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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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Malhotra S, Tadros AB. New Strategies for Locally Advanced Breast Cancer: A Review of Inflammatory Breast Cancer and Nonresponders. Clin Breast Cancer 2024; 24:301-309. [PMID: 38431513 DOI: 10.1016/j.clbc.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 01/10/2024] [Accepted: 01/16/2024] [Indexed: 03/05/2024]
Abstract
This review explores the new strategies around the management of locally advanced breast cancer (LABC), particularly for nonresponsive tumors and/or initially unresectable tumors at diagnosis, inclusive of inflammatory breast cancer. Nonresponders to neoadjuvant systemic therapy present a unique clinical challenge. Emerging medical therapeutics as well as considerations for use of radiotherapy and/or surgery in this setting are discussed. Specifically, the use of neoadjuvant radiotherapy for LABC and lymphedema prevention with lymphatic reconstruction following axillary lymph node dissection are reviewed.
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Affiliation(s)
- Simran Malhotra
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Audree B Tadros
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY.
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Wei M, Wang L, Wu X, Wu B, Xiao S, Zhang Y, Min P, Deng C. Synchronous supraclavicular vascularized lymph node transfer and liposuction for gynecological cancer-related lower extremity lymphedema: a clinical comparative analysis of three different procedures. J Vasc Surg Venous Lymphat Disord 2024:101905. [PMID: 38761979 DOI: 10.1016/j.jvsv.2024.101905] [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: 01/29/2024] [Revised: 04/08/2024] [Accepted: 04/23/2024] [Indexed: 05/20/2024]
Abstract
OBJECTIVE Gynecological cancer-related lower extremity lymphedema (GC-LEL), a chronic, progressive condition, lacks a standardized treatment. Currently, supraclavicular vascularized lymph node transfer (SC-VLNT) is a favored approach in the treatment of lymphedema, and there is a trend toward combination technology. This study conducts a comparative analysis of three techniques for treating GC-LEL with simultaneous SC-VLNT and liposuction. METHODS A cohort of 35 patients with GC-LEL was examined, comprising 13 patients who underwent single lymph nodes flap with a skin paddle (SLNF+P), 12 who received single lymph nodes flap without a skin paddle (SLNF), and 10 who accepted dual lymph nodes flap without a skin paddle (DLNF). Patient demographics and outcomes were meticulously documented, covering intra- and postoperative variables. RESULTS The median limb volume reduction were 56.4% (SLNF+P), 60.8% (SLNF), and 50.5% (DLNF) in stage II, and 54.0% (SLNF+P), 59.8% (SLNF), and 54.4% (DLNF) in stage III. DLNF group procedures entailed longer flap harvesting and transplantation times. The SLNF+P group, on average, had an 8-day postoperative hospitalization, longer than others. All patients noted subjective improvements in Lymphedema Quality of Life scores, with lymphoscintigraphy revealing enhanced lymphatic flow in 29 of the 35 cases. A notable decrease in cellulitis incidence was observed. Additionally, the occurrence of cellulitis decreased significantly, except for DLNF (Stage Ⅱ). The median follow-up time was 16 months (range, 12-36 months), with no reported severe postoperative complications. CONCLUSIONS For advanced GC-LEL, SLNF combined with liposuction is a preferred treatment, offering fewer complications, shorter operative time, and hospitalization.
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Affiliation(s)
- Miaomiao Wei
- Department of Burns and Plastic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Liangliang Wang
- Department of Burns and Plastic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Xiangkui Wu
- Department of Burns and Plastic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, China; Collaborative Innovation Center of Tissue Damage Repair and Regeneration Medicine of Zunyi Medical University, Zunyi, China
| | - Bihua Wu
- Department of Burns and Plastic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, China; Collaborative Innovation Center of Tissue Damage Repair and Regeneration Medicine of Zunyi Medical University, Zunyi, China
| | - Shune Xiao
- Department of Burns and Plastic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, China; Collaborative Innovation Center of Tissue Damage Repair and Regeneration Medicine of Zunyi Medical University, Zunyi, China
| | - Yixin Zhang
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Peiru Min
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Chengliang Deng
- Department of Burns and Plastic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, China; Collaborative Innovation Center of Tissue Damage Repair and Regeneration Medicine of Zunyi Medical University, Zunyi, China.
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Myung Y, Yun J, Beom J, Hayashi A, Lee WW, Song YS, Park JKH. Evaluating the Surgical Outcome of Lymphovenous Anastomosis in Breast Cancer-Related Lymphedema Using Tc-99m Phytate Lymphoscintigraphy: Preliminary Results. Lymphat Res Biol 2024; 22:124-130. [PMID: 38265788 DOI: 10.1089/lrb.2023.0036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2024] Open
Abstract
Background: Breast cancer-related lymphedema (BCRL) remains a significant postcancer treatment challenge with no definitive cure. Recent supermicrosurgical treatments, such as lymphovenous anastomosis (LVA), have shown promise but lack established objective indicators for outcome evaluation. We investigated the utility of Technetium-99m (Tc-99m) lymphoscintigraphy, an imaging technique providing objective information on lymphatic fluid flow, for assessing LVA surgical outcomes. Methods and Results: A retrospective cohort analysis of patients undergoing LVA for BCRL was conducted. Lymphoscintigraphy images pre- and 1-year postsurgery were compared to determine changes in lymphatic fluid flow of 18 patients based on newly defined parameters "uptake ratio" and "washout rates." Statistically significant reduction in the uptake ratio was observed in the forearm at 30 and 60 minutes postinjection phases. In addition, the forearm showed higher washout rate, indicating an improved lymphatic function in the forearm. Conclusion: Tc-99m lymphoscintigraphy can provide valuable objective data for evaluating LVA surgical outcomes in BCRL patients. However, site-specific differences in outcomes highlight the need for individualized surgical planning. Further large-scale studies are necessary to validate these preliminary findings and develop a standardized approach for LVA assessment.
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Affiliation(s)
- Yujin Myung
- Department of Plastic and Reconstructive Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
| | - Junseo Yun
- Department of Plastic and Reconstructive Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
| | - Jaewon Beom
- Department of Rehabilitation Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
| | | | - Won Woo Lee
- Department of Nuclear Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
| | - Yoo Sung Song
- Department of Nuclear Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
| | - Joseph Kyu-Hyung Park
- Department of Plastic and Reconstructive Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
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Crowley JS, Liu FC, Rizk NM, Nguyen D. Concurrent management of lymphedema and breast reconstruction with single-stage omental vascularized lymph node transfer and autologous breast reconstruction: A case series. Microsurgery 2024; 44:e31017. [PMID: 36756715 DOI: 10.1002/micr.31017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 12/13/2022] [Accepted: 01/19/2023] [Indexed: 02/10/2023]
Abstract
INTRODUCTION The omentum has gained recent popularity in vascularized lymph node transfers (VLNT) as well as its novel use as a free flap for autologous breast reconstruction. The omentum has multiple unique advantages. It can be harvested laparoscopically or in an open fashion when utilized with abdominally-based free flaps. Additionally, it can be split into multiple flaps for simultaneous autologous breast reconstruction with VLNT or for multiple sites of VLNT. We present the safe and advantageous use of the omentum for VLNT with simultaneous autologous breast reconstruction in a series of patients. METHODS From the years 2019-2022, patients who underwent breast reconstruction with deep inferior epigastric artery perforator (DIEP) or muscle sparing tram (MS-TRAM) flaps with concurrent omental VLNT through a mini-laparotomy or breast reconstruction with Omental Fat-Augmented Free Flap (O-FAFF) with concurrent laparoscopic harvesting of omental VLNT were studied. Patient demographics included age, gender, comorbidities, prior radiation or chemotherapy, body mass index, complications, hospital length of stay, and surgical outcomes. RESULTS A total of seven patients underwent omental VLNT with breast reconstruction for a total of 12 breasts and eight limbs treated. Three of the patients underwent autologous breast reconstruction using omental free flap. The mean age was 52.3 (range 40-75) years and mean body mass index (BMI) was 29.3 (range 23-38) kg/m2 . The flap survival rate was 100%. All the patients had successful reduction of extremity circumference and improvement of symptoms. The range of follow-up was 5 to 19 months, with an average follow-up of 14.6 months. There was only one complication among our 7 patients: a patient with a BMI of 38 developed a post-surgical abdominal wound treated with local wound care. Otherwise, post-operative courses were uneventful, and no further complications were reported. CONCLUSION We demonstrate here additional evidence to the growing body of literature of the versatility and safety of the omentum to be utilized as an independent tool for surgical treatment of lymphedema as well as its simultaneous use with autologous breast reconstruction.
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Affiliation(s)
- Jiwon S Crowley
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Palo Alto, California, United States
| | - Farrah C Liu
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Palo Alto, California, United States
| | - Nada M Rizk
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Palo Alto, California, United States
| | - Dung Nguyen
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Palo Alto, California, United States
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Maruccia M, Giudice G, Ciudad P, Manrique OJ, Cazzato G, Chen HC, Elia R. Lymph Node Transfer and Neolymphangiogenesis: From Theory to Evidence. Plast Reconstr Surg 2023; 152:904e-912e. [PMID: 36940155 DOI: 10.1097/prs.0000000000010434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2023]
Abstract
BACKGROUND Vascularized lymph node transfer (VLNT) has proven to be a valuable treatment for patients with advanced stages of lymphedema. Although spontaneous neolymphangiogenesis has been advocated to explain the positive effects of VLNT, there is still a lack of supportive biological evidence. The aim of this study was to demonstrate the postoperative formation of new lymphatic vessels using histologic skin sections from the lymphedematous limb. METHODS Patients with lymphedema of the extremities who had undergone gastroepiploic vascularized lymph node flap surgery between January of 2016 and December of 2018 were identified. Full-thickness 6-mm skin-punch biopsy specimens were obtained from patients at identical sites of the lymphedematous limb during the VLNT surgical procedure (T0) and 1 year later (T1). The histologic samples were immunostained with anti-podoplanin/gp36 antibody. RESULTS A total of 14 patients with lymph node transfer were included. At the 12-month follow-up, the mean circumference reduction rate was 44.3 ± 4.4 at the above-elbow/above-knee level and 60.9 ± 7 at the below-elbow/below-knee level. Podoplanin expression values were, on average, 7.92 ± 1.77 vessels/mm 2 at T0 and 11.79 ± 3.38 vessels/mm 2 at T1. The difference between preoperative and postoperative values was statistically significant ( P = 0.0008). CONCLUSION This study provides anatomic evidence that a neolymphangiogenic process is induced by the VLNT procedure because new functional lymphatic vessels can be detected in close proximity to the transferred lymph nodes. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Affiliation(s)
- Michele Maruccia
- From the Division of Plastic and Reconstructive Surgery, Department of Emergency and Organ Transplantation, University of Bari
| | - Giuseppe Giudice
- From the Division of Plastic and Reconstructive Surgery, Department of Emergency and Organ Transplantation, University of Bari
| | - Pedro Ciudad
- Department of Plastic, Reconstructive, and Burn Surgery, Arzobispo Loayza National Hospital
| | - Oscar J Manrique
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center
| | - Gerardo Cazzato
- Section of Pathology, Department of Emergency and Organ Transplantation, University of Bari "Aldo Moro"
| | - Hung-Chi Chen
- Department of Plastic Surgery, China Medical University Hospital
| | - Rossella Elia
- From the Division of Plastic and Reconstructive Surgery, Department of Emergency and Organ Transplantation, University of Bari
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Banerjee A, Jou E, Wong KY. Supermicrosurgery: past, present and future. Br J Hosp Med (Lond) 2023; 84:1-10. [PMID: 37906072 DOI: 10.12968/hmed.2022.0482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Abstract
Supermicrosurgery was popularised in 1997 and is defined as a technique of microvascular anastomosis for single nerve fascicles and vessels 0.3-0.8 mm in diameter. It requires the use of powerful microscopes, ultradelicate microsurgical instruments and specialist dyes. The development of supermicrosurgery has vastly improved the ability of microsurgeons to create true perforator flaps with minimal donor site morbidity for reconstructive surgery and improved the precision of additional microsurgical techniques. This review outlines the origins and history of supermicrosurgery, its current applications in reconstructive surgery (including fingertip reconstructions, true perforator flap surgery, nerve flaps and lymphoedema surgery), supermicrosurgery training and future directions for the field.
