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Brahma B, Yamamoto T, Panigoro SS, Haryono SJ, Yusuf PA, Priambodo PS, Harimurti K, Taher A. Supermicrosurgery lymphaticovenous and lymphaticolymphatic anastomosis: Technical detail and short-term follow-up for immediate lymphatic reconstruction in breast cancer treatment-related lymphedema prevention. J Vasc Surg Venous Lymphat Disord 2024; 12:101863. [PMID: 38428499 DOI: 10.1016/j.jvsv.2024.101863] [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: 12/17/2023] [Revised: 02/05/2024] [Accepted: 02/12/2024] [Indexed: 03/03/2024]
Abstract
OBJECTIVE We describe the feasibility and short-term outcome of our surgical technique to repair the lymph vessel disruption directly after axillary lymph node dissection during breast cancer surgery. This procedure is called immediate lymphatic reconstruction to prevent breast cancer treatment-related lymphedema (BCRL), which frequently occurs after axillary lymph node dissection. The surgical technique consisted of lymphaticovenous anastomosis (LVA) or lymphaticolymphatic anastomosis. We named the procedure lymphatic bypass supermicrosurgery (LBS). METHODS This study used a retrospective cohort design of patients with breast cancer between May 2020 and February 2023. LBS was performed by making an intima-to-intima coaptation between afferent lymph vessels and the recipient's veins (LVA) or efferent lymph vessels lymphaticolymphatic anastomosis. RESULTS A total of 82 patients underwent lymphatic bypass. The mean age of patients was 50 ± 12 years, and most had stage III breast cancer (n = 59 [72%]). LVA was the most common type of lymphatic bypass (94.6%). The median number of LVA was 1 (range, 1-4) and 1 (range, 1-3) for lymphaticolymphatic anastomosis. The median follow-up time was 12.5 months (range, 1-33 months). The 50 patients who had postoperative indocyanine green lymphography described arm dermal backflow stage 0 in 20 (40%), stage 1 in 19 (38%), stage 2 in 2 (4%), and stage 3 in 9 (18%) cases. The proportion of BCRL was 11 (22%), and subclinical lymphedema was 19 (38%) in this period. Most cases were in stable subclinical lymphedema (10, 58.8%). The 1-year and 2-year BCRL rates were 14% (95% confidence interval, 4%-23.9%) and 22% (95% confidence interval, 10.1%-33.9%), respectively. CONCLUSIONS Along with the emerging immediate lymphatic reconstruction, LBS is a feasible supermicrosurgery technique that may have a potential role in BCRL prevention. A randomized controlled study would confirm the effectiveness of the technique.
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Affiliation(s)
- Bayu Brahma
- Doctoral Program in Medical Sciences, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia; Department of Surgical Oncology, Dharmais Cancer Hospital-National Cancer Center, Jakarta, Indonesia
| | - Takumi Yamamoto
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan.
| | - Sonar Soni Panigoro
- Oncology Division, Department of Surgery, Faculty of Medicine, Universitas Indonesia - Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
| | - Samuel Johny Haryono
- Department of Surgical Oncology, Dharmais Cancer Hospital-National Cancer Center, Jakarta, Indonesia
| | - Prasandhya Astagiri Yusuf
- Department of Medical Physiology and Biophysics/Medical Technology IMERI, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Purnomo Sidi Priambodo
- Department of Electrical Engineering, Faculty of Engineering, Universitas Indonesia, Jakarta, Indonesia
| | - Kuntjoro Harimurti
- Division of Geriatrics/Clinical Epidemiological Unit, Department of Internal Medicine, Universitas Indonesia - Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
| | - Akmal Taher
- Department of Urology, Faculty of Medicine, Universitas Indonesia - Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
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Lin CH, Yamamoto T. Supermicrosurgical lymphovenous anastomosis. J Chin Med Assoc 2024; 87:455-462. [PMID: 38517403 DOI: 10.1097/jcma.0000000000001088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2024] Open
Abstract
Lymphedema impairs patients' function and quality of life. Currently, supermicrosurgical lymphovenous anastomosis (LVA) is regarded as a significant and effective treatment for lymphedema. This article aims to review recent literature on this procedure, serving as a reference for future research and surgical advancements. Evolving since the last century, LVA has emerged as a pivotal domain within modern microsurgery. It plays a crucial role in treating lymphatic disorders. Recent literature discusses clinical imaging, surgical techniques, postoperative care, and efficacy. Combining advanced tools, precise imaging, and surgical skills, LVA provides a safer and more effective treatment option for lymphedema patients, significantly enhancing their quality of life. This procedure also presents new challenges and opportunities in the realm of microsurgery.
