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Nuwayhid R, Langer S, von Dercks N. [Cost comparison of conservative vs. surgical treatment of chronic lymphedema]. CHIRURGIE (HEIDELBERG, GERMANY) 2024:10.1007/s00104-024-02123-9. [PMID: 38940836 DOI: 10.1007/s00104-024-02123-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/07/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND Lymphedema is primarily treated conservatively using complex physical decongestion treatment (CDT). Lymphovenous anastomosis (LVA), vascularized lymph node transplantation (VLNT) and liposuction are available as surgical treatment methods; however, reimbursement in the diagnosis-related groups (DRG) system is sometimes inadequate or only possible following an individual application. The costs of these relatively new surgical procedures have not yet been set in relation to those of CDT. METHOD The costs of conservative treatment were determined in accordance with the guidelines. The costs for LVA, VLNT and liposuction of the upper and lower extremities were estimated on the basis of the DRG reimbursement per case and the expected reduction in conservative measures according to current knowledge. The annual treatment costs were then compared. RESULTS The annual treatment costs of LVA and VLNT are already lower than conservative treatment alone in the second postoperative year. Liposuction reaches this point in the 6th (upper extremity) or 47th postoperative year (lower extremity). CONCLUSION The evidence for the positive effects of lymphatic surgery is still limited; however, it is recognizable that the curative surgical approach can significantly reduce the treatment costs and improve the quality of life of lymphedema patients; however, there is a lack of adequate reflection of the surgical effort in the reimbursement.
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Affiliation(s)
- Rima Nuwayhid
- Klinik für Orthopädie, Unfallchirurgie und Plastische Chirurgie, Universitätsklinikum Leipzig AöR, Liebigstraße 20, 04103, Leipzig, Deutschland.
| | | | - Nikolaus von Dercks
- Bereich Medizinmanagement, Universitätsklinikum Leipzig AöR, Liebigstraße 18, 04103, Leipzig, Deutschland
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What do we know about treating breast-cancer-related lymphedema? Review of the current knowledge about therapeutic options. Breast Cancer 2023; 30:187-199. [PMID: 36571707 PMCID: PMC9950281 DOI: 10.1007/s12282-022-01428-z] [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: 08/01/2022] [Accepted: 12/16/2022] [Indexed: 12/27/2022]
Abstract
Breast-cancer-related lymphedema (BCRL) is a common consequence of oncological treatment. Its management is a complicated, chronic, and arduous process. Therapeutic options can be divided on non-surgical and surgical methods, although there is still no clear consensus about their effectiveness in preventing or stopping the disease. That brings problems in everyday practice, as there are no guidelines about proper time for starting therapy and no agreement about which management will be beneficial for each patient. The aim of this review is to summarize current knowledge about possible treatment choices, non-surgical so as surgical, indicate knowledge gaps, and try to direct pathways for future studies.
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Seth I, Bulloch G, Gibson D, Seth N, Hunter-Smith DJ, Rozen WM. Quantification and Effectiveness of Vascularized Neck Lymph Node Transfer for Lymphedema: a Systematic Review and Meta-Analysis. Indian J Surg 2022. [DOI: 10.1007/s12262-022-03627-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Abstract
LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Discuss the natural history and pathophysiology of sarcoma. 2. Summarize the most up-to-date multidisciplinary management of soft-tissue sarcoma. 3. Provide a synopsis of reconstructive modalities based on anatomical location. 4. Highlight some novel strategies for treatment of lymphedema and phantom limb pain that are common sequelae following treatment and resection of soft-tissue sarcomas. SUMMARY The management of soft-tissue sarcoma presents unique challenges to the reconstructive surgeon. The optimal management mandates a multidisciplinary approach; however, reconstruction must take into account the extent of the resection and exposed vital structures, but often occurs in the setting of adjuvant treatments including chemotherapy and radiation therapy. Reconstruction is based on the extent of the defect and the location of the primary tumor. As such, an evidence-based, algorithmic approach following the reconstructive ladder is warranted to minimize the risks of complications and maximize success, which varies from head and neck to torso to breast to extremity sarcomas. Aside from reconstruction of the defect, advances in the surgical treatment of lymphedema and neuropathic pain resulting from treatment and extirpation of soft-tissue sarcoma are critical to maintain function and patients' quality of life.
