Imai H, Uchiki T, Sasaki A, Fujioka Y, Nagamatsu S, Yokota K, Yamashita S. Modified intraoperative distal compression method for lymphaticovenous anastomosis with high success and a low venous reflux rates. J Plast Reconstr Aesthet Surg 2021; 74:2050-2058. [PMID: 33541824 DOI: 10.1016/j.bjps.2020.12.103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 11/08/2020] [Accepted: 12/26/2020] [Indexed: 11/29/2022]
Abstract
INTRODUCTION For successful lymphaticovenous anastomosis (LVA), it is important to create anastomoses with high flow to maintain patency. To ensure that this can be achieved, we compared the efficacy of a modified intraoperative distal compression (IDC) technique with the conventional no compression (NC) method for lower limb lymphedema. PATIENTS AND METHODS In the IDC group, compression was applied to an area of the foot distal to the first LVA site. After completion of the first LVA, the distal compression was extended over the first LVA site to the distal end of the second LVA site. RESULTS There was no significant difference between the IDC (n = 25) and NC (n = 25) groups in detection rate. However, significant differences were observed in lymphatic vessel diameter and LVA success rate. No intraoperative anastomotic obstruction was seen at the conclusion of surgery. Intraoperative congestion with blood was detected in lymphatic vessels in 8 of 79 anastomoses (10.1%) in the NC group, but not in any cases in the IDC group (p = 0.002). There was a significant between-group difference in the rate of improvement in lymphedema between the IDC (16.1±3.6) and NC groups (14.0±3.4; p = 0.03). DISCUSSION IDC during LVA is thought to increase lymph flow in larger caliber lymphatics, leading to a high success rate and a low rate of venous reflux. IDC is beneficial when performing LVA.
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Affiliation(s)
- Shuhei Yoshida
- The International Center for Lymphedema, Hiroshima University Hospital, Japan.
| | - Isao Koshima
- The International Center for Lymphedema, Hiroshima University Hospital, Japan
| | - Hirofumi Imai
- The International Center for Lymphedema, Hiroshima University Hospital, Japan
| | - Toshio Uchiki
- Plastic and reconstructive Surgery, Hiroshima University, Japan
| | - Ayano Sasaki
- Plastic and reconstructive Surgery, Hiroshima University, Japan
| | - Yumio Fujioka
- Plastic and reconstructive Surgery, Hiroshima University, Japan
| | - Shogo Nagamatsu
- Plastic and reconstructive Surgery, Hiroshima University, Japan
| | - Kazunori Yokota
- Plastic and reconstructive Surgery, Hiroshima University, Japan
| | - Shuji Yamashita
- Plastic and Reconstructive Surgery, The University of Tokyo, Japan
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Schaverien MV, Chang EI. Combined deep inferior epigastric artery perforator flap with vascularized groin lymph node transplant for treatment of breast cancer-related lymphedema. Gland Surg 2021; 10:460-468. [PMID: 33634003 DOI: 10.21037/gs.2020.02.14] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
For survivors of breast cancer lymphedema is their greatest survivorship burden. Modern surgical techniques to treat lymphedema are effective at reducing limb volume, symptoms of lymphedema, episodes of cellulitis, and improving patient quality of life. Physiologic procedures, including lymphovenous bypass (LVB) and vascularized lymph node transplant (VLNT), restore physiological lymphatic function within the affected extremity. In patients with post-mastectomy breast cancer-related upper extremity lymphedema that desire breast reconstruction, microvascular abdominal flap breast reconstruction can be combined with superficial inguinal (groin) VLNT to provide breast reconstruction and treatment of lymphedema in a single operation. This article reviews the indications, preoperative assessment, surgical technique, outcomes, and tips and pearls for performing this procedure.
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Affiliation(s)
- Mark V Schaverien
- Division of Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Edward I Chang
- Division of Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Abstract
Physiologic surgical interventions, including lymphovenous bypass (LVB) and vascularized lymph node transplant (VLNT), are increasingly being used to treat lymphedema. LVB has been shown to be effective in improving the severity of lymphedema, particularly for patients with still-functional superficial lymphatic vessels that can be identified for bypass. However, in many patients, there is a paucity of functional lymphatic vessels for bypass and, thus, they are not ideal candidates for LVB alone. Unlike LVB, VLNT does not depend on the presence of functioning lymphatic vessels, but the effects of VLNT are delayed, as the proposed mechanisms of action require more time for optimal function. The author has offered a combined approach to microsurgical treatment of lymphedema for both the upper and lower extremities. Simultaneous VLNT and LVB are safe and effective for patients with both early and advanced stages of primary and secondary lymphedema. Our experience shows that a majority of patients can expect some long-term improvement, in both overall limb volume and quality of life, after surgical intervention with LVB and/or VLNT.
