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Jian Y, Li Y, Zhang Y, Tang M, Deng M, Liu C, Cheng M, Xiao S, Deng C, Wei Z. Lymphangiogenesis: novel strategies to promote cutaneous wound healing. BURNS & TRAUMA 2024; 12:tkae040. [PMID: 39328366 PMCID: PMC11427083 DOI: 10.1093/burnst/tkae040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 05/31/2024] [Accepted: 06/05/2024] [Indexed: 09/28/2024]
Abstract
The cutaneous lymphatic system regulates tissue inflammation, fluid balance and immunological responses. Lymphangiogenesis or lymphatic dysfunction may lead to lymphedema, immune deficiency, chronic inflammation etc. Tissue regeneration and healing depend on angiogenesis and lymphangiogenesis during wound healing. Tissue oedema and chronic inflammation can slow wound healing due to impaired lymphangiogenesis or lymphatic dysfunction. For example, impaired lymphangiogenesis or lymphatic dysfunction has been detected in nonhealing wounds such as diabetic ulcers, venous ulcers and bedsores. This review summarizes the structure and function of the cutaneous lymphatic vessel system and lymphangiogenesis in wounds. Furthermore, we review wound lymphangiogenesis processes and remodelling, especially the influence of the inflammatory phase. Finally, we outline how to control lymphangiogenesis to promote wound healing, assess the possibility of targeting lymphangiogenesis as a novel treatment strategy for chronic wounds and provide an analysis of the possible problems that need to be addressed.
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Affiliation(s)
- Yang Jian
- Department of Burns and Plastic Surgery, Affiliated Hospital of Zunyi Medical University, No. 149 Dalian Road, Hui chuan District, Zunyi, Guizhou, 563003, China
| | - Yanqi Li
- Department of Burns and Plastic Surgery, Affiliated Hospital of Zunyi Medical University, No. 149 Dalian Road, Hui chuan District, Zunyi, Guizhou, 563003, China
| | - Yanji Zhang
- Department of Burns and Plastic Surgery, Affiliated Hospital of Zunyi Medical University, No. 149 Dalian Road, Hui chuan District, Zunyi, Guizhou, 563003, China
| | - Mingyuan Tang
- Department of Burns and Plastic Surgery, Affiliated Hospital of Zunyi Medical University, No. 149 Dalian Road, Hui chuan District, Zunyi, Guizhou, 563003, China
| | - Mingfu Deng
- Department of Burns and Plastic Surgery, Affiliated Hospital of Zunyi Medical University, No. 149 Dalian Road, Hui chuan District, Zunyi, Guizhou, 563003, China
| | - Chenxiaoxiao Liu
- Department of Burns and Plastic Surgery, Affiliated Hospital of Zunyi Medical University, No. 149 Dalian Road, Hui chuan District, Zunyi, Guizhou, 563003, China
| | - Maolin Cheng
- Department of Burns and Plastic Surgery, Affiliated Hospital of Zunyi Medical University, No. 149 Dalian Road, Hui chuan District, Zunyi, Guizhou, 563003, China
| | - Shune Xiao
- Department of Burns and Plastic Surgery, Affiliated Hospital of Zunyi Medical University, No. 149 Dalian Road, Hui chuan District, Zunyi, Guizhou, 563003, China
- The Collaborative Innovation Center of Tissue Damage Repair and Regeneration Medicine of Zunyi Medical University, No. 6 West Xuefu Road, Xinpu District, Zunyi, Guizhou, 563003, China
| | - Chengliang Deng
- Department of Burns and Plastic Surgery, Affiliated Hospital of Zunyi Medical University, No. 149 Dalian Road, Hui chuan District, Zunyi, Guizhou, 563003, China
- The Collaborative Innovation Center of Tissue Damage Repair and Regeneration Medicine of Zunyi Medical University, No. 6 West Xuefu Road, Xinpu District, Zunyi, Guizhou, 563003, China
| | - Zairong Wei
- Department of Burns and Plastic Surgery, Affiliated Hospital of Zunyi Medical University, No. 149 Dalian Road, Hui chuan District, Zunyi, Guizhou, 563003, China
- The Collaborative Innovation Center of Tissue Damage Repair and Regeneration Medicine of Zunyi Medical University, No. 6 West Xuefu Road, Xinpu District, Zunyi, Guizhou, 563003, 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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Braizat O, Jarrar S, El-Debs M, Al-Adwan MAO, Syaj S, Abuzanouneh F, Mohammed M, Mohammedali S, Quazi SJ, Muneer M. Comparing Different Donor Sites After Vascularized Lymph Node Transfer to the Lymphedematous Upper Limb: A Systematic Review and Meta-analysis of Clinical Outcomes. Ann Plast Surg 2024; 93:130-138. [PMID: 38885169 DOI: 10.1097/sap.0000000000003918] [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: 06/20/2024]
Abstract
BACKGROUND Vascularized lymph node transfer (VLNT) involves the microvascular transplantation of functional lymph nodes from a donor site into a limb affected by lymphedema to restore the normal flow of lymphatic fluid. Despite the increasing clinical experience with VLNT, there remains insufficient data to support its routine use in clinical practice. Here, we aim to evaluate the effectiveness and safety of VLNTs for upper limb lymphedema and compare clinical outcomes when using different donor sites. METHODS We carried out a systematic search of the literature through PubMed and Scopus databases for studies on VLNT for upper limb lymphedema. Primary and secondary outcomes included circumference reduction rate (CRR) and infection reduction rate by postoperative cellulitis episodes for the efficacy and safety of VLNT. Pooled analysis was performed using the inverse variance weighting meta-analysis of single means using the meta package in R software. Subgroup analyses were performed for donor and recipient sites, age groups, follow-ups, and symptom durations. Quality assessment was performed using the Newcastle-Ottawa Scale for nonrandomized studies. RESULTS A total of 1089 studies were retrieved from the literature, and 15 studies with 448 upper limb lymphedema patients who underwent VLNT were included after eligibility assessment. The mean CRR was 34.6 (18.8) and the mean postoperative cellulitis episodes per year was 0.71 (0.7). The pooled analysis of CRR was 28.4% (95% confidence interval, 19.7-41.1) and postoperative cellulitis episodes showed a mean of 0.59 (95% confidence interval, 0.36-0.95) using the random-effect model. Subgroup analyses showed significant group differences in recipient site for CRR and postoperative cellulitis episodes with the wrist comprising the highest weights, and patients younger than 50 years showing a lower postoperative infection. CONCLUSIONS Vascularized lymph node transfer using gastroepiploic flaps at the wrists has shown a significant difference in reductions of limb circumference and cellulitis episodes in upper limb lymphedema patients when compared with other donor sites. However, further prospective studies are needed to consolidate this finding.