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Affiliation(s)
- David M Aten
- From the Departments of Medical Graphics and Plastic Surgery, University of Texas M. D. Anderson Cancer Center
| | - Edward I Chang
- From the Departments of Medical Graphics and Plastic Surgery, University of Texas M. D. Anderson Cancer Center
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Lymphatic Tissue Transfer: Ultrasound-Guided Description and Preoperative Planning of Vascularised Lymph Nodes, Lymphatic Units, and Lymphatic Vessels Transfers. J Pers Med 2022; 12:jpm12081346. [PMID: 36013294 PMCID: PMC9410514 DOI: 10.3390/jpm12081346] [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] [Received: 06/29/2022] [Revised: 08/13/2022] [Accepted: 08/16/2022] [Indexed: 11/17/2022] Open
Abstract
Background: The modern concept of lymphatic transfer includes vascularised lymph node transfer (VLNT), lymphatic vessels transfer (lymph interpositional flap transfer, LIFT) and lymphatic system transfer (vascularised lymph nodes and afferent lymphatics, LYST). The aim of this paper was to report our experience with different types of lymphatic transfer. Patients and Method: From June 2016 to June 2020, 30 consecutive patients affected by extremity lymphedema and 15 patients affected by post-traumatic lower extremity soft tissue defects, underwent lymphatic transfer (VLNT, LYST or LIFT). All cases were preoperatively evaluated by both high frequency and ultra-high frequency ultrasound. Flap features were recorded, as well as qualitative and quantitative outcomes at 1 year postoperative. Results: The mean postoperative lymphedema index reduction was 7.2 ± 5.7 for upper extremity and 20.7 ± 7.1 for lower extremity. No dismission of compression garments occurred, 12 patients (26%) referred more stable results of physical treatment and 1 case showed a 1-class compression reduction. All the LIFTs aimed as preventive did not develop post-traumatic lymphedema. In all cases of distal placement of VLNT and/or LYST, patients were dissatisfied with the aesthetic appearance of reconstruction, while no donor site scar disappointment was referred. Conclusion: When LVA is not feasible, LTT may represent a valid treatment option. This report was aimed at comprehensively describing and assessing how different lymphatic tissue transfer modalities may fulfil the different reconstructive needs of lymphedema patients.
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Shuck JW, Francis AM, Chang EI. Commentary: Gastroepiploic vascularized lymph node transfer for extremities' lymphedema: Is two better than one? A retrospective case-control study. J Plast Reconstr Aesthet Surg 2022; 75:3138-3139. [PMID: 35752589 DOI: 10.1016/j.bjps.2022.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 06/07/2022] [Indexed: 11/18/2022]
Affiliation(s)
- John W Shuck
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, 1400 Pressler St., Unit 1488, Houston 77030, TX, USA
| | - Ashleigh M Francis
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, 1400 Pressler St., Unit 1488, Houston 77030, TX, USA
| | - Edward I Chang
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, 1400 Pressler St., Unit 1488, Houston 77030, TX, USA.
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Chang EI. Optimizing Treatment of Breast Cancer Related Lymphedema Using Combined DIEP Flap and Lymphedema Surgery. Arch Plast Surg 2022; 49:150-157. [PMID: 35832680 PMCID: PMC9045539 DOI: 10.1055/s-0042-1744414] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Patients undergoing treatment for breast cancer who undergo an axillary dissection and require adjuvant therapies such as radiation and chemotherapy are at high risk of developing lymphedema of the associated extremity. Historically, patients with lymphedema were treated with ablative procedures aimed simply to remove excess fluid and adiposity; however, the field of lymphatic surgery employing super-microsurgery techniques has witnessed tremendous advances in a relatively short period of time. Advancements in surgical instruments, microscope magnification and optics, imaging technology, and surgeon experience have ushered in a new era of hope to treat patients suffering from breast cancer–related lymphedema (BCRL). Here we aim to present the available options for patients suffering from BCRL, and the pinnacle in reconstruction and restoration for these patients.
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Affiliation(s)
- Edward I. Chang
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
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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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Abstract
Tissue engineering has witnessed remarkable advancement in various fields of medicine and has the potential of revolutionizing the management of lymphedema. Combining approaches of biotechnology with the evolving understanding of lymphangiogenesis may offer promising treatment modalities for patients suffering from lymphedema. The strategies to lymphatic vessels tissue engineer can be grouped into four main categories: Delivery of chemokines, cytokines, and other growth factors to induce lymphangiogenesis; cell-based approach using lymphatic endothelial cells or stem-cells; scaffold-based tissue engineering; or a combination of these. This review will summarize the current approach to cancer-related lymphedema and advances in lymphatic tissue engineering strategies and the challenges facing the regeneration of lymphatic vasculature, particularly in an oncologic setting.
