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Gabriele G, Nigri A, Chisci G, Massarelli O, Cascino F, Komorowska-Timek E, Kazuki K, Hara H, Mihara M, Gennaro P. Combination of Supramicrosurgical Lymphatico-Venular Anastomosis (sLVA) and Lymph-Sparing Liposuction in Treating Cancer-Related Lymphedema: Rationale for a Regional One-Stage Approach. J Clin Med 2024; 13:2872. [PMID: 38792415 PMCID: PMC11121812 DOI: 10.3390/jcm13102872] [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: 04/24/2024] [Revised: 05/06/2024] [Accepted: 05/10/2024] [Indexed: 05/26/2024] Open
Abstract
Objective: Cancer-related lymphedema represents a potential complication of cancer treatment. The aim of this study is to evaluate the effectiveness of the combination of lymphatico-venular anastomosis and liposuction in the treatment of secondary lymphedema. Methods: We present a retrospective analysis of patients affected by cancer-related unilateral limb lymphedema. Inclusion criteria included previous neoplastic pathology with the consequent development of unilateral limb lymphedema, while the exclusion criteria included the presence of comorbidities and the persistence of cancer, as well as previous lymphatic surgery. The outcomes to be included were a reduction in the limb volume and lymphangitis rate, and an improvement in the quality of life. Patients' data were assessed before surgery and 1 year after surgery. Perioperative management included clinical and ultrasonographical evaluations. Under local anesthesia, lymphatico-venular anastomosis with the supramicrosurgical technique and the liposuction of the affected limb was performed in the same surgical session. Results: A total of 24 patients were enrolled in the study. One year after the surgery, an average volume reduction of 37.9% was registered (p = 0.0000000596). The lymphangitis rate decreased after surgery from 4.67 to 0.95 per year (p = 0.000007899). The quality-of-life score improved from 68.7 to 16 according to the LLIS scale. Conclusions: The combination of LVA and liposuction represents a valid strategy for treating cancer-related lymphedema, ensuring stable results over time. In addition, it can be performed under local anesthesia, resulting in being minimally invasive and well-tolerated by patients. This paper reports on the short-term efficacy of this combined technique.
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Affiliation(s)
- Guido Gabriele
- Department of Maxillo-Facial Surgery, Faculty of Medicine and Surgery, University of Siena, 53100 Siena, Italy; (O.M.); (F.C.); (P.G.)
| | - Andrea Nigri
- Department of Economics, Management and Territory, University of Foggia, 71122 Foggia, Italy;
| | - Glauco Chisci
- Oral Surgery School, Department of Medical Biotechnologies, University of Siena, Via Ricasoli 18, 58100 Grosseto, Italy
| | - Olindo Massarelli
- Department of Maxillo-Facial Surgery, Faculty of Medicine and Surgery, University of Siena, 53100 Siena, Italy; (O.M.); (F.C.); (P.G.)
| | - Flavia Cascino
- Department of Maxillo-Facial Surgery, Faculty of Medicine and Surgery, University of Siena, 53100 Siena, Italy; (O.M.); (F.C.); (P.G.)
| | - Ewa Komorowska-Timek
- Advanced Plastic Surgery, Michigan State University, East Lansing, MI 48502, USA;
| | - Kikuchi Kazuki
- Department of Plastic Surgery, Nadogaya Hospital, 2-1-1 Shinkasiwa, Kashiwa 277-0084, Japan; (K.K.); (H.H.); (M.M.)
| | - Hisako Hara
- Department of Plastic Surgery, Nadogaya Hospital, 2-1-1 Shinkasiwa, Kashiwa 277-0084, Japan; (K.K.); (H.H.); (M.M.)
| | - Makoto Mihara
- Department of Plastic Surgery, Nadogaya Hospital, 2-1-1 Shinkasiwa, Kashiwa 277-0084, Japan; (K.K.); (H.H.); (M.M.)
| | - Paolo Gennaro
- Department of Maxillo-Facial Surgery, Faculty of Medicine and Surgery, University of Siena, 53100 Siena, Italy; (O.M.); (F.C.); (P.G.)
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Karlsson T, Hoffner M, Ohlin K, Svensson B, Brorson H. Complete Reduction of Leg Lymphedema after Liposuction: A 5-Year Prospective Study in 67 Patients without Recurrence. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5429. [PMID: 38074499 PMCID: PMC10703118 DOI: 10.1097/gox.0000000000005429] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 10/05/2023] [Indexed: 09/07/2024]
Abstract
BACKGROUND Lymphedema leads to adipose tissue deposition that cannot be removed using conservative methods. Previous studies have shown a complete reduction in excess volume in limbs with lymphedema when treated with liposuction and controlled compression therapy (CCT). We present the long-term outcomes of all patients treated with liposuction and CCT for lower extremity lymphedema (LEL) who were followed up for 5 years. METHODS Sixty-seven LEL patients underwent liposuction and CCT. Thirty-six patients had primary lymphedema and 31 patients had secondary lymphedema. The outcomes included excess leg volume over a follow-up period of 5 years. Any association between patient characteristics and treatment outcomes was analyzed. RESULTS The preoperative excess volume prior was 3515 mL [interquartile range (IQR): 2225-5455 mL], and the volume ratio to the unaffected leg was 1.35 (IQR: 1.25-1.53). One year after treatment, the excess volume decreased by 101% (IQR: 84-116). The decrease in excess volume continued during the 5-year follow-up, and at the end of the study, the excess volume had decreased by 115% (IQR: 98-124). No major complications were noted. CONCLUSIONS Liposuction and CCT are safe and effective procedures for removing excess adipose tissue and normalizing the leg volume in patients with late-stage LEL. When no satisfactory results are obtained with conservative methods, such as complex decongestive therapy, and there is no or minimal pitting on limb examination, excess adipose tissue is present, and liposuction can be considered.