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Affiliation(s)
- Omar Braizat
- From the Department of Plastic and Reconstructive Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Salma Jarrar
- From the Department of Plastic and Reconstructive Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Mohammed El-Debs
- From the Department of Plastic and Reconstructive Surgery, Hamad Medical Corporation, Doha, Qatar
| | | | - Sebawe Syaj
- Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Faris Abuzanouneh
- Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Mazin Mohammed
- From the Department of Plastic and Reconstructive Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Shiyas Mohammedali
- From the Department of Plastic and Reconstructive Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Sohail Jamiluddin Quazi
- From the Department of Plastic and Reconstructive Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Mohammed Muneer
- From the Department of Plastic and Reconstructive Surgery, Hamad Medical Corporation, Doha, Qatar
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Anand NC, Campbell EH, Baum CL, Gibson LE, Todd A, Bradt JL, Alavi A. Association of Lower Extremity Lymphedema and Nonmelanoma Skin Cancers. Mayo Clin Proc 2023; 98:1653-1659. [PMID: 37923522 DOI: 10.1016/j.mayocp.2023.02.030] [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] [Received: 09/01/2022] [Revised: 02/15/2023] [Accepted: 02/22/2023] [Indexed: 11/07/2023]
Abstract
OBJECTIVE To determine whether patients with lymphedema of a lower extremity (LE) had a greater risk of skin cancer than those without lymphedema. PATIENTS AND METHODS This retrospective cohort study included patients with LE lymphedema examined at Mayo Clinic in Rochester, MN, USA, from January 1, 2000, through December 31, 2020. All patients with the phrase "lower extremity lymphedema" and a diagnostic code for lymphedema present in their electronic health record, as well as their age-, race-, and sex-matched controls without lymphedema, were included in the study. A Kaplan-Meier curve was constructed to examine the time to development of the first skin cancer for the lymphedema cohort and the controls. A Cox proportional hazards regression model was used to calculate hazard ratios. RESULTS In total, 4437 patients had lymphedema within the study period. Compared with the matched control group, the lymphedema group had a significantly increased risk of skin cancer. For the subset of patients with unilateral lymphedema, the lymphedematous extremity was 2.65 times as likely as the nonlymphedematous LE to have skin cancer, particularly basal cell carcinoma. CONCLUSION Lower extremity lymphedema appears to be a risk factor for squamous cell carcinoma, basal call carcinoma, and as expected, angiosarcoma. Clinicians caring for patients with LE lymphedema should be aware of this increased risk and monitor at-risk patients accordingly.
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Affiliation(s)
- Nimay C Anand
- Meharry Medical College, Nashville, TN, USA; Department of Dermatology, Mayo Clinic, Rochester, MN, USA
| | - Elliott H Campbell
- Department of Dermatology, Mayo Clinic, Rochester, MN, USA; Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN, USA
| | | | - Lawrence E Gibson
- Department of Dermatology, Mayo Clinic, Rochester, MN, USA; Division of Anatomic Pathology, Mayo Clinic, Rochester, MN, USA
| | - Austin Todd
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN, USA
| | - Jennifer L Bradt
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN, USA
| | - Afsaneh Alavi
- Department of Dermatology, Mayo Clinic, Rochester, MN, USA.
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Yoshida S, Imai H, Roh S, Mese T, Koshima I. Cystic Lymphatic Malformation with Lymphedema Treated by Lymphaticovenular Anastomosis Combined with Ethanol Sclerotherapy. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e4871. [PMID: 36936462 PMCID: PMC10022848 DOI: 10.1097/gox.0000000000004871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 01/27/2023] [Indexed: 03/19/2023]
Abstract
The incidence of cystic lymphatic malformation (CL) in an extremity is very rare. CL can be a cause of lymphedema in a lower limb. The most effective treatment for CL is sclerotherapy or excision; however, these treatments have the potential to cause fibrosis and obliteration of ruptured lymphatic vessels, which impairs lymphatic drainage and increases the risk of lymphedema. Lymphaticovenular anastomosis (LVA) combined with sclerotherapy may be a minimally invasive treatment option for CL in a lower limb. In this report, we describe a patient with CL complicated by lymphedema in a lower extremity, who we treated using LVA and ethanol sclerotherapy with satisfactory results. The patient was a 60-year-old man with a CL measuring 16 cm in diameter in the thigh region above the knee with lower limb lymphedema. The percentage of excess volume of the affected lower leg was 24.7%, preoperatively. Combined treatment using LVA with sclerotherapy was performed under general anesthesia. At 2 years after surgery, the reduction of excess volume of affected lower leg between preoperative and postoperative was 85.4%. In our previous report, the same combination therapy was used to treat CL and prevent lymphedema; however, in the present case, it was used to treat CL and lymphedema at one stage. LVA combined with sclerotherapy is a complementary minimally invasive treatment for CL accompanied by lymphedema.
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Affiliation(s)
- Shuhei Yoshida
- From The International Center for Lymphedema, Plastic and reconstructive Surgery, Hiroshima University Hospital, Hiroshima, Japan
| | - Hirofumi Imai
- From The International Center for Lymphedema, Plastic and reconstructive Surgery, Hiroshima University Hospital, Hiroshima, Japan
| | - Solji Roh
- From The International Center for Lymphedema, Plastic and reconstructive Surgery, Hiroshima University Hospital, Hiroshima, Japan
| | - Toshiro Mese
- From The International Center for Lymphedema, Plastic and reconstructive Surgery, Hiroshima University Hospital, Hiroshima, Japan
| | - Isao Koshima
- From The International Center for Lymphedema, Plastic and reconstructive Surgery, Hiroshima University Hospital, Hiroshima, Japan
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A Novel Dressing Composed of Adipose Stem Cells and Decellularized Wharton's Jelly Facilitated Wound Healing and Relieved Lymphedema by Enhancing Angiogenesis and Lymphangiogenesis in a Rat Model. J Funct Biomater 2023; 14:jfb14020104. [PMID: 36826903 PMCID: PMC9960849 DOI: 10.3390/jfb14020104] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 02/08/2023] [Accepted: 02/10/2023] [Indexed: 02/16/2023] Open
Abstract
Lymphedema causes tissue swelling due to the accumulation of lymphatic fluid in the tissue, which delays the process of wound-healing. Developing effective treatment options of lymphedema is still an urgent issue. In this study, we aim to fabricate tissue-engineered moist wound dressings with adipose stem cells (ASCs) and decellularized Wharton's jelly (dWJ) from the human umbilical cord in order to ameliorate lymphedema. Rat ASCs were proliferated and an apparent layer was observed on dWJ at day 7 and 14. A rat tail lymphedema model was developed to evaluate the efficacy of the treatment. Approximately 1 cm of skin near the base of the rat tail was circularly excised. The wounds were treated by secondary healing (control) (n = 5), decellularized Wharton's jelly (n = 5) and ASC-seeded dWJ (n = 5). The wound-healing rate and the tail volume were recorded once a week from week one to week five. Angiogenesis and lymphangiogenesis were assessed by immunochemistry staining with anti-CD31 and anti-LYVE1. The results showed that the wound-healing rate was faster and the tail volume was lesser in the ASC-seeded dWJ group than in the control group. More CD31+ and LYVE-1+ cells were observed at the wound-healing area in the ASC-seeded dWJ group than in the control group. This proves that tissue-engineered moist wound dressings can accelerate wound-healing and reduce lymphedema by promoting angiogenesis and lymphangiogenesis.