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Affiliation(s)
- Chih-Hsun Lin
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Surgery, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Takumi Yamamoto
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
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Brahma B, Yamamoto T, Agdelina C, Adella D, Putri RI, Hanifah W, Sundah VH, Perdana AB, Putra MRA, Taher A, Panigoro SS. Immediate-delayed lymphatic reconstruction after axillary lymph nodes dissection for locally advanced breast cancer-related lymphedema prevention: Report of two cases. Microsurgery 2024; 44:e31033. [PMID: 36896960 DOI: 10.1002/micr.31033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 02/14/2023] [Accepted: 02/24/2023] [Indexed: 03/11/2023]
Abstract
Approximately 60%-70% of breast cancer patients in Indonesia are diagnosed in the locally advanced stage. The stage carries a higher risk of lymph node metastasis which increases susceptibility to lymph obstruction. Hence, breast cancer-related lymphedema (BCRL) could present before axillary lymph node dissection (ALND). The purpose of this case report is to describe immediate-delayed lymphatic reconstructions with lymphaticovenous anastomosis in two subclinical lymphedema cases that present before ALND. There were 51 and 58 years old breast cancer patients with stage IIIC and IIIB, respectively. Both had no arm lymphedema symptoms, but arm lymphatic vessel abnormalities were found during preoperative indocyanine green (ICG) lymphography. Mastectomy and ALND were performed and proceeded with lymphaticovenous anastomoses (LVA) in both cases. One LVA at the axilla (isotopic) was done in the first patient. On the second patient, 3 LVAs at the affected arm (ectopic) and 3 isotopic LVAs were created. The patients were discharged on the second day without complications during the follow-up. The intensity of dermal backflow was reduced, and no subclinical lymphedema progression occurred during 11 and 9 months follow-up, respectively. Based on these cases, BCRL screening might be recommended for the locally advanced stage before cancer treatment. Once diagnosed, immediate lymphatic reconstruction after ALND should be recommended to cure or prevent BCRL progression.
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Affiliation(s)
- Bayu Brahma
- Department of Surgical Oncology, Dharmais Cancer Hospital-National Cancer Center, Jakarta, Indonesia
| | - Takumi Yamamoto
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Clarissa Agdelina
- Functional Medical Staff of Surgical Oncology Department, Dharmais Hospital-National Cancer Center, Jakarta, Indonesia
| | - Devina Adella
- Functional Medical Staff of Surgical Oncology Department, Dharmais Hospital-National Cancer Center, Jakarta, Indonesia
| | - Rizky Ifandriani Putri
- Department of Anatomical Pathology, Dharmais Cancer Hospital-National Cancer Center, Jakarta, Indonesia
| | - Wardah Hanifah
- Functional Medical Staff of Surgical Oncology Department, Dharmais Hospital-National Cancer Center, Jakarta, Indonesia
| | - Vincentius Henry Sundah
- Functional Medical Staff of Surgical Oncology Department, Dharmais Hospital-National Cancer Center, Jakarta, Indonesia
| | - Adhitya Bayu Perdana
- Research and Development Department, Dharmais Cancer Hospital-National Cancer Center, Jakarta, Indonesia
| | - Mohammad Reka Ananda Putra
- Functional Medical Staff of Surgical Oncology Department, Dharmais Hospital-National Cancer Center, Jakarta, Indonesia
| | - Akmal Taher
- Department of Urology, Faculty of Medicine, Universitas Indonesia - Dr Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
| | - Sonar Soni Panigoro
- Department of Surgery, Oncology Division, Faculty of Medicine, Universitas Indonesia - Dr Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
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Xiaoming L, Wei T, Yi'nan J, You P, Shipeng N, Longgui X, Xiao Z, Liying W, Tingyan L, Yi J. Application of combined preoperative indocyanine green lymphography and ultrasonography for low-pressure vein localization in secondary lymphedema surgery for breast cancer. Asian J Surg 2024; 47:289-295. [PMID: 37648547 DOI: 10.1016/j.asjsur.2023.08.121] [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: 02/11/2023] [Revised: 06/22/2023] [Accepted: 08/22/2023] [Indexed: 09/01/2023] Open
Abstract
BACKGROUND This study aimed to investigate the value of preoperative indocyanine green (ICG) lymphography combined with ultrasonography for low-pressure vein localization in secondary lymphedema surgery for breast cancer. METHODS A total of 29 patients who were admitted to the breast surgery department of our hospital from July 2019 to May 2021 were included in this study. All patients received preoperative reverse lymphography and ultrasonography for low-pressure vein in lymphedema surgery. Three arm circumferences were measured before surgery, 6 months after surgery, and 12 months after surgery for comparison with the healthy limb at the same time. RESULTS Arm circumference at 12 months after surgery was significantly different from those at the preoperative period and 6 months after surgery (P < 0.05). However, this parameter after surgery was still significantly higher than that of the healthy limb (P < 0.05). CONCLUSIONS The application of preoperative ICG lymphography combined with ultrasonography for low-pressure vein localization before surgery can greatly shorten operation duration by reducing the number of ineffective incisions and improving the probability of vein-lymphatic vessel matching, while ensuring the postoperative efficacy for patients.