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Affiliation(s)
- Arka Banerjee
- Department of Plastic Surgery, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Eric Jou
- Medical Sciences Division, Oxford University Hospitals, University of Oxford, Oxford, UK
- Kellogg College, University of Oxford, Oxford, UK
| | - Kai Yuen Wong
- Department of Plastic Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Park JKH, Choi N, Beom J, Lim JY, Kang Y, Nam SY, Myung Y. Utilization of Noncontrast Magnetic Resonance Lymphangiography for Selection of Effective Surgical Method in Breast Cancer-Related Lymphedema. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1656. [PMID: 37763775 PMCID: PMC10537151 DOI: 10.3390/medicina59091656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 09/11/2023] [Accepted: 09/12/2023] [Indexed: 09/29/2023]
Abstract
Background and Objectives: When considering surgery for patients with breast cancer-related lymphedema (BCRL), it is crucial to determine which surgery will be most effective for the patient and establish the indications for each surgery. Our study retrospectively compared the results of preoperative noncontrast MR lymphangiography (NMRL) performed on the lymphedematous limb of patients before surgery, with the aim of analyzing whether preoperative NMRL can be used as a criterion for determining the type of surgery. Materials and Methods: From January 2020 to June 2022, a total of 138 patients with lymphedema underwent surgery at Seoul National University Bundang Hospital. All patients underwent preoperative NMRL imaging and were classified into stages 1-3 based on the MRI severity index using the authors' previous reference. Three types of surgery, LVA, LVA + liposuction, and LVA + VLNT, were conducted on all patients. The effectiveness of the surgery was evaluated one year postoperatively using the interlimb volume difference before and after surgery, the fluid volume of the edematous limb measured by bioimpedance spectroscopy, and the subjective satisfaction of the patients through the Lymph Q questionnaire. Results: In this study, out of a total of 138 patients, 26 (19%) were MRI stage 1, 62 (45%) were stage 2, and 50 (36%) were stage 3. Of the 83 patients who underwent LVA surgery, the greatest decrease in interlimb volume difference was observed in stage 2 patients, and subjective satisfaction was also the most effective in stage 2. In the case of LVA + liposuction patients, a significant volume decrease and a high satisfaction were observed in stage 3 patients. In the case of LVA + VLNT patients, there was no difference in volume decrease according to the stage, but a greater decrease in body fluid volume was observed as the MRI severity index score increased through BIA. Conclusions: In conclusion, this study demonstrates that NMRL imaging is a useful modality for determining the most effective surgical method and predicting the surgical outcome in patients with lymphedema. This highlights the importance of using NMRL in the treatment planning of lymphedema patients.
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Affiliation(s)
- Joseph Kyu-hyung Park
- Department of Plastic and Reconstructive Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 300 Gumi-dong, Bundang-gu, Seongnam 07061, Republic of Korea; (J.K.-h.P.)
| | - Nakwon Choi
- Department of Plastic and Reconstructive Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 300 Gumi-dong, Bundang-gu, Seongnam 07061, Republic of Korea; (J.K.-h.P.)
| | - Jaewon Beom
- Department of Rehabilitation Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam 07061, Republic of Korea
| | - Jae-Young Lim
- Department of Rehabilitation Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam 07061, Republic of Korea
| | - Yusuhn Kang
- Department of Radiology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam 07061, Republic of Korea
| | - Sun-Young Nam
- Department of Plastic and Reconstructive Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 300 Gumi-dong, Bundang-gu, Seongnam 07061, Republic of Korea; (J.K.-h.P.)
| | - Yujin Myung
- Department of Plastic and Reconstructive Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 300 Gumi-dong, Bundang-gu, Seongnam 07061, Republic of Korea; (J.K.-h.P.)
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Lynn JV, Hespe GE, Akhter MF, David CM, Kung TA, Myers PL. Cross-Sectional Analysis of Insurance Coverage for Lymphedema Treatments in the United States. JAMA Surg 2023; 158:920-926. [PMID: 37285151 PMCID: PMC10248808 DOI: 10.1001/jamasurg.2023.2017] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 03/21/2023] [Indexed: 06/08/2023]
Abstract
Importance Lymphedema is a debilitating condition that affects approximately 1 in 1000 individuals in the United States. Complete decongestive therapy is currently the standard of care, and innovative surgical techniques have demonstrated potential to further improve outcomes. Despite the growing armamentarium of treatment options, a large proportion of patients with lymphedema continue to struggle because of limited access to care. Objective To define the current state of insurance coverage for lymphedema treatments in the United States. Design, Setting, and Participants A cross-sectional analysis of insurance reimbursement for lymphedema treatments in 2022 was designed. The top 3 insurance companies per state based on market share and enrollment data maintained by the Kaiser Family Foundation were included. Established medical policies were gathered from insurance company websites and phone interviews, and descriptive statistics were performed. Main Outcomes and Measures Treatments of interest included nonprogrammable pneumatic compression, programmable pneumatic compression, surgical debulking, and physiologic procedures. Primary outcomes included level of coverage and criteria for coverage. Results This study included 67 health insurance companies representing 88.7% of the US market share. Most insurance companies offered coverage for nonprogrammable (n = 55, 82.1%) and programmable (n = 53, 79.1%) pneumatic compression. However, few insurance companies offered coverage for debulking (n = 13, 19.4%) or physiologic (n = 5, 7.5%) procedures. Geographically, the lowest rates of coverage were seen in the West, Southwest, and Southeast. Conclusions and Relevance This study suggests that in the United States, less than 12% of individuals with health insurance, and even fewer patients without health insurance, have access to pneumatic compression and surgical treatments for lymphedema. The stark inadequacy of insurance coverage must be addressed through research and lobbying efforts to mitigate health disparities and promote health equity among patients with lymphedema.
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Affiliation(s)
- Jeremy V. Lynn
- Department of Surgery, University of Michigan, Ann Arbor
| | | | | | | | | | - Paige L. Myers
- Department of Surgery, University of Michigan, Ann Arbor
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Lee JW, Lee TY, Moon KC, You HJ, Kim DW. Lymphatic complex transfer as combined lymph vessel and node transfer for advanced stage upper extremity lymphedema. J Vasc Surg Venous Lymphat Disord 2023; 11:824-831.e3. [PMID: 36906107 DOI: 10.1016/j.jvsv.2023.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 02/05/2023] [Accepted: 02/06/2023] [Indexed: 03/11/2023]
Abstract
OBJECTIVE Lymphedema, especially in the advanced stage, is a growing challenge in extremity reconstruction, with few applicable surgical methods. Despite its importance, no consensus has been reached regarding a single surgical method yet. Herein, the authors introduce a novel concept of lymphatic reconstruction yielding promising results. METHODS We included 37 patients with advanced-stage upper extremity lymphedema who underwent lymphatic complex transfers, consisting of both lymph vessel and node transfers, from 2015 to 2020. We compared the preoperative and postoperative (last visit) mean circumferences and volume ratios between the affected and unaffected limbs. Changes in the Lymphedema Life Impact Scale scores and complications were also investigated. RESULTS The circumference ratio (affected to unaffected limbs) improved at all measuring points (P < .05), while the volume ratio showed a decrease from 1.54 to 1.39 (P < .001). The mean Lymphedema Life Impact Scale decreased from 48.1 ± 15.2 to 33.4 ± 13.8 (P < .05). No donor site morbidities, including iatrogenic lymphedema or any other major complications, were observed. CONCLUSIONS A new technique for lymphatic reconstruction, lymphatic complex transfer, may be useful in cases of advanced stage lymphedema because of its effectiveness and the low possibility of donor site lymphedema.
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Affiliation(s)
- Jun Won Lee
- Department of Plastic Surgery, Korea University College of Medicine, Seoul, Korea
| | - Tae-Yul Lee
- Department of Plastic Surgery, Korea University College of Medicine, Seoul, Korea
| | - Kyung-Chul Moon
- Department of Plastic Surgery, Korea University College of Medicine, Seoul, Korea
| | - Hi-Jin You
- Department of Plastic Surgery, Korea University College of Medicine, Seoul, Korea
| | - Deok-Woo Kim
- Department of Plastic Surgery, Korea University College of Medicine, Seoul, Korea.
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11
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Grünherz L, Barbon C, Gousopoulos E, Uyulmaz S, Giovanoli P, Lindenblatt N. PROMs after Lymphatic Reconstructive Surgery: Is There a Correlation between Volume Reduction and Quality of Life? PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5020. [PMID: 37250829 PMCID: PMC10219699 DOI: 10.1097/gox.0000000000005020] [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: 11/25/2022] [Accepted: 04/03/2023] [Indexed: 05/31/2023]
Abstract
Patients with upper limb lymphedema and lower limb lymphedema experience a wide range of physical and psychological symptoms that affect quality of life. The benefits of lymphatic reconstructive surgery for patients with lymphedema are undisputed. However, recording volume reduction alone may be insufficient with regard to postoperative outcome because measurements are often inadequate, depend on many factors, and do not reflect improvement in quality of life. Methods We conducted a prospective single center study patients receiving lymphatic reconstructive surgery. Patients received volume measurements preoperatively and at standardized postoperative intervals. To evaluate patient-reported outcomes, patients completed the following questionnaires: LYMPH-Q Upper Extremity Module, quickDASH, SF 36, Lymphoedema Functioning, Disability and Health Questionnaire for Lower Limb Lymphoedema, and Lower Extremity Functional Scale at the aforementioned intervals. Results We included 55 patients with upper limb lymphedema (24%) and lower limb lymphedema (73%) of lymphedema grades I-III. Patients received lymphovenous anastomosis only (23%), free vascularized lymph node transfer (35%) or a combination of both (42%). Analysis of patient-reported outcome measurements revealed improvements with respect to a broad range of complaints, particularly physical function, symptoms, and psychological well-being. There was no correlation between the extent of volume reduction and improvement in quality of life (Pearson correlation coefficient below ±0.7; P > 0.05). Conclusions Based on a broad range of outcome measurements, we observed an improved quality of life in almost all patients, even in those without measurable volume loss of the extremity operated on, which emphasizes the need for a standardized use of patient-reported outcome measures to evaluate the benefits of lymphatic reconstructive surgery.
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Affiliation(s)
- Lisanne Grünherz
- From the Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Carlotta Barbon
- From the Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Epameinondas Gousopoulos
- From the Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Semra Uyulmaz
- From the Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Pietro Giovanoli
- From the Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Nicole Lindenblatt
- From the Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
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Bianchi LMG, Irmici G, Cè M, D'Ascoli E, Della Pepa G, Di Vita F, Casati O, Soresina M, Menozzi A, Khenkina N, Cellina M. Diagnosis and Treatment of Post-Prostatectomy Lymphedema: What's New? Curr Oncol 2023; 30:4512-4526. [PMID: 37232799 DOI: 10.3390/curroncol30050341] [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: 03/14/2023] [Revised: 04/24/2023] [Accepted: 04/24/2023] [Indexed: 05/27/2023] Open
Abstract
Lymphedema is a chronic progressive disorder that significantly compromises patients' quality of life. In Western countries, it often results from cancer treatment, as in the case of post-radical prostatectomy lymphedema, where it can affect up to 20% of patients, with a significant disease burden. Traditionally, diagnosis, assessment of severity, and management of disease have relied on clinical assessment. In this landscape, physical and conservative treatments, including bandages and lymphatic drainage have shown limited results. Recent advances in imaging technology are revolutionizing the approach to this disorder: magnetic resonance imaging has shown satisfactory results in differential diagnosis, quantitative classification of severity, and most appropriate treatment planning. Further innovations in microsurgical techniques, based on the use of indocyanine green to map lymphatic vessels during surgery, have improved the efficacy of secondary LE treatment and led to the development of new surgical approaches. Physiologic surgical interventions, including lymphovenous anastomosis (LVA) and vascularized lymph node transplant (VLNT), are going to face widespread diffusion. A combined approach to microsurgical treatment provides the best results: LVA is effective in promoting lymphatic drainage, bridging VLNT delayed lymphangiogenic and immunological effects in the lymphatic impairment site. Simultaneous VLNT and LVA are safe and effective for patients with both early and advanced stages of post-prostatectomy LE. A new perspective is now represented by the combination of microsurgical treatments with the positioning of nano fibrillar collagen scaffolds (BioBridgeTM) to favor restoring the lymphatic function, allowing for improved and sustained volume reduction. In this narrative review, we proposed an overview of new strategies for diagnosing and treating post-prostatectomy lymphedema to get the most appropriate and successful patient treatment with an overview of the main artificial intelligence applications in the prevention, diagnosis, and management of lymphedema.