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7
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Wu M, Matar DY, Yu Z, Chen Z, Knoedler S, Ng B, Darwish O, Haug V, Friedman L, Orgill DP, Panayi AC. Modulation of Lymphangiogenesis in Incisional Murine Diabetic Wound Healing Using Negative Pressure Wound Therapy. Adv Wound Care (New Rochelle) 2023. [PMID: 36424821 DOI: 10.1089/wound.2022.0074] [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] [Indexed: 11/27/2022] Open
Abstract
Objective: Despite the significant function of lymphatics in wound healing, and frequent clinical use of Negative Pressure Wound Therapy (NPWT), the effect of mechanical force application on lymphangiogenesis remains to be elucidated. We utilize a murine incisional wound healing model to assess the mechanisms of lymphangiogenesis following NPWT. Approach: Dorsal incisional skin wounds were created on diabetic mice (genetically obese leptin receptor-deficient mice [db/db]; n = 30) and covered with an occlusive dressing (Control, n = 15) or NPWT (-125 mmHg, continuous, 24 h for 7 days; NPWT, n = 15). The wounds were macroscopically assessed for 28 days. Tissue was harvested on day 10 for analysis. Qualitative functional analysis of lymphatic drainage was performed on day 28 using Evans Blue staining (n = 2). Results: NPWT increased lymphatic vessel density (40 ± 20 vs. 12 ± 6 podoplanin [PDPN]+ and 25 ± 9 vs. 14 ± 8 lymphatic vessel endothelial receptor 1 [LYVE-1]+) and vessel diameter (28 ± 9 vs. 12 ± 2 μm). Western blotting verified the upregulation of LYVE-1 with NPWT. Leukocyte presence was higher with NPWT (22% ± 3.7% vs. 9.1% ± 4.1% lymphocyte common antigen [CD45]+) and the leukocytes were predominately B cells clustered within vessels (8.8% ± 2.5% vs. 18% ± 3.6% B-lymphocyte antigen CD20 [CD20]+). Macrophage presence was lower in the NPWT group. Lymphatic drainage was increased in the NPWT group, which exhibited greater Evans Blue positivity. Innovation: The lymphangiogenic effects take place independent of macrophage infiltration, appearing to correlate with B cell presence. Conclusion: NPWT promotes lymphangiogenesis in incisional wounds, significantly increasing the lymph vessel density and diameter. This study highlights the potential of NPWT to stimulate lymphatic drainage and wound healing of surgical incisions.
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Affiliation(s)
- Mengfan Wu
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA.,Department of Plastic Surgery, Peking University Shenzhen Hospital, Shenzhen, China
| | - Dany Y Matar
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA.,Department of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Zhen Yu
- Opthalmology Department, Shenzhen Eye Hospital, Shenzhen Key Ophthalmic Laboratory, Jinan University, Shenzhen, China.,Angiogenesis Laboratory, Ophthalmology Department, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA
| | - Ziyu Chen
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Samuel Knoedler
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA.,Department for Plastic Surgery and Hand Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Brian Ng
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA.,Department of Medicine, Saint Louis University School of Medicine, St. Louis, Missouri, USA
| | - Oliver Darwish
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA.,Department of Medicine, California Northstate University College of Medicine, Elk Grove, California, USA
| | - Valentin Haug
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA.,Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Leigh Friedman
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA.,Department of Medicine, Lehigh University, Bethlehem, Pennsylvania, USA.,Department of Medicine, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Dennis P Orgill
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Adriana C Panayi
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA.,Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
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Torgbenu E, Luckett T, Buhagiar MA, Phillips JL. Guidelines Relevant to Diagnosis, Assessment, and Management of Lymphedema: A Systematic Review. Adv Wound Care (New Rochelle) 2023; 12:15-27. [PMID: 35196892 DOI: 10.1089/wound.2021.0149] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Significance: Lymphedema is a common, distressing and debilitating condition with various etiologies. Effective diagnosis, assessment, and management rely on evidence-based clinical practice guidelines ("guidelines"). This study aims to describe and compare international guidelines on lymphedema diagnosis, assessment, and management. Recent Advances: The review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and registered on the International Prospective Register of Systematic Reviews (PROSPERO). Systematic searches of electronic literature databases and the web were completed in December 2020 for lymphedema guidelines published in English since 2000. Quality was assessed using the Appraisal of Guidelines for Research and Evaluation (AGREE)-II reporting checklist. Synthesis took a narrative approach to compare guideline recommendations and associated levels of evidence. Critical Issues: This systematic review of 1,564 articles and 159 web pages yielded 14 guidelines. All guidelines were from high-income countries. Ten focused exclusively on lymphedema, and four on cancer. Most (n = 13) guidelines recommended an integrated medical, psychological assessment, and physical examination, with a limb volume measurement of >10% in the affected limb compared, confirming a lymphedema diagnosis. Recommended management involved Complex Decongestive Therapy (CDT) followed by self-management using skincare, self-lymphatic drainage massage, exercise, and compression. Future Directions: The underlying etiology of lymphedema appeared to make little difference to guideline recommendations regarding care. High-quality guidelines are available to guide lymphedema care. However, their suitability for low-resource settings is unclear.