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Affiliation(s)
- Liao Xiaoming
- Department of Breast Surgery/Lymphedema Treatment Center of Guangxi Medical University Cancer Hospital, Nanning, 530021, China
| | - Tang Wei
- Department of Breast Surgery/Lymphedema Treatment Center of Guangxi Medical University Cancer Hospital, Nanning, 530021, China
| | - Ji Yi'nan
- Department of Breast Surgery/Lymphedema Treatment Center of Guangxi Medical University Cancer Hospital, Nanning, 530021, China
| | - Pan You
- Department of Breast Surgery/Lymphedema Treatment Center of Guangxi Medical University Cancer Hospital, Nanning, 530021, China
| | - Ning Shipeng
- Department of Breast Surgery/Lymphedema Treatment Center of Guangxi Medical University Cancer Hospital, Nanning, 530021, China
| | - Xie Longgui
- Department of Breast Surgery/Lymphedema Treatment Center of Guangxi Medical University Cancer Hospital, Nanning, 530021, China
| | - Zhou Xiao
- Department of Breast Surgery/Lymphedema Treatment Center of Guangxi Medical University Cancer Hospital, Nanning, 530021, China
| | - Wei Liying
- College of Oncology of Guangxi Medical University, Nanning, 530021, China
| | - Ling Tingyan
- College of Oncology of Guangxi Medical University, Nanning, 530021, China
| | - Jiang Yi
- Department of Breast Surgery/Lymphedema Treatment Center of Guangxi Medical University Cancer Hospital, Nanning, 530021, China.
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Meuli JN, Guiotto M, Elmers J, Mazzolai L, di Summa PG. Outcomes after microsurgical treatment of lymphedema: a systematic review and meta-analysis. Int J Surg 2023; 109:1360-1372. [PMID: 37057889 PMCID: PMC10389392 DOI: 10.1097/js9.0000000000000210] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 01/03/2023] [Indexed: 04/15/2023]
Abstract
BACKGROUND Microsurgical treatment options for lymphedema consist mainly of lymphovenous anastomosis (LVA) and vascularized lymph node transfers (VLNTs). There are no standard measurements of the effectiveness of these interventions and reported outcomes vary among studies. METHODS A systematic review and meta-analysis were performed based on a structured search in Embase, Medline, PubMed, Cinahl, Cochrane, and ProQuest in October 2020, with an update in February 2022. Firstly, a qualitative summary of the main reported outcomes was performed, followed by a pooled meta-analysis of the three most frequently reported outcomes using a random effects model. Randomized controlled trials, prospective cohorts, retrospective cohorts, and cross-sectional and case-control studies that documented outcomes following microsurgery in adult patients were included. Studies of other surgical treatments (liposuction, radical excision, lymphatic vessel transplantation) or without reported outcomes were excluded. The study protocol was registered on PROSPERO (International Prospective Register of Systematic Reviews) (ID: CRD42020202417). No external funding was received for this review. RESULTS One hundred fifty studies, including 6496 patients, were included in the systematic review. The qualitative analysis highlighted the three most frequently reported outcomes: change in circumference, change in volume, and change in the number of infectious episodes per year. The overall pooled change in excess circumference across 29 studies, including 1002 patients, was -35.6% [95% CI: -30.8 to -40.3]. The overall pooled change in excess volume across 12 studies including 587 patients was -32.7% [95% CI: -19.8 to -45.6], and the overall pooled change in the number of cutaneous infections episodes per year across 8 studies including 248 patients was -1.9 [95% CI: -1.4 to -2.3]. The vast majority of the studies included were case series and cohorts, which were intrinsically exposed to a risk of selection bias. CONCLUSION The currently available evidence supports LVA and vascularized lymph node transfers as effective treatments to reduce the severity of secondary lymphedema. Standardization of staging method, outcomes measurements, and reporting is paramount in future research in order to allow comparability across studies and pooling of results.