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Affiliation(s)
| | - Giovanni Irmici
- Postgraduation School in Radiodiagnostics, University of Milan, 20122 Milan, Italy
| | - Maurizio Cè
- Postgraduation School in Radiodiagnostics, University of Milan, 20122 Milan, Italy
| | - Elisa D'Ascoli
- Postgraduation School in Radiodiagnostics, University of Milan, 20122 Milan, Italy
| | - Gianmarco Della Pepa
- Postgraduation School in Radiodiagnostics, University of Milan, 20122 Milan, Italy
| | - Filippo Di Vita
- Postgraduation School in Plastic Surgery, University of Milan, Via Festa del Perdono, 7, 20122 Milan, Italy
| | - Omar Casati
- Postgraduation School in Plastic Surgery, University of Milan, Via Festa del Perdono, 7, 20122 Milan, Italy
| | - Massimo Soresina
- Plastic Surgery Department, Fatebenefratelli Hospital, ASST Fatebenefratelli Sacco, 20121 Milan, Italy
| | - Andrea Menozzi
- Plastic Surgery Department, Fatebenefratelli Hospital, ASST Fatebenefratelli Sacco, 20121 Milan, Italy
| | - Natallia Khenkina
- Postgraduation School in Radiodiagnostics, University of Milan, 20122 Milan, Italy
| | - Michaela Cellina
- Radiology Department, Fatebenefratelli Hospital, ASST Fatebenefratelli Sacco, 20121 Milan, Italy
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13
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Chu CK, Hanasono MM, Chang EI. Treatment of multiple limb lymphedema with combined supermicrosurgical techniques. Microsurgery 2023; 43:13-19. [PMID: 35244958 DOI: 10.1002/micr.30878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Revised: 01/01/2022] [Accepted: 02/24/2022] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Lymphedema surgery including lymphovenous anastomosis (LVA) and vascularized lymph node transfer (VLNT) are effective treatments for lymphedema; however, treating multiple limbs in a single operation using both approaches has not been described. We hypothesize multiple limb lymphedema can be treated effectively in one operation. PATIENT AND METHODS Retrospective review of seven patients undergoing extreme lymphedema surgery (mean age: 53.2 years; range: 33-66 years) with an average BMI of 34.8 kg/m2 (range: 17.6-53.6 kg/m2 ). Two patients developed bilateral upper extremity (UE) lymphedema secondary to breast cancer treatment, three had bilateral lower extremity (LE) lymphedema, and two suffered from lymphedema of all four extremities due to breast cancer treatment. RESULTS One patient with bilateral UE lymphedema was treated with bilateral inguinal node transfers with LVA and the other with combined bilateral DIEP flaps and inguinal node transfers with LVA. Three patients had bilateral LE lymphedema: two were treated with split omental/gastroepiploic nodes, and one underwent simultaneous supraclavicular and submental node transfers. LVAs were performed in one leg in each patient. Two patients with four-limb lymphedema underwent bilateral inguinal node transfers with DIEP flaps and bilateral LE LVA. In total, there were eight UE and 10 LE treated. Average follow-up was 15.8 months (range: 12.6-28.4 months), all patients reported subjective improvement in symptoms, were able to decrease use of compression garments and pumps, and no patients developed cellulitis. CONCLUSION Patients suffering from lymphedema of multiple extremities can be treated safely and effectively combining both LVA and VLNT in a single operation.
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Affiliation(s)
- Carrie K Chu
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Matthew M Hanasono
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Edward I Chang
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Manrique OJ, Bustos SS, Ciudad P, Adabi K, Chen WF, Forte AJ, Cheville AL, Jakub JW, McLaughlin SA, Chen HC. Overview of Lymphedema for Physicians and Other Clinicians: A Review of Fundamental Concepts. Mayo Clin Proc 2022; 97:1920-1935. [PMID: 32829905 DOI: 10.1016/j.mayocp.2020.01.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 10/17/2019] [Accepted: 01/06/2020] [Indexed: 12/16/2022]
Abstract
Lymphedema has historically been underrated in clinical practice, education, and scholarship to the detriment of many patients with this chronic, debilitating condition. The mechanical insufficiency of the lymphatic system causes the abnormal accumulation of protein-rich fluid in the interstitium, which triggers a cascade of adverse consequences such as fat deposition and fibrosis. As the condition progresses, patients present with extremity heaviness, itchiness, skin infections, and, in later stages, dermal fibrosis, skin papillomas, acanthosis, and other trophic skin changes. Correspondingly, lymphedema results in psychological morbidity, including anxiety, depression, social avoidance, and a decreased quality of life, encompassing emotional, functional, physical, and social domains. For this review, we conducted a literature search using PubMed and EMBASE and herein summarize the evidence related to the fundamental concepts of lymphedema. This article aims to raise awareness of this serious condition and outline and review the fundamental concepts of lymphedema.
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Affiliation(s)
- Oscar J Manrique
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, MN.
| | - Samyd S Bustos
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, MN
| | - Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Kian Adabi
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, MN
| | - Wei F Chen
- Division of Plastic and Reconstructive Surgery, University of Iowa, Iowa City
| | | | - Andrea L Cheville
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN
| | | | | | - Hung-Chi Chen
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
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Brown S, Mehrara BJ, Coriddi M, McGrath L, Cavalli M, Dayan JH. A Prospective Study on the Safety and Efficacy of Vascularized Lymph Node Transplant. Ann Surg 2022; 276:635-653. [PMID: 35837897 PMCID: PMC9463125 DOI: 10.1097/sla.0000000000005591] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE While vascularized lymph node transplant (VLNT) has gained popularity, there are a lack of prospective long-term studies and standardized outcomes. The purpose of this study was to evaluate the safety and efficacy of VLNT using all available outcome measures. METHODS This was a prospective study on all consecutive patients who underwent VLNT. Outcomes were assessed with 2 patient-reported outcome metrics, limb volume, bioimpedance, need for compression, and incidence of cellulitis. RESULTS There were 89 patients with the following donor sites: omentum (73%), axilla (13%), supraclavicular (7%), groin (3.5%). The mean follow-up was 23.7±12 months. There was a significant improvement at 2 years postoperatively across all outcome measures: 28.4% improvement in the Lymphedema Life Impact Scale, 20% average reduction in limb volume, 27.5% improvement in bioimpedance score, 93% reduction in cellulitis, and 34% of patients no longer required compression. Complications were transient and low without any donor site lymphedema. CONCLUSIONS VLNT is a safe and effective treatment for lymphedema with significant benefits fully manifesting at 2 years postoperatively. Omentum does not have any donor site lymphedema risk making it an attractive first choice.
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Affiliation(s)
- Stav Brown
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
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16
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Leppäpuska IM, Hartiala P, Suominen S, Suominen E, Kaartinen I, Mäki M, Seppänen M, Kiiski J, Viitanen T, Lahdenperä O, Vuolanto A, Alitalo K, Saarikko AM. Phase 1 Lymfactin® Study: 24-month Efficacy and Safety Results of Combined Adenoviral VEGF-C and Lymph Node Transfer Treatment for Upper Extremity Lymphedema. J Plast Reconstr Aesthet Surg 2022; 75:3938-3945. [DOI: 10.1016/j.bjps.2022.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 08/01/2022] [Indexed: 11/16/2022]
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Clinical and Histological Effects of Partial Blood Flow Impairment in Vascularized Lymph Node Transfer. J Clin Med 2022; 11:jcm11144052. [PMID: 35887816 PMCID: PMC9322400 DOI: 10.3390/jcm11144052] [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: 06/14/2022] [Revised: 06/28/2022] [Accepted: 07/10/2022] [Indexed: 11/28/2022] Open
Abstract
Regarding vascularized lymph node transfer (VLNT) for lymphedema, partial blood flow impairment in transferred lymph node (LN) flaps may adversely affect the therapeutic results. We investigated the clinical and histological effects of partial blood flow impairment in LN flaps. In upper extremity lymphedema cases, based on ultrasonographic examination at 2 weeks after VLNT, we compared the treatment results depending on whether the postoperative blood flow in transferred LNs was good (Group G) or poor (Group P). Novel partial ischemia and congestion of LN flap mouse models were developed to determine their histological features. In 42 cases, significant differences were observed between Group G (n = 37) and Group P (n = 5) based on the amount of volume reduction (136.7 ± 91.7 mL and 55.4 ± 60.4 mL, respectively; p = 0.04) and lymph flow recanalization rate in indocyanine green fluorescent lymphography (67.6% and 0%, respectively; p = 0.0007). In mouse models, thrombi formation in the marginal sinus and numerous Myl9/12-positive immunocompetent cells in follicles were observed in congested LNs. Blood flow maintenance in the transferred LNs is an essential factor influencing the therapeutic effect of VLNT. Postoperatively, surgeons should closely monitor blood flow in the transferred LNs, particularly in cases of congestion.
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Ogino R, Yokooji T, Hayashida M, Suda S, Yamakawa S, Hayashida K. Emerging Anti-Inflammatory Pharmacotherapy and Cell-Based Therapy for Lymphedema. Int J Mol Sci 2022; 23:ijms23147614. [PMID: 35886961 PMCID: PMC9322118 DOI: 10.3390/ijms23147614] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 07/05/2022] [Accepted: 07/07/2022] [Indexed: 02/04/2023] Open
Abstract
Secondary lymphedema is a common complication of lymph node dissection or radiation therapy for cancer treatment. Conventional therapies such as compression sleeve therapy, complete decongestive physiotherapy, and surgical therapies decrease edema; however, they are not curative because they cannot modulate the pathophysiology of lymphedema. Recent advances reveal that the activation and accumulation of CD4+ T cells are key in the development of lymphedema. Based on this pathophysiology, the efficacy of pharmacotherapy (tacrolimus, anti-IL-4/IL-13 antibody, or fingolimod) and cell-based therapy for lymphedema has been demonstrated in animal models and pilot studies. In addition, mesenchymal stem/stromal cells (MSCs) have attracted attention as candidates for cell-based lymphedema therapy because they improve symptoms and decrease edema volume in the long term with no serious adverse effects in pilot studies. Furthermore, MSC transplantation promotes functional lymphatic regeneration and improves the microenvironment in animal models. In this review, we focus on inflammatory cells involved in the pathogenesis of lymphedema and discuss the efficacy and challenges of pharmacotherapy and cell-based therapies for lymphedema.
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Affiliation(s)
- Ryohei Ogino
- Department of Frontier Science for Pharmacotherapy, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8553, Japan; (R.O.); (T.Y.)
| | - Tomoharu Yokooji
- Department of Frontier Science for Pharmacotherapy, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8553, Japan; (R.O.); (T.Y.)
| | - Maiko Hayashida
- Department of Psychiatry, Faculty of Medicine, Shimane University, 89-1 Enya-cho, Izumo 693-8501, Japan;
| | - Shota Suda
- Division of Plastic and Reconstructive Surgery, Faculty of Medicine, Shimane University, 89-1 Enya-cho, Izumo 693-8501, Japan; (S.S.); (S.Y.)
| | - Sho Yamakawa
- Division of Plastic and Reconstructive Surgery, Faculty of Medicine, Shimane University, 89-1 Enya-cho, Izumo 693-8501, Japan; (S.S.); (S.Y.)
| | - Kenji Hayashida
- Division of Plastic and Reconstructive Surgery, Faculty of Medicine, Shimane University, 89-1 Enya-cho, Izumo 693-8501, Japan; (S.S.); (S.Y.)
- Correspondence: ; Tel.: +81-853-20-2210
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Cheon H, Gelvosa MN, Kim SA, Song H, Jeon JY. Lymphatic channel sheet of polydimethylsiloxane for preventing secondary lymphedema in the rat upper limb model. Bioeng Transl Med 2022; 8:e10371. [PMID: 36684082 PMCID: PMC9842043 DOI: 10.1002/btm2.10371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 05/20/2022] [Accepted: 06/12/2022] [Indexed: 01/25/2023] Open
Abstract
Secondary lymphedema is a severe complication of cancer treatment, but there is no effective curative method yet. Lymph node dissection and radiation therapy for cancer treatment may lead to secondary lymphedema, which is a chronic disease induced by malfunction of lymphatic flow. The lymphatic channel sheet (LCS) is an artificial micro-fluidic structure that was fabricated with polydimethylsiloxane to maintain lymphatic flow and induce lymphangiogenesis. The structure has two-dimensional multichannels that increase the probability of lymphangiogenesis and allow for relatively easy application. We verified the efficacy of the lymphatic channel sheet through macroscopic and microscopic observation in small animal models, which underwent brachial lymph node dissection and irradiation. The lymphatic channel sheet enabled the successful transport of lymphatic fluid from the distal to the proximal area in place of the removed brachial lymph nodes. It prevented swelling and abnormal lymphatic drainage during the follow-up period. Lymphangiogenesis was also identified inside the channel by histological analysis after 8 weeks. According to these experimental results, we attest to the roles of the lymphatic channel sheet as a lymphatic pathway and scaffold in the rat upper limb model of secondary lymphedema. The lymphatic channel sheet maintained lymphatic flow after lymph node dissection and irradiation in an environment where lymph flow is cut off. It also relieved symptoms of secondary lymphedema by providing a lymph-friendly space and inducing lymphangiogenesis.