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Affiliation(s)
- Eric Torgbenu
- Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT), Faculty of Health, University of Technology Sydney, Sydney, Australia.,Department of Physiotherapy and Rehabilitation Sciences, University of Health and Allied Sciences, Ho, Ghana
| | - Tim Luckett
- Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT), Faculty of Health, University of Technology Sydney, Sydney, Australia
| | - Mark A Buhagiar
- Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT), Faculty of Health, University of Technology Sydney, Sydney, Australia.,Catholic Diocese of Parramatta, Parramatta, Australia
| | - Jane L Phillips
- Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT), Faculty of Health, University of Technology Sydney, Sydney, Australia.,School of Nursing, Queensland University of Technology, Brisbane, Australia
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9
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Soft-Tissue Considerations in Shoulder Surgery in the Patient With Lymphedema. J Am Acad Orthop Surg 2022; 30:925-932. [PMID: 35486892 DOI: 10.5435/jaaos-d-21-01136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 03/20/2022] [Indexed: 02/01/2023] Open
Abstract
Lymphedema is a chronic, progressive, and often debilitating condition that results in swelling of the affected tissue. Secondary lymphedema is most commonly recognized by unilateral swelling of the ipsilateral extremity after the treatment of cancer. It is estimated that nearly 1.45 million women suffer from breast cancer-related lymphedema in the United States. The number of patients suffering from upper extremity lymphedema is expected to increase because multimodal treatment of breast cancer increases the long-term survival after diagnosis. Because this population ages, the likelihood of encountering a patient with concurrent lymphedema and shoulder pathology requiring orthopaedic intervention is likely to rise. A patient with an already edematous arm and/or impaired drainage of that arm is likely to have different and more complex intraoperative and postoperative courses than patients with normal lymphatic drainage. Although a lymphedematous arm should not preclude surgical intervention, there are considerations when approaching shoulder surgery in the setting of upper extremity lymphedema that may help mitigate complications and aid the patient in their orthopaedic recovery.
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Borman P, Yaman A, Denizli M, Yüzer A, Terzioğlu F. Complex decongestive therapy in a patient with poliomyelitis, bilateral lymphoedema and a deep wound: a case study. J Wound Care 2022; 31:792-798. [PMID: 36113540 DOI: 10.12968/jowc.2022.31.9.792] [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: 11/11/2022]
Abstract
OBJECTIVE The aim of this case report is to describe the results of complex decongestive therapy (CDT) in a patient with poliomyelitis and bilateral lymphoedema, and to emphasise the effect of CDT on wound healing. METHOD A 48-year-old female patient was given CDT for bilateral grade 3 lymphoedema in the lower extremities and a deep wound on the right foot. She had been diagnosed with poliomyelitis sequela and mobilised with a wheelchair for 26 years. The lymphoedema on both legs and the wound on the right foot sole had been present for five years and eight months, respectively. Detailed wound care had been performed previously upon the green, malodorous infected wound, without healing. The patient received skin care education, manual lymphatic drainage, multilayer bandaging and exercises for 4 weeks in a total of 20 sessions. The improvement was assessed by limb volumes prior to and at the end of the treatments. RESULTS The right and left lower limb volumes were decreased significantly at the end of treatments (3042cm³ (R) and 3165cm³ (L) before versus 2702cm3 (R) and 2401cm3 (L) afterward). The wound size decreased considerably and the green malodorous flow ceased. The patient continued self-massage and self-bandaging after hospital discharge. The control follow-up, one month later, revealed a completely healed wound with maintained volume. CONCLUSION In conclusion CDT for a duration of 4 weeks in a female patient with poliomyelitis, bilateral lymphoedema and an infectious hard-to-heal wound, improved both the lymphoedema and wound healing.
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Affiliation(s)
- Pinar Borman
- University of Health Sciences Ankara City Hospital, Rehabilitation Hospital, Unit of Lymphedema, Ankara, Turkey
| | - Ayşegül Yaman
- Gulhane Education and Research Hospital Department of PMR, Ankara, Turkey
| | - Merve Denizli
- Hendek State Hospital, Department of PMR, Sakarya, Turkey
| | - Ayşe Yüzer
- Kastamonu University Health Sciences Faculty Department of PMR, Kastamonu, Turkey
| | - Füsun Terzioğlu
- Kocaeli Health and Technical University Faculty of Health Sciences, Vice Rector, İzmit, Turkey
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11
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Yang JCS, Hayashi A, Visconti G, Wu SC, Lin WC, Tsai PY, Chien PC, Hsieh CH. Impact of retrograde anastomosis during supermicrosurgical lymphaticovenous anastomosis for cancer-related lower limb lymphedema: A retrospective cohort propensity-score-matched outcome analysis. Int J Surg 2022; 104:106720. [PMID: 35724806 DOI: 10.1016/j.ijsu.2022.106720] [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: 03/08/2022] [Revised: 05/29/2022] [Accepted: 06/14/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND In addition to antegrade anastomosis, retrograde anastomosis has been thought to offer further improvements after lymphaticovenous anastomosis (LVA) by bypassing the retrograde lymphatic flow. However, this concept has yet to be validated. The aim of this study was to determine the impacts on outcomes of performing both retrograde and antegrade anastomosis, as compared to antegrade-only anastomosis for treating lower limb lymphedema. STUDY DESIGN This was a retrospective cohort propensity score-matched study. Eighty-seven patients with gynecologic cancer-related lower limb lymphedema were enrolled, including 58 patients who had received both antegrade and retrograde anastomoses (Group I) and 29 patients who had received antegrade-only anastomoses (Group II) as the control group. LVA was the primary treatment. Patients who had previous LVA, liposuction, or excisional therapy were excluded. Patient characteristics, intraoperative findings, and functional parameters including the ratio of indocyanine green-enhanced and flow-positive lymphatic vessels were recorded. Magnetic resonance volumetry was used for outcome assessments. The primary endpoint was the volume change at 6 months after LVA. RESULTS After matching, a total of 26 patients have remained in each group. All parameters were matched except that Group I still had significantly more median LVA performed compared to Group II (8 [IQR: 5.3-10.0] vs. 5.5 [4.3-6.0], p = 0.001, respectively). Group II showed more post-LVA improvements at six-month and one-year follow-up compared to Group I but without statistically significant differences. CONCLUSION The use of supplementary retrograde anastomoses is discouraged since it may lead to inferior post-LVA outcome compared to antegrade-only anastomoses.