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Affiliation(s)
| | | | | | - Lucia Mazzolai
- Angiology Division, Heart and Vessel Department, Lausanne University Hospital, University of Lausanne, Switzerland
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Yamamoto T, Yamamoto N. Office-Based Lymphatic Supermicrosurgery: Supermicrosurgical Lymphaticovenular Anastomosis at an Outpatient Clinic. J Reconstr Microsurg 2023; 39:131-137. [PMID: 35817051 DOI: 10.1055/s-0042-1750123] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Supermicrosurgical lymphaticovenular anastomosis (LVA) has become popular for the treatment of compression-refractory lymphedema. With advancement of navigation tools, LVA can be performed with more ease and safety, allowing office-based LVA at an outpatient clinic. METHODS Office-based LVA was performed on patients with compression-refractory secondary extremity lymphedema by a well-experienced supermicrosurgeon (T.Y.) under local infiltration anesthesia. Indocyanine green (ICG) lymphography and vein visualizer were used to localize vessels preoperatively. A stereoscopic microscope (Leica S6E, Leica Microsystems, Germany) or a relatively small operative microscope (OPMI pico, Carl Zeiss, Germany) was used for LVA. Operative records and postoperative results were reviewed to evaluate feasibility of office-based LVA. RESULTS LVAs were performed on 27 arms and 42 legs, which resulted in 131 anastomoses via 117 incisions. ICG lymphography stage included stage II in 47 limbs, and stage III in 22 limbs. Time required for one LVA procedure (from skin incision to skin closure in one surgical field) ranged from 13 to 37 minutes (average, 24.9 minutes). One year after LVA, all cases showed significant volume reduction (lymphedematous volume reduction; 0.5-23.6%, average 13.23%). No postoperative complication was observed. CONCLUSION LVA can be performed with safety and effectiveness outside an operation theater. Patient selection, precise preoperative mapping, and experience of a surgeon are key to successful office-based LVA.
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Affiliation(s)
- Takumi Yamamoto
- Department of Plastic and Reconstructive Surgery, Center Hospital of the National Center for Global Health and Medicine, Tokyo, Japan.,Department of Plastic Surgery, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Nana Yamamoto
- Department of Plastic and Reconstructive Surgery, Center Hospital of the National Center for Global Health and Medicine, Tokyo, Japan.,Department of Plastic Surgery, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
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Bianchi A, Salgarello M, Hayashi A, Yang JCS, Visconti G. Recipient Venule Selection and Anastomosis Configuration for Lymphaticovenular Anastomosis in Extremity Lymphedema: Algorithm Based on 1,000 Lymphaticovenular Anastomosis. J Reconstr Microsurg 2021; 38:472-480. [PMID: 34583393 DOI: 10.1055/s-0041-1735836] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND The lymphaticovenular anastomosis (LVA) has three components, lymphatics, venules, and anastomosis, and all of them influence the anastomotic pressure gradient. Although it has been demonstrated that venule flow dynamics has an independent impact on the outcomes regardless the degeneration status of lymphatic vessels, recipient venules (RV) have been mainly neglected in literature. PATIENTS AND METHODS From January 2016 to February 2020, 232 nonconsecutive patients affected by extremity lymphedema underwent LVA, for a total of 1,000 LVAs. Only patients with normal-to-ectasic lymphatic collectors were included to focus the evaluation on the RV only. The preoperative collected data included the location, diameter, and continence of the selected venules, the expected number, the anastomoses configuration, and their flow dynamics according to BSO classification. RESULTS The 232 patients included 117 upper limb lymphedema (ULL) and 115 lower limb lymphedema (LLL). The average size of RV was 0.81 ± 0.32 mm in end-to-end (E-E), 114 ± 0.17 mm in end-to-side (E-S), 0.39 ± 0.22 mm in side-to-end (S-E), and 0.76 ± 0.38 mm in side-to-side (S-S) anastomoses. According to the BSO classification, on a total of 732 RV, 105(14%) were backflow venules, 136 (19%) were slack, and 491 (67%) were outlet venules. Also, 824 (82%) were E-E, 107 (11%) were E-S, 51 (5%) were S-E, and 18 (2%) were S-S anastomoses. CONCLUSION Based on 1,000 LVAs with similar lymphatic characteristics, we propose our algorithm that may aid the lymphatic microsurgeon in the selection of RV and the consequent anastomosis configuration, in order of obtain the best flow dynamic through the LVA. This therapeutic study reflects level of evidence IV.
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Affiliation(s)
- Alessandro Bianchi
- Unità Operativa Complessa (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
- Unità Operativa Complessa (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
| | - Akitatsu Hayashi
- Department of Plastic Surgery, Lymphedema Clinic, Kameda Medical Centre, Kamogawa, Chiba, Japan
| | - Johnson C-S Yang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Lymphedema Center, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Niaosong District, Taiwan
| | - Giuseppe Visconti
- Unità Operativa Complessa (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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