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Affiliation(s)
- Malke Asaad
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Summer E Hanson
- Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
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Technical Challenges in "Micro" Lymph Node Identification during Vascularized Submental Lymph Node Flap Harvesting. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e3330. [PMID: 33425628 PMCID: PMC7787339 DOI: 10.1097/gox.0000000000003330] [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: 07/13/2020] [Accepted: 10/21/2020] [Indexed: 11/26/2022]
Abstract
Background: The outcome of autologous lymph node (LN) transfer has depended on the number of LNs in the donor site. Unknown accuracy of the LN counting method has thrown some doubts on the reliability of the previous statistics. This study aimed to assess the accuracy of naked eye (NK) and stereo microscopy (SM) as tools for LN count. Methods: In total, 40 vascularized submental LN flaps were harvested from 23 fresh cadavers. The colored polymer was injected into the external carotid arteries before the harvest. LNs in each flap were counted by NK, SM, and histology in sequential order. Results: An estimated 175 LNs were confirmed, 4.4 ± 1.8 per flap. NK sensitivity was 33.7% compared with that of SM at 63.5%. Both methods missed all micro-lymph nodes (micro-LNs), contributing to 5.1% (9 nodes) of all LNs. Non-LN structures (647 negative counts) were composed of fat lobules, salivary gland lobules, and muscle fibers. NK specificity was 98.0%, compared with that of SM at 96.1%. SM showed a higher false positive rate at 14.3%, compared with NK at 7.4%. False positive counts were located mostly in Ib sublevel. Conclusions: NK and SM are imperfect tools for LN count due to poor sensitivity. If the method needs to be applied, points of considerations are (1) undetectable micro-LNs, (2) interposition of LNs with the digastric muscle and submandibular salivary gland, (3) confusion of LNs with lobules of salivary gland supplied by glandular artery or fat lobules supplied by lobular artery.
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Flores T, Bergmeister KD, Staudenherz A, Pieber K, Schrögendorfer KF. [Diagnosis, prevention and therapy of lymphedema]. Wien Klin Wochenschr 2020; 133:855-868. [PMID: 33226525 PMCID: PMC8452052 DOI: 10.1007/s00508-020-01766-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Tonatiuh Flores
- Karl Landsteiner Privatuniversität für Gesundheitswissenschaften, Dr. Karl-Dorrek-Straße 30, 3500, Krems, Österreich. .,Klinische Abteilung für Plastische, Ästhetische und Rekonstruktive Chirurgie, Universitätsklinikum St. Pölten, Dunant-Platz 1, 3100, St. Pölten, Österreich.
| | - Konstantin D Bergmeister
- Karl Landsteiner Privatuniversität für Gesundheitswissenschaften, Dr. Karl-Dorrek-Straße 30, 3500, Krems, Österreich.,Klinische Abteilung für Plastische, Ästhetische und Rekonstruktive Chirurgie, Universitätsklinikum St. Pölten, Dunant-Platz 1, 3100, St. Pölten, Österreich
| | - Anton Staudenherz
- Karl Landsteiner Privatuniversität für Gesundheitswissenschaften, Dr. Karl-Dorrek-Straße 30, 3500, Krems, Österreich.,Klinisches Institut für Nuklearmedizin, molekulare Bildgebung und spezielle Endokrinologie, Universitätsklinikum St. Pölten, Dunant-Platz 1, 3100, St. Pölten, Österreich
| | - Karin Pieber
- Karl Landsteiner Privatuniversität für Gesundheitswissenschaften, Dr. Karl-Dorrek-Straße 30, 3500, Krems, Österreich.,Klinisches Institut für Physikalische Medizin und Rehabilitation, Universitätsklinikum St. Pölten, Dunant-Platz 1, 3100, St. Pölten, Österreich
| | - Klaus F Schrögendorfer
- Karl Landsteiner Privatuniversität für Gesundheitswissenschaften, Dr. Karl-Dorrek-Straße 30, 3500, Krems, Österreich.,Klinische Abteilung für Plastische, Ästhetische und Rekonstruktive Chirurgie, Universitätsklinikum St. Pölten, Dunant-Platz 1, 3100, St. Pölten, Österreich
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