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Affiliation(s)
- Hwayeong Cheon
- Biomedical Engineering Research CenterAsan Institute for Life Sciences, Asan Medical CenterSeoulRepublic of Korea
| | - Ma. Nessa Gelvosa
- Department of Rehabilitation MedicineAsan Medical Center, University of Ulsan College of MedicineSeoulRepublic of Korea
| | - Sang Ah Kim
- Department of Rehabilitation MedicineAsan Medical Center, University of Ulsan College of MedicineSeoulRepublic of Korea
| | - Ho‐Young Song
- Department of Minimal‐Invasive InterventionThe Affiliated Cancer Hospital of Zhengzhou UniversityZhengzhou CityChina
| | - Jae Yong Jeon
- Department of Rehabilitation MedicineAsan Medical Center, University of Ulsan College of MedicineSeoulRepublic of Korea
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20
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Francis EC, Kim BS, Lin MCY, Cheng MH. Vascularized Lymph Node Transfer Improved Outcomes of Elderly Patients with Secondary Upper Extremity Lymphedema. Ann Surg Oncol 2022; 29:7868-7878. [PMID: 35780215 DOI: 10.1245/s10434-022-12035-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 05/30/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Secondary lymphedema is a debilitating morbidity. This study investigated the outcomes of vascularized lymph node transfer (VLNT) in elderly patients with secondary upper extremity lymphedema. METHODS Between 2008 and 2018, elderly (≥65 years) patients with secondary upper extremity lymphedema who underwent VLNT were retrospectively reviewed. Cheng's Lymphedema Grading, Taiwan Lymphoscintigraphy Staging, and indocyanine green lymphography were used to select the procedures. Outcome measurements included complications, circumferential difference, episodes of cellulitis, and the Lymphedema-Specific Quality of Life questionnaire (LYMQoL). RESULTS Eleven patients with a mean age of 70.2 ± 5.3 years (range 65-80 years) who underwent VLNT survived and no major complications were encountered. At a mean follow-up of 6.5 ± 3.6 years (range 2-13 years), the mean limb circumferential difference was significantly improved from 25.6 ± 11.5% to 8.3 ± 4.2% (p = 0.016), and the mean episode of cellulitis was statistically reduced from 2.4 ± 1.3 to 0.4 ± 0.9 times/year (p = 0.007). At a follow-up of 24 months, four domains of Function (from 30.6 ± 2.8 to 14.5 ± 2.5), Appearance (from 18.2 ± 1.9 to 8.5 ± 2.1), Symptoms (from 30.4 ± 5.9 to 10.9 ± 1.0) and Mood (from 29.2 ± 4.4 to 10.7 ± 1.0), as well as overall LYMQoL score (from 3.9 ± 1.1 to 7.4 ± 0.5), showed statistical improvement (all p < 0.05). CONCLUSIONS VLNT for secondary upper extremity lymphedema in elderly patients significantly decreased the limb circumferential difference and frequency of cellulitis and improved quality of life without using compression garments postoperatively.
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Affiliation(s)
- Eamon C Francis
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Plastic and Reconstructive Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Bong-Sung Kim
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Plastic and Hand Surgery, University Hospital of Zurich, Zurich, Switzerland
| | - Miffy Chia-Yu Lin
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Center for Lymphedema Microsurgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Ming-Huei Cheng
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan. .,Center for Tissue Engineering, Chang Gung Memorial Hospital, Taoyuan, Taiwan. .,Center for Lymphedema Microsurgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan. .,Section of Plastic Surgery, The University of Michigan, Ann Arbor, MI, USA.
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21
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Physical and Functional Outcomes of Simultaneous Vascularized Lymph Node Transplant and Lymphovenous Bypass in the Treatment of Lymphedema. Plast Reconstr Surg 2022; 150:169-180. [PMID: 35583944 DOI: 10.1097/prs.0000000000009247] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The authors analyze the outcomes of simultaneous vascularized lymph node transplant and lymphovenous bypass for treatment of primary and secondary lymphedema. To the best of their knowledge, this is the largest study to date with long-term outcome data of this novel approach. METHODS Three hundred twenty-eight patients who underwent physiologic surgical treatment over a 5.5-year period were evaluated using a prospective database and chart review. Preoperative characteristics, operative details, and postoperative outcomes (volume difference change, Lymphedema Life Impact Scale score) were assessed. Statistical analysis including multivariate regression was performed. RESULTS Two hundred twenty patients (67.1 percent) underwent simultaneous vascularized lymph node transplant and lymphovenous bypass. Mean body mass index was 26.9 ± 4.7 kg/m 2 . Ninety-two patients (41.8 percent) had lymphedema of the lower extremity, 121 (55.0 percent) had upper extremity involvement, and seven had lymphedema of upper and lower extremities (3.2 percent). Average duration of lymphedema was 95.4 ± 103.6 months. Thirty patients (13.6 percent) had primary lymphedema and 190 patients (86.4 percent) had secondary lymphedema. The majority improved and experienced volume reduction of an average 21.4 percent at 1 year ( p < 0.0001), 36.2 percent at 2 years ( p < 0.0001), 25.5 percent at 3 years ( p = 0.1), and 19.6 percent at 4 years. Median Lymphedema Life Impact Scale scores were 7.0 points lower ( p < 0.0001) at 3 months and improved progressively over time to 27.5 points lower at 3 years postoperatively ( p < 0.005). CONCLUSIONS Simultaneous vascularized lymph node transplant and lymphovenous bypass is an appropriate and effective approach for both early and advanced stages of primary and secondary lymphedema, with significant objective and subjective improvements. Volume reduction in the affected limb was observed at all time points postoperatively, with significant improvement in Lymphedema Life Impact Scale scores. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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22
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Wang H, Dong D, Liu C, Yuan M, Chen L, Liu T. The Effects of Methylene Blue and Carbon Nanoparticles on Transplanted Lymph Node Survival, Reconstructed Lymphatic Function, and Changes in Inflammatory and Fibrosis Factors. World J Surg 2022; 46:2166-2173. [PMID: 35618946 DOI: 10.1007/s00268-022-06594-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND OBJECTIVES Methylene blue (MB) and carbon nanoparticles (CNs) can be used as a simple method for reverse lymphatic mapping. We investigated whether the two tracers had an impact on the survival of lymph nodes and the function of reconstructed lymph vessels after transplantation, as well as the changes in surrounding related factors. METHODS The stained lymph nodes were non-vascularized transplanted into the contralateral popliteal fossa in mice. After 4 weeks, the lymphatic recanalization was detected. The samples were harvested for pathological detection and PCR. In addition, the transport ability of the recanalized lymphatics to tumor cells was also explored. RESULTS Compared with the control group, there was no significant difference of the MB and CNs groups in the drainage function of recanalized lymphatic vessels, the survival of lymph nodes, or the transport capacity to tumor cells. TNF-α and IL-6 were significantly higher in the two tracer groups (**p < 0.01). Besides, the α-SMA was significantly increased in the CNs group (*p < 0.05). CONCLUSIONS Two tracers have no effect on the survival of transplanted lymph nodes, nor do they affect the drainage ability or tumor cell capture ability of the reconstructed lymphatics, despite improving TNF-α and IL-6 levels and the deposition of CNs.
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Affiliation(s)
- Heng Wang
- Department of Plastic and Aesthetic Surgery, Huadong Hospital Affiliated to Fudan University, Shanghai, China
- Shanghai Key Laboratory of Clinical Geriatric Medicine, Shanghai, China
| | - Dong Dong
- Department of Plastic and Aesthetic Surgery, Huadong Hospital Affiliated to Fudan University, Shanghai, China
- Shanghai Key Laboratory of Clinical Geriatric Medicine, Shanghai, China
| | - Chi Liu
- Department of Plastic and Aesthetic Surgery, Huadong Hospital Affiliated to Fudan University, Shanghai, China
- Shanghai Key Laboratory of Clinical Geriatric Medicine, Shanghai, China
| | - Mingjie Yuan
- Department of Plastic and Aesthetic Surgery, Huadong Hospital Affiliated to Fudan University, Shanghai, China
- Shanghai Key Laboratory of Clinical Geriatric Medicine, Shanghai, China
| | - Liang Chen
- Department of Plastic and Aesthetic Surgery, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Tianyi Liu
- Department of Plastic and Aesthetic Surgery, Huadong Hospital Affiliated to Fudan University, Shanghai, China.
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Hooks JST, Bernard FC, Cruz-Acuña R, Nepiyushchikh Z, Gonzalez-Vargas Y, García AJ, Dixon JB. Synthetic hydrogels engineered to promote collecting lymphatic vessel sprouting. Biomaterials 2022; 284:121483. [PMID: 35428014 PMCID: PMC9134840 DOI: 10.1016/j.biomaterials.2022.121483] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 03/14/2022] [Accepted: 03/21/2022] [Indexed: 12/16/2022]
Abstract
The lymphatic vasculature is an essential component of the body's circulation providing a network of vessels to return fluid and proteins from the tissue space to the blood, to facilitate immune ce-ll and antigen transport to lymph nodes, and to take up dietary lipid from the intestine. The development of biomaterial-based strategies to facilitate the growth of lymphatics either for regenerative purposes or as model system to study lymphatic biology is still in its nascent stages. In particular, platforms that encourage the sprouting and formation of lymphatic networks from collecting vessels are particularly underdeveloped. Through implementation of a modular, poly(ethylene glycol) (PEG)-based hydrogel, we explored the independent contributions of matrix elasticity, degradability, and adhesive peptide presentation on sprouting of implanted segments of rat lymphatic collecting vessels. An engineered hydrogel with 680 Pa elasticity, 2.0 mM RGD adhesive peptide, and full susceptibility to protease degradability produced the highest levels of sprouting relative to other physicochemical matrix properties. This engineered hydrogel was then utilized as a scaffold to facilitate the implantation of a donor vessel that functionally grafted into the host vasculature. This hydrogel provides a promising platform for facilitating lymphangiogenesis in vivo or as a means to understand the cellular mechanisms involved in the sprout process during collecting lymphatic vessel collateralization.
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Affiliation(s)
- Joshua S T Hooks
- Parker H. Petit Institute for Bioengineering and Bioscience, Georgia Institute of Technology, 315 Ferst Dr. Atlanta, GA, 30332, USA; George W. Woodruff School of Mechanical Engineering, Georgia Institute of Technology, 801 Ferst Dr. Atlanta, GA, 30313, USA
| | - Fabrice C Bernard
- Parker H. Petit Institute for Bioengineering and Bioscience, Georgia Institute of Technology, 315 Ferst Dr. Atlanta, GA, 30332, USA; Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, 313 Ferst Dr NW, Atlanta, GA, 30332, USA
| | - Ricardo Cruz-Acuña
- Parker H. Petit Institute for Bioengineering and Bioscience, Georgia Institute of Technology, 315 Ferst Dr. Atlanta, GA, 30332, USA; Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, 313 Ferst Dr NW, Atlanta, GA, 30332, USA
| | - Zhanna Nepiyushchikh
- Parker H. Petit Institute for Bioengineering and Bioscience, Georgia Institute of Technology, 315 Ferst Dr. Atlanta, GA, 30332, USA; George W. Woodruff School of Mechanical Engineering, Georgia Institute of Technology, 801 Ferst Dr. Atlanta, GA, 30313, USA
| | - Yarelis Gonzalez-Vargas
- Parker H. Petit Institute for Bioengineering and Bioscience, Georgia Institute of Technology, 315 Ferst Dr. Atlanta, GA, 30332, USA; George W. Woodruff School of Mechanical Engineering, Georgia Institute of Technology, 801 Ferst Dr. Atlanta, GA, 30313, USA
| | - Andrés J García
- Parker H. Petit Institute for Bioengineering and Bioscience, Georgia Institute of Technology, 315 Ferst Dr. Atlanta, GA, 30332, USA; George W. Woodruff School of Mechanical Engineering, Georgia Institute of Technology, 801 Ferst Dr. Atlanta, GA, 30313, USA; Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, 313 Ferst Dr NW, Atlanta, GA, 30332, USA
| | - J Brandon Dixon
- Parker H. Petit Institute for Bioengineering and Bioscience, Georgia Institute of Technology, 315 Ferst Dr. Atlanta, GA, 30332, USA; George W. Woodruff School of Mechanical Engineering, Georgia Institute of Technology, 801 Ferst Dr. Atlanta, GA, 30313, USA; Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, 313 Ferst Dr NW, Atlanta, GA, 30332, USA.