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Affiliation(s)
- Johnson Chia-Shen Yang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan.
| | - Akitatsu Hayashi
- Department of Lymphedema Center, Kameda General Hospital, Chiba, Japan
| | - Giuseppe Visconti
- Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, UOC Chirurgia Plastica, Università Cattolica del "Sacro Cuore" - Fondazione Policlinico Universitario A. Gemelli IRCSS, Rome, Italy
| | - Shao-Chun Wu
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Wei-Che Lin
- Department of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Pei-Yu Tsai
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Peng-Chen Chien
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ching-Hua Hsieh
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
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Kwon HR, Hwang JH, Mun GH, Hyun SH, Moon SH, Lee KH, Choi JY. Predictive role of lymphoscintigraphy undergoing lymphovenous anastomosis in patients with lower extremity lymphedema: a preliminary study. BMC Med Imaging 2021; 21:188. [PMID: 34879819 PMCID: PMC8653590 DOI: 10.1186/s12880-021-00713-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 11/22/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We investigated whether preoperative lymphoscintigraphy could predict the treatment response of unilateral lymphovenous anastomosis (LVA) in patients with lower extremity lymphedema. MATERIALS AND METHODS A total of 17 patients undergoing lymphoscintigraphy subsequent to LVA was included. As qualitative lymphoscintigraphic indicators, ilioinguinal lymph node uptake, main lymphatic vessel, collateral vessel, and four types of dermal backflow patterns (absent; distal only; proximal only; whole lower limb) were evaluated. Lymph node uptake ratio, extremity uptake ratio, and injection site clearance ratio were obtained as quantitative lymphoscintigraphic indicators at 1 and 2-h after injection. To evaluate therapy response, the volume difference ratio of the whole lower limb at 3 months (early response) and 1 year (late response) was measured. Volume difference ratios (continuous variable and binary variable with a cut-off value of zero) were compared according to the lymphoscintigraphic variables. RESULTS The group with whole lower limb dermal backflow had a greater volume change than the other groups (p = 0.047). The group with dermal backflow in the whole lower limb OR only in the distal part had a higher rate of volume reduction than the group with dermal backflow only in the proximal part OR absent (p = 0.050). The 2-h extremity uptake ratio was the only indicator that positively correlated with early and late volume difference ratio (p = 0.016, p = 0.001). The rate of volume decrease at 1 year was high in patients with high 2-h extremity uptake ratio (p = 0.027). As the amount of dermal backflow increases, the postoperative therapeutic effect increases (p = 0.040). CONCLUSIONS Preoperative lymphoscintigraphy is useful to predict both early and late therapy response in patients with lower extremity lymphedema undergoing LVA. Both dermal backflow pattern and extremity uptake ratio may be predictive lymphoscintigraphic indicators.
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Affiliation(s)
- Hye Ryeong Kwon
- Department of Nuclear Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Korea
| | - Ji Hye Hwang
- Department of Physical and Rehabilitation Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Goo-Hyun Mun
- Department of Plastic and Reconstructive Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung Hyup Hyun
- Department of Nuclear Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Korea
| | - Seung Hwan Moon
- Department of Nuclear Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Korea
| | - Kyung-Han Lee
- Department of Nuclear Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Korea
| | - Joon Young Choi
- Department of Nuclear Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Korea.
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13
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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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Rothfusz CA, Emara AK, McLaughlin JP, Molloy RM, Krebs VE, Piuzzi NS. Wound Dressings for Hip and Knee Total Joint Arthroplasty: A Narrative Review. JBJS Rev 2021; 9:01874474-202107000-00011. [PMID: 34270476 DOI: 10.2106/jbjs.rvw.20.00301] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
» Dressing choice following lower-extremity total joint arthroplasty has substantial ramifications for postoperative outcomes and should be carefully made to prevent complications such as periprosthetic joint infection. » Patient risk factors are essential components in the selection of wound dressings in total joint arthroplasty. » Traditional dressings are inexpensive per unit; nevertheless, the associated higher complication profile in patients at a high risk for poor wound healing and sequelae-associated costs may outweigh the up-front savings. » Modern dressings have the potential to yield better safety outcomes and increased patient satisfaction; however, there is a paucity of evidence regarding the ideal interactive dressing. » Active dressings, such as silver-ion dressings and closed-incisional negative-pressure wound therapy, have shown promising results to reduce surgical site and periprosthetic joint infection, especially in patients at a high risk for poor wound healing following hip and knee total joint arthroplasty.
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15
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Yoshida S, Koshima I, Imai H, Uchiki T, Sasaki A, Nagamatsu S, Yokota K. Investigation of flow velocity in recipient perforator artery for a reliable indicator for the flap transfer with perforator to perforator anastomosis. Microsurgery 2021; 41:550-556. [PMID: 34213025 DOI: 10.1002/micr.30783] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 05/26/2021] [Accepted: 06/25/2021] [Indexed: 11/08/2022]
Abstract
INTRODUCTION In flap transfer with perforator to perforator anastomosis (FTPPA), encountering poor pulsation and blood flow in a recipient perforator intraoperatively often makes FTPPA impossible. This study sought to identify color and spectral Doppler ultrasonography (CSDUS) parameters that can aid reliable preoperative selection of a recipient perforator artery. PATIENTS AND METHODS The study enrolled 38 patients with lower extremity lymphedema who underwent vascularized lymphatic tissue transfer with perforator to perforator anastomosis for physiological lymphatic flow reconstruction. In all cases, three candidate recipient perforators were searched in each lower extremities, and vessel diameter and peak systolic flow velocity (PSFV) were measured. The inclusion criteria for candidates were a vessel diameter of >0.5 mm and a PSFV of >10 cm/s. These measures were compared with intraoperative findings, diameters and if there was pulsation and visible spurting evident. RESULTS A total of 114 candidates were selected, and 52 of the candidates were dissected until suitable perforators were found. PSFV (cm/s) on CSDUS was ≥20.0 in 32 perforators (84.2%) and was 15.0-19.9 in 6 perforators (15.8%) in the group with pulsation and visible spurting evident, and 15.0-19.9 in one perforator (7.1%) and ≤ 14.9 in 13 perforators (92.9%) in the group without pulsation and visible spurting evident. There was a statistically significant correlation between preoperative PSFV and intraoperative pulsation and visible spurting evident after dissection (P = 0.021 × 10-3 ). The flap survival rate was 92.1%. CONCLUSION PSFV is an important preoperative determinant of the suitability of a recipient perforator artery for FTPPA.