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Affiliation(s)
- David W Chang
- Section of Plastic and Reconstructive Surgery, Department of Surgery, The University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
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Abstract
Lymphoedema is the accumulation of protein-rich interstitial fluid within subcutaneous tissue and skin as a result of dysfunction of the lymphatic system. It is an underestimated, widely neglected and debilitating chronic condition. This article presents an overview of lymphoedema and recent advances in its management.
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Affiliation(s)
- Kai Yuen Wong
- Plastic and Reconstructive Surgery Department, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Dominic Furniss
- Plastic and Reconstructive Surgery Department, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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40
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Evolution in Surgical Management of Breast Cancer-related Lymphedema: The MD Anderson Cancer Center Experience. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2674. [PMID: 32537338 PMCID: PMC7253265 DOI: 10.1097/gox.0000000000002674] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 12/18/2019] [Indexed: 11/28/2022]
Abstract
Lymphedema is a lifelong, debilitating condition that plagues a large portion of patients who have undergone multimodality therapy for breast cancer. With the increasing experience in supermicrosurgical treatment of lymphedema, reconstructive surgeons have made a tremendous impact in improving the quality of life of patients suffering from breast cancer related lymphedema.
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Mechanical Dilation Using Nylon Monofilament Aids Multisite Lymphaticovenous Anastomosis Through Improving the Quality of Anastomosis. Ann Plast Surg 2020; 82:201-206. [PMID: 30557189 DOI: 10.1097/sap.0000000000001681] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Lymphaticovenous anastomosis (LVA) is now a common treatment for lymphedema. It is important to create as many bypasses as possible to maximize the efficacy of LVA. We have developed a method whereby nylon monofilaments are placed inside the vessel lumen to act as dilators. We refer to this technique as mechanical dilation (MD) to distinguish it from intravascular stenting. In this study, we investigated the efficacy of the conventional supermicrosurgery technique performed with and without MD as a treatment for lower limb lymphedema. The LVA was performed using conventional supermicrosurgery alone in 10 patients (group without MD) and in combination with MD in another 10 patients (group with MD). The mean number of successful LVAs performed per hour was significantly higher in the group with MD than in the group without MD (1.42 ± 0.16 vs 1.14 ± 0.15; P < 0.05). The mean amount of improvement in the lower extremity lymphedema index was significantly greater in the group with MD than in the group without MD (7.34 ± 1.57 vs 4.41 ± 1.53; P = 0.003 < 0.05). A statistically significant correlation was found between the number of successful LVAs and amount of improvement in lymphedema (r = 0.449, P = 0.047 < 0.05). Our findings suggest that use of MD does not shorten the operating time or increase the number of LVAs that can be performed but may make it possible to increase the number of successful LVAs that can be performed between vessels with a diameter of less than 0.3 mm. Use of MD could increase the improvement rate of lymphedema to a greater extent than that achieved by conventional microsurgery alone.
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Kareh AM, Xu KY. Surgical Management of Lymphedema. MISSOURI MEDICINE 2020; 117:143-148. [PMID: 32308240 PMCID: PMC7144713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Lymphedema is a chronic debilitating disease in which impaired drainage of lymphatic fluid causes accumulation of fluid in the soft tissues resulting in a swollen heavy limb. This ultimately leads to severe fibrosis, recurrent infections, non-healing wounds, and a poorly functioning limb that negatively affects a patient's quality of life. Primary lymphedema is due to abnormal development of the lymphatic system and patients can present with lymphedema at birth or later in life. Secondary lymphedema is caused by damage to the lymphatic system from infection, surgery to treat malignancies, trauma, and obesity. In the past, the only treatment was controlling the swelling to prevent progression of the disease by lymphatic therapy and various types of compression which is still currently the first line treatment. Advances in supermicrosurgery (connecting vessels less than 0.8 mm) have made way for surgical treatment options for lymphedema, including lymphovenous bypass and vascularized lymph node transplant. These new surgical treatment options combined with lymphatic therapy and compression have led to better results and improved patient's quality of life. After reading this article, the participant should be familiar with diagnosis, imaging, and surgical treatment of lymphedema.