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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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Bolletta A, di Taranto G, Losco L, Elia R, Sert G, Ribuffo D, Cigna E, Chen HC. Combined lymph node transfer and suction-assisted lipectomy in lymphedema treatment: A prospective study. Microsurgery 2022; 42:433-440. [PMID: 34994481 DOI: 10.1002/micr.30855] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 09/22/2021] [Accepted: 11/29/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Recent studies have analyzed the combination of suction-assisted lipectomy (SAL) and vascularized lymph node transfer (VLNT) in lymphedema treatment, reporting positive outcomes. However, it is difficult to draw conclusions due to the heterogeneity of the studies. Aim of this prospective study is to evaluate the effectiveness of the combination of VLNT and SAL in lymphedema treatment. PATIENTS AND METHODS Between January 2016 and May 2019, 94 patients with upper or lower limb stage IIb-III lymphedema were enrolled and treated with the gastroepiploic VLNT followed by SAL. Patients were prospectively evaluated through circumference measurement and clinical examination, including number of episodes of cellulitis. RESULTS Among patients enrolled in the study 83 were affected by lower limb lymphedema (LLL) and 11 were affected by upper limb lymphedema (ULL). Average follow-up was 3 ± 0.8 years. In the LLL group, the mean circumference reduction rates (CRR) were 60.4, 56.9, 29.6, and 55.4% above and below the knee, above the ankle, and at the foot level, respectively. A statistically significant difference was noted at all the levels (p < .05), but above the ankle (p = .059). Regarding the ULL group, the mean CRR were 80.7, 60.7, 65.0 and 49.6% above and below the elbow, at wrist and at mid-hand, respectively. CRR were reported at all the levels but no statistical difference was noted. The number of episodes of cellulitis dropped significantly (p < .05). CONCLUSION This study supports the use of VLNT+SAL in lymphedema grades IIb-III, with important implications for the clinical practice.
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Affiliation(s)
- Alberto Bolletta
- Department of Plastic Surgery, China Medical University Hospital, Taichung, Taiwan.,Plastic Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Giuseppe di Taranto
- Department of Plastic Surgery, China Medical University Hospital, Taichung, Taiwan.,Plastic Surgery Unit, Department of surgery, Sapienza University of Rome, Italy
| | - Luigi Losco
- Department of Plastic Surgery, China Medical University Hospital, Taichung, Taiwan.,Plastic Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Rossella Elia
- Department of Plastic Surgery, China Medical University Hospital, Taichung, Taiwan.,Unit of Plastic and Reconstructive Surgery, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Gokhan Sert
- Department of Plastic Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Diego Ribuffo
- Plastic Surgery Unit, Department of surgery, Sapienza University of Rome, Italy
| | - Emanuele Cigna
- Plastic Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Hung-Chi Chen
- Department of Plastic Surgery, China Medical University Hospital, Taichung, Taiwan
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26
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Chocron Y, Azzi AJ, Bouhadana G, Kokosis G, Vorstenbosch J. Axilla versus Wrist as the Recipient Site in Vascularized Lymph Node Transfer for Breast Cancer-Related Lymphedema: A Systematic Review and Meta-Analysis. J Reconstr Microsurg 2021; 38:539-548. [PMID: 34875698 DOI: 10.1055/s-0041-1740132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Vascularized lymph node transfers (VLNT) are being used with increasing frequency for the treatment of breast cancer-related lymphedema (BCRL). However, there is a lack of consensus in the surgical field as to which recipient site should be utilized. We, therefore, aim to assess the evidence comparing the wrist and axilla as recipient sites for VLNT in BCRL. METHODS We conducted a systematic literature review to compare the wrist and axilla as recipient sites for VLNT in BCRL. Demographic data, as well as circumference reduction rate (CRR), excess volume reduction (EVR), postoperative decrease in infections per year, postoperative discontinuation of compression garments, and overall pooled complication rate were extracted from included studies. These were compared through a meta-analysis. RESULTS A total of 37 studies met the inclusion criteria for a total of 689 patients. VLNTs to the wrist and axilla resulted in a decrease in CRR of 42.1 and 51.5%, and a decrease in EVR of 35.6 and 48.8%, respectively. However, our meta-analysis showed no significant differences between CRR or EVR and between wrist and axilla as recipient sites. Similarly, we found no differences in postoperative decrease in infections per year, postoperative discontinuation of compression garments, and overall pooled complication rate. CONCLUSION These data suggest noninferiority between the wrist and axilla as recipient sites for VLNT in the context of BCRL. In the absence of randomized, prospective data, we hope these results can be used as an evidence-based reference and facilitate future studies.
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Affiliation(s)
- Yehuda Chocron
- Division of Plastic and Reconstructive Surgery, Department of Surgery, McGill University, Montreal, Quebec, Canada
| | - Alain J Azzi
- Division of Plastic and Reconstructive Surgery, Department of Surgery, McGill University, Montreal, Quebec, Canada
| | | | - George Kokosis
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Joshua Vorstenbosch
- Division of Plastic and Reconstructive Surgery, Department of Surgery, McGill University, Montreal, Quebec, Canada
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Nanofibrillar Collagen Scaffold Enhances Edema Reduction and Formation of New Lymphatic Collectors after Lymphedema Surgery. Plast Reconstr Surg 2021; 148:1382-1393. [PMID: 34705812 DOI: 10.1097/prs.0000000000008590] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Treatment of secondary lymphedema remains challenging, with suboptimal rates of edema reduction following physiologic procedures (i.e., lymphaticovenous anastomosis and vascularized lymph node transfer). The objective of this study was to investigate the long-term effect of a nanofibrillar collagen scaffold on edema reduction in lymphedema patients treated with lymphaticovenous anastomosis or vascularized lymph node transfer. METHODS A retrospective cohort study was performed, comparing stage 1 to 3 lymphedema patients who underwent lymphaticovenous anastomosis and/or vascularized lymph node transfer with or without delayed implantation of nanofibrillar collagen scaffold (BioBridge) from 2016 to 2019. The primary endpoint was excess volume reduction. Indocyanine green lymphatic mapping was performed to evaluate superficial lymphatic flow. RESULTS Edema reduction was significantly greater for the BioBridge cohort (12-month follow-up, n = 18) compared to controls (18.2-month follow-up, n = 11) (111.5 ± 34.5 percent versus 70.0 ± 19.0 percent; p = 0.0004). This held true in lymphaticovenous anastomosis and vascularized lymph node transfer subgroup analysis. The average rate of edema reduction increased by 3.5-fold in lymphaticovenous anastomosis and 7.6-fold in vascularized lymph node transfer following BioBridge placement. Eighty-eight percent of patients with concurrent liposuction and BioBridge implantation maintained normal volumes at 13 months postoperatively. Lymphatic mapping following BioBridge placement showed significantly more new lymphatic collectors and decreased dermal backflow. The majority of patients (77.8 percent) achieved and maintained normal limb volume at an average total follow-up of 29 months. CONCLUSION Nanofibrillar collagen scaffold implantation enhances overall effectiveness of physiologic procedures, even in the presence of liposuction, and is a promising adjunct therapy for treatment of lymphedema. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Bamba R, Chu A, Gallegos J, Herrera FA, Hassanein AH. Outcomes analysis of microsurgical physiologic lymphatic procedures for the upper extremity from the United States National Surgical Quality Improvement Program. Microsurgery 2021; 42:305-311. [PMID: 34812535 DOI: 10.1002/micr.30844] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 08/21/2021] [Accepted: 10/28/2021] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Physiologic microsurgical procedures to treat lymphedema include vascularized lymph node transfer (VLNT) and lymphovenous bypass (LVB). The purpose of this study was to assess 30-day outcomes of VLNT and LVB using the National Surgical Quality Improvement Program (NSQIP) database. METHODS NSQIP was queried (2012-2018) for lymphatic procedures for upper extremity lymphedema after mastectomy. Prophylactic lymphatic procedures and those for lower extremity lymphedema were excluded. Outcomes were assessed for three groups: LVB, VLNT, and patients who had procedures simultaneously (VLNA+LVB). Primary outcomes measured were operative time, 30-day morbidities, and hospital length of stay. RESULTS The study included 199 patients who had LVB (n = 43), VLNT (n = 145), or VLNT+LVB (n = 11). There was no difference in co-morbidities between the groups (p = 0.26). 30-day complication rates including unplanned reoperation (6.9% VLNT vs. 2.3% LVB) and readmission (0.69% VLNT vs. none in LVB) were not statistically significant (p = 0.54). Surgical site infection, wound complications, deep vein thromboembolism, and cardiac arrest was also similar among the three groups. Postoperative length of stay for VLNT (2.5 days± 2.3), LVB (1.9 days± 1.9), and VLNT+LVB (2.8 days± 0.3) did not differ significantly (p = 0.20). Operative time for LVB (305.4 min ± 186.7), VLNT (254 min ± 164.4), and VLNT+LVB (295.3 min ± 43.2) was not significantly different (p = 0.21). CONCLUSIONS Our analysis of the NSQIP data revealed that VLNT and LVB are procedures with no significant difference in perioperative morbidity. Our results support that choice of VLNT versus LVB can be justifiably made per the surgeon's preference and experience as the operations have similar complication rates.
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Affiliation(s)
- Ravinder Bamba
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Amanda Chu
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jose Gallegos
- Division of Plastic Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Fernando A Herrera
- Division of Plastic Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Aladdin H Hassanein
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
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29
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Daniel BW, Sonnenberg AM, Stern JE, Tannapfel A, Yamamoto T, Ring A. Intra-abdominal lymph node flaps in lymphedema therapy: An anatomical guide to donor site selection. J Surg Oncol 2021; 125:134-144. [PMID: 34634138 DOI: 10.1002/jso.26705] [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: 04/05/2021] [Revised: 09/21/2021] [Accepted: 09/25/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Secondary lymphedema is a leading sequela of cancer surgery and radiotherapy. The microsurgical transfer of lymph node flaps (LNFs) to affected limbs can improve the symptoms. The intra-abdominal cavity contains an abundant heterogenic source. The aim of this study is to aid selection among intra-abdominal LNFs. METHODS Eight LNFs were harvested in a microsurgical fashion at five sites in 16 cadavers: gastroepiploic, jejunal, ileal, ileocolic, and appendicular. These flaps were compared regarding size, weight, arterial diameter, and lymph node (LN) count after histologic verification. RESULTS One hundred and sixteen flaps were harvested. The exposed area correlated with the flap weight and volume (r2 = 0.86, r = 0.9). While gastroepiploic LNFs (geLNFs) showed the highest median weight of 99 ml, the jejunal LNFs (jLNFs) had the highest density with 3.8 LNs per 10 ml. The most reliable jLNF was 60 cm from the ligament of Treitz. Three or more LNs were contained in 94% of the jejunal, 88% of the ileal/ileocolic, and 63% of the omental LNs. The ileocolic LNF had the largest arterial diameter of 3 mm, yet the smallest volume. CONCLUSIONS jLNF and ileal LNF provide a reliable, high LN density for simultaneous, smaller recipient sites. geLNFs are more suitable for larger recipient sites.
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Affiliation(s)
- Bassem W Daniel
- Department of Plastic and Reconstructive Surgery, St. Rochus-Hospital, Castrop-Rauxel, Germany.,Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University and Medical College, Taoyuan City, Taiwan.,Department of Plastic Surgery, Freiburg University Medical Center, Freiburg, Germany
| | - Anna M Sonnenberg
- Department of Plastic and Reconstructive Surgery, St. Rochus-Hospital, Castrop-Rauxel, Germany.,Faculty of Medicine, Ruhr-University Bochum, Bochum, Germany
| | - Josef E Stern
- Department of Plastic and Reconstructive Surgery, St. Rochus-Hospital, Castrop-Rauxel, Germany
| | - Andrea Tannapfel
- Institute of Pathology, University Hospital Bergmannsheil, Ruhr-University Bochum, Bochum, Germany
| | - Takumi Yamamoto
- Department of Plastic and Reconstructive Surgery, Center Hospital of National Center for Global Health and Medicine, Tokyo, Japan
| | - Andrej Ring
- Department of Plastic and Reconstructive Surgery, St. Rochus-Hospital, Castrop-Rauxel, Germany.,Faculty of Medicine, Ruhr-University Bochum, Bochum, Germany
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30
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Jarvis NR, Torres RA, Avila FR, Forte AJ, Rebecca AM, Teven CM. Vascularized omental lymphatic transplant for upper extremity lymphedema: A systematic review. Cancer Rep (Hoboken) 2021; 4:e1370. [PMID: 33826249 PMCID: PMC8388172 DOI: 10.1002/cnr2.1370] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 02/20/2021] [Accepted: 03/01/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Vascularized omental lymphatic transplant (VOLT) is an increasingly popular treatment of extremity lymphedema given its promising donor site. While the success of VOLT in the treatment of lymphedema has been reported previously, several questions remain. AIM To further elucidate appropriate use of VOLT in the treatment of lymphedema, specifically addressing patient selection, harvest technique, and operative methods. METHODS AND RESULTS A systematic review of VOLT for upper extremity lymphedema was performed. Of 115 yield studies, seven were included for analysis based on inclusion and exclusion criteria. Included studies demonstrated significant reductions in extremity circumference/volume (average volume reduction, 22.7%-39.5%) as well as subjective improvements using patient-reported outcomes. Though studies are heterogenous and limited, when analyzed in aggregate, suggest the efficacy of VOLT in lymphedema treatment. CONCLUSION This is the largest systematic review of VOLT to date. VOLT continues to show promise as a safe and efficacious surgical intervention for lymphedema in the upper extremity. Further studies are warranted to more definitively identify patients for whom this technique is appropriate as well as ideal harvest and inset technique.