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Affiliation(s)
- Tobias Karlsson
- From the Department of Clinical Sciences, Malmö, Lund University, Lund, Sweden
- Australian Lymphoedema Education Research Treatment (ALERT) Program, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
- Department of Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, Sweden
| | - Mattias Hoffner
- From the Department of Clinical Sciences, Malmö, Lund University, Lund, Sweden
- Department of Surgery, Blekinge Hospital, Karlskrona, Sweden
| | - Karin Ohlin
- Department of Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, Sweden
| | - Barbro Svensson
- Department of Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, Sweden
| | - Håkan Brorson
- From the Department of Clinical Sciences, Malmö, Lund University, Lund, Sweden
- Department of Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, Sweden
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Ciudad P, Escandón JM, Manrique OJ, Bustos VP. Lessons Learnt from an 11-year Experience with Lymphatic Surgery and a Systematic Review of Reported Complications: Technical Considerations to Reduce Morbidity. Arch Plast Surg 2022; 49:227-239. [PMID: 35832669 PMCID: PMC9045509 DOI: 10.1055/s-0042-1744412] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Complications experienced during lymphatic surgery have not been ubiquitously reported, and little has been described regarding how to prevent them. We present a review of complications reported during the surgical management of lymphedema and our experience with technical considerations to reduce morbidity from lymphatic surgery. A comprehensive search across different databases was conducted through November 2020. Based on the complications identified, we discussed the best approach for reducing the incidence of complications during lymphatic surgery based on our experience. The most common complications reported following lymphovenous anastomosis were re-exploration of the anastomosis, venous reflux, and surgical site infection. The most common complications using groin vascularized lymph node transfer (VLNT), submental VLNT, lateral thoracic VLNT, and supraclavicular VLNT included delayed wound healing, seroma and hematoma formation, lymphatic fluid leakage, iatrogenic lymphedema, soft-tissue infection, venous congestion, marginal nerve pseudoparalysis, and partial flap loss. Regarding intra-abdominal lymph node flaps, incisional hernia, hematoma, lymphatic fluid leakage, and postoperative ileus were commonly reported. Following suction-assisted lipectomy, significant blood loss and transient paresthesia were frequently reported. The reported complications of excisional procedures included soft-tissue infections, seroma and hematoma formation, skin-graft loss, significant blood loss, and minor skin flap necrosis. Evidently, lymphedema continues to represent a challenging condition; however, thorough patient selection, compliance with physiotherapy, and an experienced surgeon with adequate understanding of the lymphatic system can help maximize the safety of lymphatic surgery.
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Affiliation(s)
- Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
- Academic Department of Surgery, School of Medicine Hipolito Unanue, Federico Villarreal National University, Lima, Perú
| | - Joseph M. Escandón
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York
| | - Oscar J. Manrique
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York
| | - Valeria P. Bustos
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical University, Boston, Massachusetts
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Liposuction in cancer-related lower extremity lymphedema: an investigative study on clinical applications. World J Surg Oncol 2022; 20:6. [PMID: 34986860 PMCID: PMC8729041 DOI: 10.1186/s12957-021-02472-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 12/13/2021] [Indexed: 01/26/2023] Open
Abstract
Background Lymphedema is a progressive, noncurable condition consisting of increases in subcutaneous fat and interstitial fluid in the limbs and fibrosis during later stages. The disease most commonly affects the limbs following injury to or removal of the lymph nodes. The aim of this study was to investigate the therapeutic outcomes of liposuction for cancer-related lower extremity lymphedema. Methods Sixty-two patients with cancer-related lymphedema in the unilateral lower extremity were recruited for this study, and all patients underwent liposuction. The volume of hemorrhage and lipids, the operation time, and the volume changes of the affected extremity were compared by applying the t tests, and the subjective feelings of patients were compared with the chi-square tests. Results The total lipid volume was 2539 ± 1253.5 ml, and the hemorrhage volume was 828 ± 311.8 ml. For the comparison of objective indices, (1) the percent volume differences (PVDs) before surgery, intraoperatively, and at the 3-month follow-up were 5.5 ± 12.2 vs. 11.6 ± 18.4 vs. 43.2 ± 23.7, P < 0.05, respectively; (2) greater lipid volumes and higher liposuction rates were observed for female patients, as was a smaller volume of hemorrhage; (3) greater hemorrhage volumes were observed in patients with a history of recurrent erysipelas; and (4) greater lipid volumes and liposuction rates (LRs) and smaller hemorrhage volumes were observed for stage II than for stage III patients. Conclusions Liposuction is an effective therapy for cancer-related lower extremity lymphedema. Sex, stage, and recurrent erysipelas history influence the course and effect of liposuction.