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Affiliation(s)
- Aurora M Kareh
- Aurora M. Kareh, MD, is a Resident Physician, Division of Plastic and Reconstructive Surgery, and Kyle Y. Xu, MD, is an Attending Physician, Plastic Surgery, Microsurgery and Hand Surgery, Division of Plastic and Reconstructive Surgery, Department of Surgery, Saint Louis University School of Medicine, St. Louis, Missouri
| | - Kyle Y Xu
- Aurora M. Kareh, MD, is a Resident Physician, Division of Plastic and Reconstructive Surgery, and Kyle Y. Xu, MD, is an Attending Physician, Plastic Surgery, Microsurgery and Hand Surgery, Division of Plastic and Reconstructive Surgery, Department of Surgery, Saint Louis University School of Medicine, St. Louis, Missouri
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Abstract
Lymphedema-the accumulation of fluid in tissues, usually in the upper and lower extremities-often results from lymph node dissection or radiation and can cause painful and debilitating swelling that may interfere with a patient's daily living activities and quality of life. The goal of treatment for lymphedema is to reduce the volume of fluid in the affected area. Lymphedema is staged according to presenting characteristics, and interventions may be surgical or nonsurgical, such as complex decongestive therapy. Lymphovenous bypass is a surgical procedure performed for the management of lymphedema and involves rerouting microvascular channels to allow for the drainage of fluid that has accumulated in the lymphatic tissue of the upper or lower extremities. It requires supermicrosurgery techniques because of the small size of the vessels being anastomosed. Perioperative nursing implications for lymphovenous bypass include OR preparation and providing emotional support for patients living with lymphedema.
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Wiser I, Mehrara BJ, Coriddi M, Kenworthy E, Cavalli M, Encarnacion E, Dayan JH. Preoperative Assessment of Upper Extremity Secondary Lymphedema. Cancers (Basel) 2020; 12:E135. [PMID: 31935796 PMCID: PMC7016742 DOI: 10.3390/cancers12010135] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 12/04/2019] [Accepted: 12/18/2019] [Indexed: 11/17/2022] Open
Abstract
Introduction: The purpose of this study was to evaluate the most commonly used preoperative assessment tools for patients undergoing surgical treatment for secondary upper extremity lymphedema. Methods: This was a prospective cohort study performed at a tertiary cancer center specializing in the treatment of secondary lymphedema. Lymphedema evaluation included limb volume measurements, bio-impedance, indocyanine green lymphography, lymphoscintigraphy, magnetic resonance angiography, lymphedema life impact scale (LLIS) and upper limb lymphedema 27 (ULL-27) questionnaires. Results: 118 patients were evaluated. Limb circumference underestimated lymphedema compared to limb volume. Bioimpedance (L-Dex) scores highly correlated with limb volume excess (r2 = 0.714, p < 0.001). L-Dex scores were highly sensitive and had a high positive predictive value for diagnosing lymphedema in patients with a volume excess of 10% or more. ICG was highly sensitive in identifying lymphedema. Lymphoscintigraphy had an overall low sensitivity and specificity for the diagnosis of lymphedema. MRA was highly sensitive in diagnosing lymphedema and adipose hypertrophy as well as useful in identifying axillary vein obstruction and occult metastasis. Patients with minimal limb volume difference still demonstrated significantly impaired quality of life. Conclusion: Preoperative assessment of lymphedema is complex and requires multimodal assessment. MRA, L-Dex, ICG, and PROMs are all valuable components of preoperative assessment.
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Affiliation(s)
| | | | | | | | | | | | - Joseph H. Dayan
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA; (I.W.); (B.J.M.); (M.C.); (E.K.); (M.C.); (E.E.)
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Chang EI, Chu CK, Chang EI. Advancements in imaging technology for microvascular free tissue transfer. J Surg Oncol 2018; 118:729-735. [DOI: 10.1002/jso.25194] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 07/10/2018] [Indexed: 11/06/2022]
Affiliation(s)
| | - Carrie K. Chu
- Department of Plastic SurgeryThe University of Texas MD Anderson Cancer CenterHouston Texas
| | - Edward I. Chang
- Department of Plastic SurgeryThe University of Texas MD Anderson Cancer CenterHouston Texas
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