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Affiliation(s)
| | | | | | | | - Alanna M. Rebecca
- Division of Plastic and Reconstructive Surgery, Department of SurgeryMayo ClinicPhoenixArizonaUSA
| | - Chad M. Teven
- Division of Plastic and Reconstructive Surgery, Department of SurgeryMayo ClinicPhoenixArizonaUSA
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31
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Gupta N, Verhey EM, Torres-Guzman RA, Avila FR, Jorge Forte A, Rebecca AM, Teven CM. Outcomes of Lymphovenous Anastomosis for Upper Extremity Lymphedema: A Systematic Review. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3770. [PMID: 34476159 PMCID: PMC8386908 DOI: 10.1097/gox.0000000000003770] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 06/21/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Lymphovenous anastomosis (LVA) is an accepted microsurgical treatment for lymphedema of the upper extremity (UE). This study summarizes and analyzes recent data on the outcomes associated with LVA for UE lymphedema at varying degrees of severity. METHODS A literature search was conducted in the PubMed database to extract articles published through June 19, 2020. Studies reporting data on postoperative improvement in limb circumference/volume or subjective improvement in quality of life for patients with primary or secondary lymphedema of the UE were included. Extracted data consisted of demographic data, number of patients and upper limbs, duration of symptoms before LVA, surgical technique, follow-up, and objective and subjective outcomes. RESULTS A total of 92 articles were identified, of which 16 studies were eligible for final inclusion comprising a total of 349 patients and 244 upper limbs. The average age of patients ranged from 38.4 to 64 years. The duration of lymphedema before LVA ranged from 9 months to 7 years. The mean length of follow-up ranged from 6 months to 8 years. Fourteen studies reported an objective improvement in limb circumference or volume measurements following LVA, ranging from 0% to 100%. Patients included had varying severity of lymphedema, ranging from Campisi stage I to IV. The maximal improvement in objective measurements was found in patients with lower stage lymphedema. CONCLUSION LVA is a safe, effective technique for the treatment of UE lymphedema refractory to decompressive treatment. Results of LVA indicate greater efficacy in earlier stages of lymphedema before advanced lymphatic sclerosis.
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Affiliation(s)
- Nikita Gupta
- From the Mayo Clinic Alix School of Medicine, Scottsdale, Ariz
| | - Erik M. Verhey
- University of Notre Dame, Department of Biological Sciences, Notre Dame, Ind
| | - Ricardo A. Torres-Guzman
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Mayo Clinic, Jacksonville, Fla
| | - Francisco R. Avila
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Mayo Clinic, Jacksonville, Fla
| | - Antonio Jorge Forte
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Mayo Clinic, Jacksonville, Fla
| | - Alanna M. Rebecca
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Mayo Clinic, Jacksonville, Fla
| | - Chad M. Teven
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Mayo Clinic, Phoenix, Ariz
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Yang JCS, Wu SC, Hayashi A, Lin WC, Huang GK, Tsai PY, Chien PC, Hsieh CH. Lower Limb Lymphedema Patients Can Still Benefit from Supermicrosurgical Lymphaticovenous Anastomosis (LVA) after Vascularized Lymph Node Flap Transfer (VLNT) as Delayed Lymphatic Reconstruction-A Retrospective Cohort Study. J Clin Med 2021; 10:jcm10143121. [PMID: 34300287 PMCID: PMC8305302 DOI: 10.3390/jcm10143121] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 07/12/2021] [Accepted: 07/13/2021] [Indexed: 12/17/2022] Open
Abstract
Background: For lymphedema patients who received a vascularized lymph node flap transfer (VLNT) as their primary treatment, what are the treatment options when they seek further improvement? With recent publications supporting the use of lymphaticovenous anastomosis (LVA) for treating severe lymphedema, we examined whether LVA could benefit post-VLNT patients seeking further improvement. Methods: This retrospective cohort study enrolled eight lymphedema patients with nine lymphedematous limbs (one patient suffered from bilateral lower limb lymphedema) who had received VLNT as their primary surgery. Patients with previous LVA, liposuction, excisional therapy, or incomplete data were excluded. LVA was performed on nine lower lymphedematous limbs. Demographic data and intraoperative findings were recorded. Preoperative and postoperative limb volumes were measured with magnetic resonance volumetry. The primary outcome was the limb volume measured 6 months post-LVA. Results: The median duration of lymphedema before LVA was 10.5 (4.9–15.3) years. The median waiting time between VLNT and LVA was 41.4 (22.3–97.9) months. The median volume gained in the lymphedematous limb was 3836 (2505–4584) milliliters (mL). The median post-LVA follow-up period was 18 (6–30) months. Significant 6-month and 1-year post-LVA percentage volume reductions were found compared to pre-LVA volume (both p < 0.001). Conclusion: Based on the results from this study, the authors recommend the use of LVA as a secondary procedure for post-VLNT patients seeking further improvement.
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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 833253, Taiwan; (P.-Y.T.); (P.-C.C.); (C.-H.H.)
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
- Correspondence: ; Tel.: +886-7-7317123 (ext. 8002)
| | - Shao-Chun Wu
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833253, Taiwan;
- College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan; (W.-C.L.); (G.-K.H.)
| | - Akitatsu Hayashi
- Department of Lymphedema Center, Kameda General Hospital, Chiba 296-0041, Japan;
| | - Wei-Che Lin
- College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan; (W.-C.L.); (G.-K.H.)
- Department of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833253, Taiwan
| | - Gong-Kai Huang
- College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan; (W.-C.L.); (G.-K.H.)
- Department of Pathology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833253, Taiwan
| | - Pei-Yu Tsai
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833253, Taiwan; (P.-Y.T.); (P.-C.C.); (C.-H.H.)
- College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan; (W.-C.L.); (G.-K.H.)
| | - Peng-Chen Chien
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833253, Taiwan; (P.-Y.T.); (P.-C.C.); (C.-H.H.)
- College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan; (W.-C.L.); (G.-K.H.)
| | - Ching-Hua Hsieh
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833253, Taiwan; (P.-Y.T.); (P.-C.C.); (C.-H.H.)
- College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan; (W.-C.L.); (G.-K.H.)
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Ward J, King I, Monroy-Iglesias M, Russell B, van Hemelrijck M, Ramsey K, Khan AA. A meta-analysis of the efficacy of vascularised lymph node transfer in reducing limb volume and cellulitis episodes in patients with cancer treatment-related lymphoedema. Eur J Cancer 2021; 151:233-244. [PMID: 34092349 DOI: 10.1016/j.ejca.2021.02.043] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 02/22/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND Lymphoedema after cancer treatment is a chronic and disabling complication that presents a significant health care burden during survivorship with limited treatment options. Vascularised lymph node transfer (VLNT) can reconstruct lymphatic flow to reduce limb volumes, but limited higher-order evidence exists to support its effectiveness. AIM The aim of the study was to systematically review and meta-analyse the effectiveness of VLNT in reducing upper limb (UL) or lower limb (LL) volume and cellulitis episodes in patients with cancer treatment-related lymphoedema (CTRL). METHODS PubMed, Medline (Ovid) and Embase databases were searched between January 1974 and December 2019. Full-length articles where VLNT was the sole therapeutic procedure for CTRL, reporting volumetric limb, frequency of infection episodes and/or lymphoedema-specific quality-of-life data, were included in a random-effects meta-analysis of circumferential reduction rate (CRR). Methodological quality was assessed using STROBE/CONSORT, and a novel, lymphoedema-specific scoring tool was used to assess lymphoedema-specific methodological reporting. Sensitivity analyses on the site of VLNT harvest and recipient location were performed. RESULTS Thirty-one studies (581 patients) were eligible for inclusion. VLNT led to significant limb volume reductions in UL (above elbow pooled CRRs [CRRP] = 42.7% [95% confidence interval (CI): 36.5-48.8]; below elbow CRRP = 34.1% [95% CI: 33.0-35.1]) and LL (above knee CRRP = 46.8% [95% CI: 43.2-50.4]; below knee CRRP = 54.6% [95% CI: 39.0-70.2]) CTRL. VLNT flaps from extra-abdominal donor sites were associated with greater volume reductions (CRRP = 49.5% [95% CI: 46.5-52.5]) than those from intra-abdominal donor sites (CRRP = 39.6% [95% CI: 37.2-42.0]) and synchronous autologous breast reconstruction/VLNT flaps (CRRP = 32.7% [95% CI: 11.1-54.4]) (p < 0.05). VLNT was also found to reduce the mean number of cellulitis episodes by 2.1 episodes per year (95% CI: -2.7- -1.4) and increased lymphoedema-specific quality-of-life scores (mean difference in Lymphoedema-Specific Quality of Life (LYMQOL) "overall domain" = +4.26). CONCLUSIONS VLNT is effective in reducing excess limb volume and cellulitis episodes in both UL and LL lymphoedema after cancer treatment. However, significant heterogeneity exists in outcome reporting, and standardisation of reporting processes is recommended.
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Affiliation(s)
- Joseph Ward
- Department of Plastic Surgery, The Royal Marsden NHS Foundation Trust, London, UK
| | - Ian King
- Department of Plastic Surgery, The Royal Marsden NHS Foundation Trust, London, UK
| | - Maria Monroy-Iglesias
- Department of Translational Oncology and Urology Research, King's College London, London, UK
| | - Beth Russell
- Department of Translational Oncology and Urology Research, King's College London, London, UK
| | - Mieke van Hemelrijck
- Department of Translational Oncology and Urology Research, King's College London, London, UK
| | - Kelvin Ramsey
- Department of Plastic Surgery, The Royal Marsden NHS Foundation Trust, London, UK
| | - Aadil A Khan
- Department of Plastic Surgery, The Royal Marsden NHS Foundation Trust, London, UK.
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The Lymph-Sparing Quotient: A Retrospective Risk Analysis on Extremity Radiation for Soft Tissue Sarcoma Treatment. Cancers (Basel) 2021; 13:cancers13092113. [PMID: 33925683 PMCID: PMC8125651 DOI: 10.3390/cancers13092113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 04/22/2021] [Accepted: 04/24/2021] [Indexed: 01/06/2023] Open
Abstract
Simple Summary Soft tissue sarcomas, a heterogenous group of tumors with a mesenchymal origin, are mostly located in the extremities and are commonly treated with surgery and radiotherapy. Using opportunities of reducing long-term therapy-related side effects in soft tissue sarcoma treatment is an important task for all physicians involved in soft tissue sarcoma treatment. The extent of lymph-sparing volume in adjuvant radiation therapy of extremity soft tissue sarcoma as a risk factor for lymphedema was analyzed in this study. Patients with a low lymph-sparing volume showed an increased risk of lymphedema in this retrospective study. Maximizing the potential oncologically justifiable lymph-sparing volume should be considered to reduce the risk of high-grade lymphedema when applying RT to extremities. Abstract Radiation therapy (RT) for extremity soft tissue sarcoma is associated with lymphedema risk. In this study, we analyzed the influence of lymph-sparing volume on the lymphedema occurrence in patients who received adjuvant extremity RT. The lymph-sparing quotient (LSQ) was calculated by dividing the lymph-sparing volume by the total extremity volume with double weightingfor the narrowest lymph-sparing region. A total of 34 patients were enrolled in this analysis. The median applied total radiation dose was 66.3 Gy in 36 fractions. Acute lymphedema appeared in 12 patients (35%). Most of them (n = 8) were lymphedema grade 1 and five patients had grade 2 to 3 lymphedema. Chronic lymphedema appeared in 22 patients (65%). 17 of these patients had at least a grade 2 lymphedema. In 13 of 14 patients with an LSQ ≤ 0.2 and 11 of 20 patients with an LSQ > 0.2, an acute or chronic lymphedema ≥ grade 2 was observed. A Kaplan–Meier Analysis of the two groups with the endpoint of a two-year lymph edema-free survival (=2-YLEFS) was estimated with an univariate, significant result (2-YLEFS LSQ ≤ 0.2 vs. LSQ > 0.2: 0% vs. 39%; p = 0.006; hazard ratio LSQ ≤ 0.2 vs. > 0.2 2-YLEFS 2.822 (p = 0.013); 95% confidence interval (CI): 1.24–6.42). Maximizing the potential oncologically-justifiable lymph-sparing volume should be considered to reduce the risk of high-grade lymphedema when applying RT to extremities.