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Affiliation(s)
- Shuhei Yoshida
- The International Center for Lymphedema, Hiroshima University Hospital, Hiroshima, Japan
| | - Isao Koshima
- The International Center for Lymphedema, Hiroshima University Hospital, Hiroshima, Japan
| | - Hirofumi Imai
- The International Center for Lymphedema, Hiroshima University Hospital, Hiroshima, Japan
| | - Toshio Uchiki
- Plastic and Reconstructive Surgery, Hiroshima University, Hiroshima, Japan
| | - Ayano Sasaki
- Plastic and Reconstructive Surgery, Hiroshima University, Hiroshima, Japan
| | - Shogo Nagamatsu
- Plastic and Reconstructive Surgery, Hiroshima University, Hiroshima, Japan
| | - Kazunori Yokota
- Plastic and Reconstructive Surgery, Hiroshima University, Hiroshima, Japan
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16
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Cigna E, Pierazzi DM, Sereni S, Marcasciano M, Losco L, Bolletta A. Lymphatico-venous anastomosis in chronic ulcer with venous insufficiency: A case report. Microsurgery 2021; 41:574-578. [PMID: 33991012 DOI: 10.1002/micr.30753] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 02/08/2021] [Accepted: 05/06/2021] [Indexed: 12/31/2022]
Abstract
Patients presenting with chronic wounds in venous insufficiency often represent a challenge, like other conditions, like lymphatic impairment, may complicate the wound healing process. The purpose of this report is to highlight how the treatment of lymphatic impairment may be beneficial in patients affected by chronic ulcers with concomitant venous insufficiency. We present the case of a 78-year-old woman affected by chronic venous insufficiency (CVI) with long-lasting ulcers secondary to sclerosing agents treatment for varicose veins. The patient's condition was refractory to both conservative and surgical treatment. Since the patient also presented with severe lymphorrhea, with a significant amount of daily secretion, ICG-lymphography was performed subcutaneously, to visualize the pathway of lymphatic drainage and leakage. It also allowed marking on the skin the exact location of lymphatic vessels distally to the wound area. Hence, two lymphatico-venous anastomoses were performed between the two major collecting lymphatic vessels and two subcutaneous veins of adequate size. The postoperative course was uneventful and the procedure allowed for immediate resolution of lymphatic leakage and complete wound healing within 2 weeks with no recurrence in the follow-up time of 1.5 years. Based on the outcomes of this case, it is possible to consider the use of CVI treatment and lymphedema surgery as a combined approach to complicated cases of long-standing venous ulcers with lymphorrhea.
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Affiliation(s)
- Emanuele Cigna
- Plastic Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Diletta Maria Pierazzi
- Plastic Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Simone Sereni
- Plastic Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Marco Marcasciano
- Plastic Surgery Unit, Department of surgery, Sapienza University of Rome, Rome, Italy
| | - Luigi Losco
- Plastic Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Alberto Bolletta
- Plastic Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
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Chávez MN, Fuchs B, Moellhoff N, Hofmann D, Zhang L, Selão TT, Giunta RE, Egaña JT, Nickelsen J, Schenck TL. Use of photosynthetic transgenic cyanobacteria to promote lymphangiogenesis in scaffolds for dermal regeneration. Acta Biomater 2021; 126:132-143. [PMID: 33753313 DOI: 10.1016/j.actbio.2021.03.033] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 02/28/2021] [Accepted: 03/15/2021] [Indexed: 02/06/2023]
Abstract
Impaired wound healing represents an unsolved medical need with a high impact on patients´ quality of life and global health care. Even though its causes are diverse, ischemic-hypoxic conditions and exacerbated inflammation are shared pathological features responsible for obstructing tissue restoration. In line with this, it has been suggested that promoting a normoxic pro-regenerative environment and accelerating inflammation resolution, by reinstating the lymphatic fluid transport, could allow the wound healing process to be resumed. Our group was first to demonstrate the functional use of scaffolds seeded with photosynthetic microorganisms to supply tissues with oxygen. Moreover, we previously proposed a photosynthetic gene therapy strategy to create scaffolds that deliver other therapeutic molecules, such as recombinant human growth factors into the wound area. In the present work, we introduce the use of transgenic Synechococcus sp. PCC 7002 cyanobacteria (SynHA), which can produce oxygen and lymphangiogenic hyaluronic acid, in photosynthetic biomaterials. We show that the co-culture of lymphatic endothelial cells with SynHA promotes their survival and proliferation under hypoxic conditions. Also, hyaluronic acid secreted by the cyanobacteria enhanced their lymphangiogenic potential as shown by changes to their gene expression profile, the presence of lymphangiogenic protein markers and their capacity to build lymph vessel tubes. Finally, by seeding SynHA into collagen-based dermal regeneration materials, we developed a viable photosynthetic scaffold that promotes lymphangiogenesis in vitro under hypoxic conditions. The results obtained in this study lay the groundwork for future tissue engineering applications using transgenic cyanobacteria that could become a therapeutic alternative for chronic wound treatment. STATEMENT OF SIGNIFICANCE: In this study, we introduce the use of transgenic Synechococcus sp. PCC 7002 (SynHA) cyanobacteria, which were genetically engineered to produce hyaluronic acid, to create lymphangiogenic photosynthetic scaffolds for dermal regeneration. Our results confirmed that SynHA cyanobacteria maintain their photosynthetic capacity under standard human cell culture conditions and efficiently proliferate when seeded inside fibrin-collagen scaffolds. Moreover, we show that SynHA supported the viability of co-cultured lymphatic endothelial cells (LECs) under hypoxic conditions by providing them with photosynthetic-derived oxygen, while cyanobacteria-derived hyaluronic acid stimulated the lymphangiogenic capacity of LECs. Since tissue hypoxia and impaired lymphatic drainage are two key factors that directly affect wound healing, our results suggest that lymphangiogenic photosynthetic biomaterials could become a treatment option for chronic wound management.
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Affiliation(s)
- Myra N Chávez
- Molecular Plant Science, Department Biology I, LMU Munich, Munich, Germany
| | - Benedikt Fuchs
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Nicholas Moellhoff
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Daniel Hofmann
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Lifang Zhang
- School of Biological Sciences, Nanyang Technological University, Singapore, Singapore
| | - Tiago Toscano Selão
- School of Biological Sciences, Nanyang Technological University, Singapore, Singapore
| | - Riccardo E Giunta
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Munich, Germany
| | - José Tomás Egaña
- Institute for Biological and Medical Engineering, Schools of Engineering, Biological Sciences and Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Jörg Nickelsen
- Molecular Plant Science, Department Biology I, LMU Munich, Munich, Germany; School of Biological Sciences, Nanyang Technological University, Singapore, Singapore
| | - Thilo L Schenck
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Munich, Germany; Frauenklinik Dr. Geisenhofer, Munich, Germany.