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Stephen E. Lymphedema – The stepchild of vascular surgeons. INDIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2022. [DOI: 10.4103/ijves.ijves_48_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Chollet C, Malloizel-Delaunay J, Cabarrou B, Chantalat E, Leray H, Garmy-Susini B, Yannoutsos A, Chaput B, Vaysse C. Liposuction-assisted brachioplasty in breast cancer-related lymphedema: Impact on volume reduction and quality of life. J Plast Reconstr Aesthet Surg 2021; 74:1633-1701. [DOI: 10.1016/j.bjps.2020.11.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 10/30/2020] [Accepted: 11/22/2020] [Indexed: 10/22/2022]
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Chen WF, Tuncer FB, Zeng W. Advanced Technical Pearls for Successful Supermicrosurgical Lymphaticovenular Anastomosis. Ann Plast Surg 2021; 86:S165-S172. [PMID: 33443891 DOI: 10.1097/sap.0000000000002689] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
ABSTRACT Lymphaticovenular anastomosis (LVA) is now accepted as one of the mainstays of surgical treatment of lymphedema. The unique advantages of LVA that set it apart from other procedures such as vascularized lymph node transfer are its safety and its minimally invasive nature. To date, there has been no report of worsening of disease as a result of LVA, even when performed unsuccessfully. Despite these notable advantages, the procedure is much less frequently performed compared with vascularized lymph node transfer because of inconsistent procedural outcome. In our experience, LVA is highly effective when performed with proper patient selection and meticulous technical execution. In this article, we share the senior author's LVA "tips and tricks" to help readers achieve greater success when performing this extraordinary supermicrosurgical procedure.
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Affiliation(s)
- Wei F Chen
- From the Center for Lymphedema Research and Reconstruction, Department of Plastic Surgery, Cleveland Clinic, Cleveland, OH
| | - Fatma Betul Tuncer
- From the Center for Lymphedema Research and Reconstruction, Department of Plastic Surgery, Cleveland Clinic, Cleveland, OH
| | - Weifeng Zeng
- Division of Plastic Surgery, Department of Surgery, University of Wisconsin, Madison, WI
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Knackstedt R, Chen WF. Reply to: 'Liposuction-assisted brachioplasty in breast cancer-related lymphedema: Impact on volume reduction and quality of life'. J Plast Reconstr Aesthet Surg 2020; 74:1633-1701. [PMID: 32891552 DOI: 10.1016/j.bjps.2020.02.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 02/24/2020] [Indexed: 11/17/2022]
Affiliation(s)
- Rebecca Knackstedt
- Department of Plastic Surgery, Cleveland Clinic, 2049 E. 100th Street, Mail Code A 60, Cleveland, OH 44195, United States
| | - Wei F Chen
- Department of Plastic Surgery, Cleveland Clinic, 2049 E. 100th Street, Mail Code A 60, Cleveland, OH 44195, United States.
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Azhar SH, Lim HY, Tan BK, Angeli V. The Unresolved Pathophysiology of Lymphedema. Front Physiol 2020; 11:137. [PMID: 32256375 PMCID: PMC7090140 DOI: 10.3389/fphys.2020.00137] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 02/11/2020] [Indexed: 12/29/2022] Open
Abstract
Lymphedema is the clinical manifestation of impaired lymphatic transport. It remains an under-recognized and under-documented clinical condition that still lacks a cure. Despite the substantial advances in the understanding of lymphatic vessel biology and function in the past two decades, there are still unsolved questions regarding the pathophysiology of lymphedema, especially in humans. As a consequence of impaired lymphatic drainage, proteins and lipids accumulate in the interstitial space, causing the regional tissue to undergo extensive and progressive architectural changes, including adipose tissue deposition and fibrosis. These changes are also associated with inflammation. However, the temporal sequence of these events, the relationship between these events, and their interplay during the progression are not clearly understood. Here, we review our current knowledge on the pathophysiology of lymphedema derived from human and animal studies. We also discuss the possible cellular and molecular mechanisms involved in adipose tissue and collagen accumulation during lymphedema. We suggest that more studies should be dedicated to enhancing our understanding of the human pathophysiology of lymphedema to pave the way for new diagnostic and therapeutic avenues for this condition.
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Affiliation(s)
- Syaza Hazwany Azhar
- Department of Microbiology and Immunology, Life Science Institute, Yoon Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Hwee Ying Lim
- Department of Microbiology and Immunology, Life Science Institute, Yoon Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Bien-Keem Tan
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Singapore General Hospital, Singapore, Singapore
| | - Veronique Angeli
- Department of Microbiology and Immunology, Life Science Institute, Yoon Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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