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Ciudad P, Chen HC, Bustos SS, Manrique OJ, Bolletta A, Forte AJ, Huayllani MT, Agko M, Urbina JA, Date S, Kaya B. The deep inferior epigastric lymphatic cable flap connected to gastroepiploic lymph node flap for treatment of refractory chylous ascites: Report of two cases. Microsurgery 2021; 41:376-383. [PMID: 33864636 DOI: 10.1002/micr.30736] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 02/04/2021] [Accepted: 03/03/2021] [Indexed: 12/23/2022]
Abstract
Chylous ascites is the leakage of lipid-rich lymph into the peritoneal cavity usually due to disruption of lymphatics or increased peritoneal lymphatic pressure. Various surgical options have been proposed to treat chylous ascites but most have shown suboptimal outcomes. The gastroepiploic vascularized lymph node (GE-VLN) flap has been described previously for the treatment of lymphedema. In chylous ascites, this flap could provide an alternate drainage pathway for the intraperitoneal chylous fluid. The purpose of this report is to present another option for the microsurgical treatment of refractory chylous ascites. Herein, we report two patients with refractory chylous ascites secondary to cancer who have undergone deep inferior epigastric-based lymphatic "cable" flap (DIE-LCF) connected to a pedicle GE-VLN flap. Patients were followed-up for a minimum of 2 years. Within the first 3 months following surgery, the patient's nutritional parameters improved along with drastic reduction of ascites. At 2 years follow-up postoperative abdominal circumference decreased significantly. None required further peritoneal paracentesis and all patients were free of chylous ascites symptoms. In conclusion, the DIE-LCF connected to a pedicle GE-VLN flap could be a feasible option for the microsurgical treatment of refractory chylous ascites.
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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.,Department of Biotechnology, Experimental Surgery Unit, The Child Health's Institute (Breña), Lima, Peru
| | - Hung-Chi Chen
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Samyd S Bustos
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Oscar J Manrique
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York, USA
| | - Alberto Bolletta
- Department of Translational Research and New Technologies in Medicine and Surgery, Plastic Surgery Unit, University of Pisa, Pisa, Italy
| | - Antonio J Forte
- Department of Plastic and Reconstructive Surgery, Mayo Clinic, Florida, Jacksonville, USA
| | - Maria T Huayllani
- Department of Plastic and Reconstructive Surgery, Mayo Clinic, Florida, Jacksonville, USA
| | - Mouchammed Agko
- Section of Plastic Surgery, Medical College of Georgia, Augusta University, Augusta, Georgia, USA
| | | | - Shivprasad Date
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan.,Padmashree Dr D Y Patil Medical College, Plastic & Reconstructive Surgery, Nerul Navi, Mumbai, India.,China Medical University Hospital, Plastic & Reconstructive Surgery, Taichung, Taiwan
| | - Burak Kaya
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
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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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Jia W, Hitchcock-Szilagyi H, He W, Goldman J, Zhao F. Engineering the Lymphatic Network: A Solution to Lymphedema. Adv Healthc Mater 2021; 10:e2001537. [PMID: 33502814 PMCID: PMC8483563 DOI: 10.1002/adhm.202001537] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Revised: 11/06/2020] [Indexed: 12/18/2022]
Abstract
Secondary lymphedema is a life-long disorder characterized by chronic tissue swelling and inflammation that obstruct interstitial fluid circulation and immune cell trafficking. Regenerating lymphatic vasculatures using various strategies represents a promising treatment for lymphedema. Growth factor injection and gene delivery have been developed to stimulate lymphangiogenesis and augment interstitial fluid resorption. Using bioengineered materials as growth factor delivery vehicles allows for a more precisely targeted lymphangiogenic activation within the injured site. The implantation of prevascularized lymphatic tissue also promotes in situ lymphatic capillary network formation. The engineering of larger scale lymphatic tissues, including lymphatic collecting vessels and lymph nodes constructed by bioengineered scaffolds or decellularized animal tissues, offers alternatives to reconnecting damaged lymphatic vessels and restoring lymph circulation. These approaches provide lymphatic vascular grafting materials to reimpose lymphatic continuity across the site of injury, without creating secondary injuries at donor sites. The present work reviews molecular mechanisms mediating lymphatic system development, approaches to promoting lymphatic network regeneration, and strategies for engineering lymphatic tissues, including lymphatic capillaries, collecting vessels, and nodes. Challenges of advanced translational applications are also discussed.
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Affiliation(s)
- Wenkai Jia
- Department of Biomedical Engineering, Texas A&M University, College Station, TX 77845
| | | | - Weilue He
- Department of Biomedical Engineering, Michigan Technological University, Houghton, MI 49931
| | - Jeremy Goldman
- Department of Biomedical Engineering, Michigan Technological University, Houghton, MI 49931
| | - Feng Zhao
- Department of Biomedical Engineering, Texas A&M University, College Station, TX 77845
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Advancements in Reconstructive Surgery Broaden Opportunities for Salvage of the Injured Lower Extremity. Ann Plast Surg 2021; 84:238-245. [PMID: 31513085 DOI: 10.1097/sap.0000000000001977] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Advancements in microsurgery have made lower extremity reconstruction possible even after major soft tissue loss or tibial nerve disruption. There is an ongoing paradigm shift in the indications for amputation versus salvage and in flap selection protocols for different areas of the lower extremity. Initial evaluation, patient selection, triage, and timing of reconstruction are essential factors that can influence functional and aesthetic outcomes. The emergence of perforator flaps and the application of new concepts such as free-style flaps, propeller perforator flaps, thinning of free flaps, and supermicrosurgery have provided reconstructive surgeons with many techniques to decrease donor-site morbidity and improve outcomes. This includes options for reconstruction on extremities with single or no adequate runoff vessels. We present a review of the major advancements in reconstructive surgery for salvage of the traumatic lower extremity.
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Albano NJ, Zeng W, Lin C, Uselmann AJ, Eliceiri KW, Poore SO. Augmentation of Chicken Thigh Model with Fluorescence Imaging Allows for Real-Time, High Fidelity Assessment in Supermicrosurgery Training. J Reconstr Microsurg 2020; 37:514-518. [PMID: 33378772 DOI: 10.1055/s-0040-1722184] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND The skills required for supermicrosurgery are hard-earned and difficult to master. The University of Wisconsin "blue-blood" chicken thigh model incorporates perfusion of the thigh vessels with a blue liquid solution, allowing users to visualize flow across their anastomoses. This model has proven to be an excellent source of small vessels (down to 0.3 mm) but assessing the quality of anastomoses at this spatial scale has proven difficult. We evaluated whether fluorescent imaging with indocyanine green (ICG) in this realistic training model would enhance the assessment of supermicrosurgical anastomoses, and therefore improve real-time feedback to trainees. METHODS Anastomoses of vessels ranging from 0.35 to 0.55mm in diameter were performed followed by the capture of white light with and without fluorescence imaging overlay during infusion of "blue-blood" and ICG. Videos were randomized and shown to seven fellowship-trained microsurgeons at the University of Wisconsin-Madison who rated each anastomosis as "patent," "not patent," or "unsure." Surgeon accuracy, uncertainty, and inter-rater agreement were measured for each imaging modality. RESULTS Use of fluorescence significantly increased surgeon accuracy to 91% compared with 47% with white light alone (p = 0.015), decreased surgeon uncertainty to 4% compared with 41% with white light alone (p = 0.011), and improved inter-rater agreement from 53.1% with white light alone to 91.8% (p = 0.016). CONCLUSION Augmentation of the University of Wisconsin "blue-blood" chicken thigh model with ICG fluorescence improves accuracy, decreases uncertainty, and improves inter-rater agreement when assessing supermicrosurgical anastomoses in a training setting. This improved, real-time feedback enhances this model's value as a supermicrosurgical training tool.
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Affiliation(s)
- Nicholas J Albano
- Division of Plastic Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Weifeng Zeng
- Division of Plastic Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Christie Lin
- OnLume Inc., Madison, Wisconsin.,Department of Medical Physics, University of Wisconsin, Madison, Wisconsin
| | | | - Kevin W Eliceiri
- OnLume Inc., Madison, Wisconsin.,Department of Medical Physics, University of Wisconsin, Madison, Wisconsin
| | - Samuel O Poore
- Division of Plastic Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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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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41
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Decreasing donor site morbidity after groin vascularized lymph node transfer with lessons learned from a 12-year experience and review of the literature. J Plast Reconstr Aesthet Surg 2020; 74:540-548. [PMID: 33248939 DOI: 10.1016/j.bjps.2020.10.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 05/23/2020] [Accepted: 10/19/2020] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Donor site morbidity related to vascularized lymph node transfer (VLNT) remains a cause of worry among surgeons. As such, our study explores donor site morbidity after VLNT with or without concomitant deep inferior epigastric artery perforator (DIEP) flap breast reconstruction. Furthermore, we evaluate our surgical approach to ascertain whether it reduces the morbidity rate. MATERIALS AND METHODS A retrospective chart review of donor site complications and surgical techniques was performed from 2006 to 2018. The patients' medical histories and demographic data were analyzed for risk factors. Patients were contacted by telephone for a long-term follow-up questionnaire. A literature review was implemented to evaluate the reported donor site complications and surgical strategies in literature. Complications were evaluated with and without concomitant autologous breast reconstruction (DIEP flap). RESULTS Eighty-nine patients were included in our case series. Sixty-five cases (73%) were combined with DIEP flap breast reconstruction. Seroma rate diminished from 60% in the first 39 cases to 18% in the last five years (50 cases) (p < 0,001). Lymphedema of the afferent lower limb is described in the literature but did not occur in our series. CONCLUSIONS Seroma formation is the most common donor site morbidity after groin VLNT flap harvest, particularly when combined with DIEP flap breast reconstruction. This paper contains the largest reported series of combined VLNT + DIEP flaps and describes surgical strategies on how to decrease seroma formation and avoid iatrogenic lymphedema of the lower limb.
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Phan R, Seifman MA, Dhillon R, Lim P, Hunter-Smith DJ, Rozen WM. Use of submental and submandibular free vascularized lymph node transfer for treatment of scrotal lymphedema: Report of two cases. Microsurgery 2020; 40:808-813. [PMID: 32985738 DOI: 10.1002/micr.30651] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 08/02/2020] [Accepted: 08/28/2020] [Indexed: 02/05/2023]
Abstract
Genital lymphedema is a rare condition in males that can lead to difficulty in voiding, sexual function, hygiene, and mobility. Only several methods of treatment have been developed and studied, primarily focusing on restoring patency of diseased lymph channels or resection of affected tissue. We are the first to describe the surgical technique and our experience of using free submental and submandibular arterio-venous vascularized lymph node transfer specifically for the treatment of scrotal edema. We report on two patients who have undergone selective neck dissection of submental and submandibular lymph nodes based off the facial artery and vein. These vascularized lymph nodes were then transferred to the groin, with anastomosis to the deep inferior epigastric perforator artery and vein. The first patient, a 63 year old had initial pretreatment measurement of the anal verge to base of penis was 18 cm in length, and maximum circumference of scrotum 27 cm for the first patient, and 31-42 cm, respectively, for the second patient, a 66 year old. At 9-month review for the first patient and 6-month review for the second patient, both donor and recipient site wounds had healed. The anal verge to base of penis length had decreased to 16 cm, while maximum circumference of scrotum had decreased to 23 cm, and 25-38 cm, respectively, for the second patient. We have had good success with reducing the burden on patients using this novel technique, and hence it should be considered as a viable treatment methodology in appropriately selected patients.