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Pawar KB, Desai S, Bhonde RR, Bhole RP, Deshmukh AA. Wound with Diabetes: Present Scenario and Future. Curr Diabetes Rev 2021; 17:136-142. [PMID: 32619172 DOI: 10.2174/1573399816666200703180137] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 06/12/2020] [Accepted: 06/18/2020] [Indexed: 11/22/2022]
Abstract
Diabetes is a chronic metabolic disorder of the endocrine system characterized by an increase in blood glucose level. Several factors, such as pancreatic damage, oxidative stress, infection, genetic factor, obesity, liver dysfunction, play a vital role in the pathogenesis of diabetes, which further leads to serious diabetic complications. The diabetic wound is one such complication where the wound formation occurs, especially due to pressure and its healing process is disrupted due to factors, such as hyperglycemia, neuropathy, nephropathy, peripheral vascular disease, reduction of blood flow, atherosclerosis, impaired fibroblast. The process of wound healing is delayed due to different abnormalities like alteration in nitric oxide level, increase in aldose reductase, sorbitol, and fructose. Therefore, diabetic wound requires more time to heal as compared to the normal wound. Healing time is delayed in diabetic wound due to many factors, such as stress, decreased oxygenation supply, infection, decreased blood flow, impaired proliferation and migration rate, impaired growth factor production, impaired keratinocytes proliferation and migration, and altered vascular endothelial mediators. The current treatment for diabetic wounds includes wound patches, oxygenation therapy, hydrogel patches, gene therapy, laser therapy, and stem cell therapy. Medications with phytoconstituents are also one way to manage the diabetic wound, but it is not more effective for quick healing. The objective of this review is to understand the potential of various management options which are available for diabetic wound, with a special focus on biological cells.
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Affiliation(s)
- Kuldeep B Pawar
- Department of Pharmacology, Dr. D.Y. Patil Institute of Pharmaceutical Sciences and Research, Pune, India
| | - Shivani Desai
- Department of Pharmacology, Dr. D.Y. Patil Institute of Pharmaceutical Sciences and Research, Pune, India
| | | | - Ritesh P Bhole
- Department of Pharmaceutical Chemistry, Dr. D.Y. Patil Institute of Pharmaceutical Sciences and Research, Pune, India
| | - Atul A Deshmukh
- Department of Pharmacology, Dr. D.Y. Patil Institute of Pharmaceutical Sciences and Research, Pune, India
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Role of microRNAs in Pressure Ulcer Immune Response, Pathogenesis, and Treatment. Int J Mol Sci 2020; 22:ijms22010064. [PMID: 33374656 PMCID: PMC7793489 DOI: 10.3390/ijms22010064] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 12/16/2020] [Accepted: 12/22/2020] [Indexed: 02/07/2023] Open
Abstract
Pressure ulcers are preventable, yet highly prevalent, chronic wounds that have significant patient morbidity and high healthcare costs. Like other chronic wounds, they are characterized by impaired wound healing due to dysregulated immune processes. This review will highlight key biochemical pathways in the pathogenesis of pressure injury and how this signaling leads to impaired wound healing. This review is the first to comprehensively describe the current literature on microRNA (miRNA, miR) regulation of pressure ulcer pathophysiology.
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20
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Shimbo K, Okuhara Y, Yokota K. Hybrid Treatment Combining Lymphaticovenous Anastomoses and the Oriental Herbal Medicine Bofutsushosan for Obesity-Associated Lower Leg Elephantiasis Nostras Verrucosa: A Case Report. INT J LOW EXTR WOUND 2020; 20:282-284. [PMID: 32519905 DOI: 10.1177/1534734620932802] [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] [Indexed: 11/16/2022]
Abstract
Elephantiasis nostras verrucosa (ENV) is a rare dermatological disease associated with chronic lymphedema caused by obesity, soft tissue infection, or chronic venous insufficiency. Although surgical debridement may be sufficient to treat the skin manifestations of ENV, treatment of ENV should focus on reducing lymph stasis to improve the skin changes and prevent recurrence. In this case report, we present the case of a 79-year-old woman who developed obesity-associated ENV in the lower leg. She was successfully treated by a combination of lymphaticovenous anastomoses and the oriental herbal medicine Bofutsushosan. To our knowledge, this is the first reported obesity-associated ENV case in which skin pathology was not only healed, but both edema relief and weight loss were successful. A treatment combining both surgery and the herbal medicine could be a potential therapeutic candidate for obesity-associated ENV.
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Yoshida S, Hamada Y, Koshima I, Imai H, Uchiki T, Sasaki A, Fujioka Y, Nagamatsu S, Yokota K, Harima M, Yamashita S. Role of lymphatico venular anastomosis for treatment of lymphorrhea in lower limbs. J Plast Reconstr Aesthet Surg 2020; 73:1357-1404. [PMID: 32113962 DOI: 10.1016/j.bjps.2020.02.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 10/07/2019] [Accepted: 02/08/2020] [Indexed: 11/19/2022]
Affiliation(s)
- Shuhei Yoshida
- The International Center for Lymphedema, Hiroshima University Hospital, Hiroshima, Japan.
| | - Yuichi Hamada
- Plastic and Reconstructive Surgery, Japanese Red Cross Fukuoka Hospital, Japan
| | - Isao Koshima
- The International Center for Lymphedema, Hiroshima University Hospital, Hiroshima, Japan
| | - Hirofumi Imai
- The International Center for Lymphedema, Hiroshima University Hospital, Hiroshima, Japan
| | - Toshio Uchiki
- Plastic and Reconstructive Surgery, Japanese Red Cross Fukuoka Hospital, Japan
| | - Ayano Sasaki
- Department of Plastic Surgery, Hiroshima University Hospital, Hiroshima, Japan
| | - Yumio Fujioka
- Department of Plastic Surgery, Hiroshima University Hospital, Hiroshima, Japan
| | - Shogo Nagamatsu
- Department of Plastic Surgery, Hiroshima University Hospital, Hiroshima, Japan
| | - Kazunori Yokota
- Department of Plastic Surgery, Hiroshima University Hospital, Hiroshima, Japan
| | - Mitsunobu Harima
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Shuji Yamashita
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Yoshida S, Koshima I, Imai H, Uchiki T, Sasaki A, Fujioka Y, Nagamatsu S, Yokota K, Harima M, Yamashita S, Tashiro K. Characteristics and outcomes of lymphaticovenular anastomosis in older patients with bilateral involvement versus younger patients with unilateral involvement in lower extremity lymphedema. J Vasc Surg Venous Lymphat Disord 2019; 8:646-657. [PMID: 31843479 DOI: 10.1016/j.jvsv.2019.10.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 10/10/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE We have previously reported that patients with idiopathic primary lymphedema of adult onset can be classified into an older group with bilateral involvement and a younger group with unilateral involvement and that there are significant differences in the characteristics of these groups. The aims of this study were to investigate the features of these two groups further by evaluating the lymphatics while performing lymphaticovenular anastomosis (LVA) and to compare the effectiveness of LVA between the two groups. METHODS This study enrolled 74 patients (136 edematous legs) in whom indocyanine green (ICG) lymphography and LVA were performed. The rate of detection and the diameter of the lymphatic vessels were recorded. The lower extremity lymphedema index (the total sum of the squares of the circumference for five areas in each leg divided by the body mass index) was obtained before and 6 months after LVA. The rate of improvement in the affected lower limbs after LVA was also calculated. RESULTS The clinical lymphedema pattern was determined to be bilateral in 62 patients and unilateral in 12. Patients with bilateral lymphedema were significantly older than those with unilateral lymphedema (77.1 ± 7.8 years vs 55.5 ± 12.77 years; P < .01). A linear pattern was seen in 23 patients (46 legs), a low enhancement (LE) pattern in 12 patients (24 legs), a distal dermal backflow (dDB) pattern in 20 patients (40 legs), and an extended dermal backflow (eDB) pattern in 7 patients (14 legs). The lymphedema was unilateral in 12 patients (12 legs). There were significant between-group differences in lymphatic diameter in relation to lower leg area: linear (0.9 ± 0.1 mm) vs dDB (0.7 ± 0.2 mm), linear vs eDB (0.7 ± 0.2 mm), linear vs unilateral (0.5 ± 0.1 mm), LE (0.9 ± 0.2 mm) vs dDB, LE vs eDB, LE vs unilateral, and dDB vs unilateral, P < .01; and eDB vs unilateral, P < .05. There were also significant between-group differences in the rate of improvement in the lower extremity lymphedema index according to the ICG lymphography pattern and laterality: linear (10.5% ± 2.4%) vs unilateral (6.7% ± 0.6%), LE (10.4% ± 1.5%) vs unilateral, dDB (11.0% ± 1.3%) vs eDB (8.9% ± 1.5%), and dDB vs unilateral, P < .01; linear vs eDB, P < .05; and eDB vs unilateral, P < .05. CONCLUSIONS The lymphatic vessel diameter tended to be greater in older patients with bilateral lymphedema than in younger patients with unilateral lymphedema. The rate of detection and improvement tended to decrease with worsening of the ICG lymphography pattern. LVA is thought to be more effective in older patients with early-stage bilateral lower leg lymphedema than in their younger counterparts with late-stage unilateral lymphedema.
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Affiliation(s)
- Shuhei Yoshida
- International Center for Lymphedema, Hiroshima University, Hiroshima, Japan.
| | - Isao Koshima
- International Center for Lymphedema, Hiroshima University, Hiroshima, Japan
| | - Hirofumi Imai
- International Center for Lymphedema, Hiroshima University, Hiroshima, Japan
| | - Toshio Uchiki
- Department of Plastic and Reconstructive Surgery, Hiroshima University, Hiroshima, Japan
| | - Ayano Sasaki
- Department of Plastic and Reconstructive Surgery, Hiroshima University, Hiroshima, Japan
| | - Yumio Fujioka
- Department of Plastic and Reconstructive Surgery, Hiroshima University, Hiroshima, Japan
| | - Shogo Nagamatsu
- Department of Plastic and Reconstructive Surgery, Hiroshima University, Hiroshima, Japan
| | - Kazunori Yokota
- Department of Plastic and Reconstructive Surgery, Hiroshima University, Hiroshima, Japan
| | - Mitsunobu Harima
- Department of Plastic and Reconstructive Surgery, Tokyo University, Tokyo, Japan
| | - Shuji Yamashita
- Department of Plastic and Reconstructive Surgery, Tokyo University, Tokyo, Japan
| | - Kensuke Tashiro
- Department of Plastic and Reconstructive Surgery, Jichi Medical University, Tochigi, Japan
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23
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Yoshida S, Koshima I, Imai H, Uchiki T, Sasaki A, Fujioka Y, Nagamatsu S, Yokota K, Harima M, Yamashita S. Localized lymphedema after treatment for soft tissue sarcoma in the lower limbs: Comparison of improvement according to duration before lymphaticovenular anastomosis. Clin Case Rep 2019; 7:1534-1538. [PMID: 31428383 PMCID: PMC6692988 DOI: 10.1002/ccr3.2278] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 05/25/2019] [Accepted: 05/29/2019] [Indexed: 11/09/2022] Open
Abstract
Surgically invasive procedures involving the medial knee and inguinal regions can cause lymphedema. Lymphaticovenular anastomosis (LVA) could improve volume reduction and decrease the risk of cellulitis. However, it may be preferable to performed LVA as early as possible to achieve optimal results.
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Affiliation(s)
- Shuhei Yoshida
- The International Center for LymphedemaHiroshima University HospitalHiroshimaJapan
| | - Isao Koshima
- The International Center for LymphedemaHiroshima University HospitalHiroshimaJapan
| | - Hirofumi Imai
- The International Center for LymphedemaHiroshima University HospitalHiroshimaJapan
| | - Toshio Uchiki
- Plastic and reconstructive SurgeryHiroshima UniversityHiroshimaJapan
| | - Ayano Sasaki
- Plastic and reconstructive SurgeryHiroshima UniversityHiroshimaJapan
| | - Yumio Fujioka
- Plastic and reconstructive SurgeryHiroshima UniversityHiroshimaJapan
| | - Shogo Nagamatsu
- Plastic and reconstructive SurgeryHiroshima UniversityHiroshimaJapan
| | - Kazunori Yokota
- Plastic and reconstructive SurgeryHiroshima UniversityHiroshimaJapan
| | | | - Shuji Yamashita
- Plastic and Reconstructive SurgeryTokyo UniversityTokyoJapan
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