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Affiliation(s)
- Robert Phan
- Peninsula Clinical School, Central Clinical School, Faculty of Medicine, Monash University, Frankston, Victoria, Australia
| | - Marc A Seifman
- Peninsula Clinical School, Central Clinical School, Faculty of Medicine, Monash University, Frankston, Victoria, Australia
| | - Raminder Dhillon
- Peninsula Clinical School, Central Clinical School, Faculty of Medicine, Monash University, Frankston, Victoria, Australia
| | - Pelicia Lim
- Peninsula Clinical School, Central Clinical School, Faculty of Medicine, Monash University, Frankston, Victoria, Australia
| | - David J Hunter-Smith
- Peninsula Clinical School, Central Clinical School, Faculty of Medicine, Monash University, Frankston, Victoria, Australia
| | - Warren M Rozen
- Peninsula Clinical School, Central Clinical School, Faculty of Medicine, Monash University, Frankston, Victoria, Australia
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Michelini S, Ricci M, Serrani R, Stuppia L, Beccari T, Veselenyiova D, Kenanoglu S, Barati S, Kurti D, Baglivo M, Basha SH, Krajcovic J, Dundar M, Bertelli M. Possible Role of the RORC Gene in Primary and Secondary Lymphedema: Review of the Literature and Genetic Study of Two Rare Causative Variants. Lymphat Res Biol 2020; 19:129-133. [PMID: 32960152 DOI: 10.1089/lrb.2020.0030] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background: RAR-related Orphan Receptor C (RORC) is a DNA-binding transcription factor and the key transcription factor responsible for differentiation of T helper 17 cells. The RORC gene plays a role in lymphoid organogenesis, thymopoiesis, and lymph node organogenesis. The aim of our study was to determine the possible role of RORC in the development of lymphatic system malformations by combining data from the scientific literature and next-generation sequencing of RORC in lymphedema patients negative for known causative genes. Methods and Results: We sequenced RORC in 235 lymphedema patients negative for known lymphedema-associated genes. We found two probands carrying nonsense RORC variants. Conclusions: We show that RORC is important for normal function of the lymphatic system and that a rare variant with a possible causative effect may imply predisposition for lymphedema.
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Affiliation(s)
- Sandro Michelini
- Department of Vascular Rehabilitation, San Giovanni Battista Hospital, Rome, Italy
| | - Maurizio Ricci
- Rehabilitative Medicine, University Hospital, Ospedali Riuniti of Ancona, Torrette, Italy
| | - Roberta Serrani
- Rehabilitative Medicine, University Hospital, Ospedali Riuniti of Ancona, Torrette, Italy
| | - Liborio Stuppia
- Aging and Translational Medicine Research Center (CeSI-MeT), University "G. d'Annunzio," Chieti-Pescara, Italy
| | - Tommaso Beccari
- Department of Pharmaceutical Sciences, University of Perugia, Via Fabretti 48, Perugia, Italy
| | - Dominika Veselenyiova
- Department of Biology, Faculty of Natural Sciences, University of Ss. Cyril and Methodius in Trnava, Trnava, Slovakia
- MAGI Euregio, Bolzano, Italy
| | - Sercan Kenanoglu
- MAGI Euregio, Bolzano, Italy
- Department of Medical Genetics, Erciyes University, Kayseri, Turkey
| | | | - Danjela Kurti
- MAGI Euregio, Bolzano, Italy
- MAGI-Balkan, Tirana, Albania
| | | | | | - Juraj Krajcovic
- Department of Biology, Faculty of Natural Sciences, University of Ss. Cyril and Methodius in Trnava, Trnava, Slovakia
| | - Munis Dundar
- Department of Medical Genetics, Erciyes University, Kayseri, Turkey
| | - Matteo Bertelli
- MAGI Euregio, Bolzano, Italy
- EBTNA-Lab, Rovereto, TN, Italy
- MAGI's Lab, Rovereto, TN, Italy
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Ramachandran S, Chew KY, Tan BK, Kuo YR. Current operative management and therapeutic algorithm of lymphedema in the lower extremities. Asian J Surg 2020; 44:46-53. [PMID: 32950353 DOI: 10.1016/j.asjsur.2020.08.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 08/16/2020] [Accepted: 08/19/2020] [Indexed: 10/23/2022] Open
Abstract
Lymphedema is defined as the abnormal accumulation of interstitial fluid in subcutaneous tissues resulting from cancer, cancer treatment (surgery and/or radiotherapy), infection, inflammatory disorders, obesity, and hereditary syndromes. Surgical management of lymphedema can be broadly classified into two categories, reductive surgical techniques such as direct excision, suction assisted protein lipectomy (SAPL) or radical reduction with perforator preservation (RRPP); and physiological surgical procedures such as lymphaticovenous anastomosis (LVA) and vascularised lymph node transfer (VLNT). These techniques and their various combinations were evaluated. The results revealed patients with reversible lymphedema (ISL stage I, mild severity) benefit most from physiological procedures (LVA or VLNT) which can reduce the chance of disease progression to the chronic, solid phase. Reductive techniques such as SAPL, RPPP, or direct excision procedures should be reserved for patients with advanced - severe lymphedema (ISL stages II and especially stage III) as the surgical treatment of choice. In this study, current literature on the surgical treatment of lower extremity lymphedema is reviewed and discussed in conjunction with authors' clinical experiences. An algorithm is presented, based on clinical evidence and experience which aims to provide a structured approach to managing lower limb lymphedema.
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Affiliation(s)
- Savitha Ramachandran
- Department of Plastic and Reconstructive Surgery, Singapore General Hospital, Singapore
| | - Khong-Yik Chew
- Department of Plastic and Reconstructive Surgery, Singapore General Hospital, Singapore
| | - Bien-Keem Tan
- Department of Plastic and Reconstructive Surgery, Singapore General Hospital, Singapore
| | - Yur-Ren Kuo
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Biological Sciences, National Sun Yat-sen University, Kaohsiung, Taiwan; SingHealth Duke-NUS Musculoskeletal Sciences Academic Clinical Programme, Singapore.
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Hartiala P, Suominen S, Suominen E, Kaartinen I, Kiiski J, Viitanen T, Alitalo K, Saarikko AM. Phase 1 LymfactinⓇ Study: Short-term Safety of Combined Adenoviral VEGF-C and Lymph Node Transfer Treatment for Upper Extremity Lymphedema. J Plast Reconstr Aesthet Surg 2020; 73:1612-1621. [DOI: 10.1016/j.bjps.2020.05.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 04/01/2020] [Accepted: 05/09/2020] [Indexed: 11/24/2022]
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Hu LR, Pan J. Adipose-derived stem cell therapy shows promising results for secondary lymphedema. World J Stem Cells 2020; 12:612-620. [PMID: 32843917 PMCID: PMC7415246 DOI: 10.4252/wjsc.v12.i7.612] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 03/29/2020] [Accepted: 06/02/2020] [Indexed: 02/06/2023] Open
Abstract
Lymphedema is mainly identified by progressive soft tissue swelling in impaired lymphatic system. Secondary lymphedema attributed to cancer therapy, parasite infection, and trauma remains a serious global disease. Patients with lymphedema suffer swelling, pain, and fatigue, with the dysfunction of the deformed extremities reducing the quality of life and increasing the risk of infection and lymphangiosarcoma. Adipose-derived stem cells (ADSCs) possess prominent regenerative potential to differentiate into multilineage cells, and produce various lymphangiogenic factors, making ADSC therapy a promising approach for lymphedema. The development of lymphedema consists of local inflammation, the fibrosis of lymphatic vessels, and the deposition of adipose fat. Existing animal models do not mimic the chronic inflammation environment, therefore suitable models are required in further studies. Some signal pathways and molecular mechanisms in physiological and pathological lymphagiogenesis remain unclear. In previous animal and human trials, ADSC therapy reduced edema in varying degrees. A larger number of trials with larger samples and longer follow-up periods are required to verify the efficiency and feasibility of ADSC therapy. ADSCs are of easy availability and immune exemption, making them a candidate for lymphedema treatment. Whether ADSCs enhance malignant characteristics or trigger the malignant change deserves further exploration and study before ADSC therapy can be made widely available.
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Affiliation(s)
- Li-Ru Hu
- State Key Laboratory of Oral Diseases, West China College of Stomatology, Sichuan University, Chengdu 610041, Sichuan Province, China
- Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Jian Pan
- Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu 610041, Sichuan Province, China
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Will PA, Rafiei A, Pretze M, Gazyakan E, Ziegler B, Kneser U, Engel H, Wängler B, Kzhyshkowska J, Hirche C. Evidence of stage progression in a novel, validated fluorescence-navigated and microsurgical-assisted secondary lymphedema rodent model. PLoS One 2020; 15:e0235965. [PMID: 32701960 PMCID: PMC7377415 DOI: 10.1371/journal.pone.0235965] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 06/25/2020] [Indexed: 11/19/2022] Open
Abstract
Secondary lymphedema (SL)is a frequent and devastating complication of modern oncological therapy and filarial infections. A lack of a reliable preclinical model to investigate the underlying mechanism of clinical stage progression has limited the development of new therapeutic strategies. Current first line treatment has shown to be merely symptomatic and relies on lifetime use of compression garments and decongestive physiotherapy. In this study, we present the development of a secondary lymphedema model in 35 rats using pre- and intraoperative fluorescence-guided mapping of the lymphatics and microsurgical induction. In contrast to the few models reported so far, we decided to avoid the use of radiation for lymphedema induction. It turned out, that the model is nearly free of complications and capable of generating a statistically significant limb volume increase by water displacement measurements, sustained for at least 48 days. A translational, accurate lymphatic dysfunction was visualized by a novel VIS-NIR X-ray ICG-Clearance-Capacity imaging technology. For the first-time SL stage progression was validated by characteristic histological alterations, such as subdermal mast cell infiltration, adipose tissue deposition, and fibrosis by increased skin collagen content. Immunofluorescence confocal microscopy analysis suggested that stage progression is related to the presence of a characteristic α SMA+/HSP-47+/vimentin+ fibroblast subpopulation phenotype. These findings demonstrate that the in-vivo model is a reliable and clinically relevant SL model for the development of further secondary lymphedema therapeutic strategies and the analysis of the veiled molecular mechanisms of lymphatic dysfunction.
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Affiliation(s)
- P. A. Will
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Centre, BG-Trauma Hospital Ludwigshafen, Ludwigshafen, Germany
| | - A. Rafiei
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Centre, BG-Trauma Hospital Ludwigshafen, Ludwigshafen, Germany
| | - M. Pretze
- Department of Clinical Radiology and Nuclear Medicine, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - E. Gazyakan
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Centre, BG-Trauma Hospital Ludwigshafen, Ludwigshafen, Germany
| | - B. Ziegler
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Centre, BG-Trauma Hospital Ludwigshafen, Ludwigshafen, Germany
| | - U. Kneser
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Centre, BG-Trauma Hospital Ludwigshafen, Ludwigshafen, Germany
| | - H. Engel
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Centre, BG-Trauma Hospital Ludwigshafen, Ludwigshafen, Germany
- Ethianum Klinik Heidelberg, Heidelberg, Germany
| | - B. Wängler
- Department of Clinical Radiology and Nuclear Medicine, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - J. Kzhyshkowska
- Institute of Transfusion Medicine and Immunology, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
- German Red Cross Blood Service Baden-Württemberg—Hessen, Frankfurt, Germany
| | - C. Hirche
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Centre, BG-Trauma Hospital Ludwigshafen, Ludwigshafen, Germany
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Surgical Approaches to the Prevention and Management of Breast Cancer–Related Lymphedema. CURRENT BREAST CANCER REPORTS 2020. [DOI: 10.1007/s12609-020-00372-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Paulus VAA, Winters H, Hummelink S, Schulten S, Ulrich DJO, Vasilic D. Submental flap for vascularized lymph node transfer; a CTA-based study on lymph node distribution. J Surg Oncol 2020; 122:1226-1231. [PMID: 32668040 PMCID: PMC7689706 DOI: 10.1002/jso.26117] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 06/27/2020] [Indexed: 01/03/2023]
Abstract
Background Amongst various options of vascularized lymph node transfers, the submental flap has the lowest risk for iatrogenic lymphedema. The aim of this study was to gain insight into distribution, number, and size of lymph nodes along the mandible using computed tomography angiography (CTA). Methods A total of 52 CTA scans of head/neck region were evaluated retrospectively. Lymph nodes in the submental and submandibular region, related to the origin of the submental artery, were recorded using a three‐dimensional coordinate system, and standardized using an iterative closest point algorithm. Results were analyzed for gender, location, size, and number. Results The mean number and size of lymph nodes were 5.30 ± 2.00 and 5.28 ± 1.29 mm, respectively. The mean distance of the lymph nodes to the origin of the submental artery was 25.53 ± 15.27 mm. There was no significant difference between both sides when comparing size (left: 5.39 ± 1.28; right: 5.17 ± 1.34; P = .19), number (left: 5.46 ± 2.10; right: 5.17 ± 1.96; P = .49), and distance (left: 24.78 ± 12.23; right: 26.32 ± 14.73; P = .19). No significance was found between males and females concerning number (P = .60), size (P = .50), and distance (P = .06). Conclusion The variance of lymph node distribution along the mandible may warrant conducting a CTA scan to maximize the number of transferred lymph nodes and aid in flap design.
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Affiliation(s)
- Vera A A Paulus
- Department of Plastic Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Harm Winters
- Department of Plastic Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Stefan Hummelink
- Department of Plastic Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Sascha Schulten
- Department of Plastic Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Dietmar J O Ulrich
- Department of Plastic Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Dalibor Vasilic
- Department of Plastic Surgery, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Plastic Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
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Cheng M, Liu TT. Lymphedema microsurgery improved outcomes of pediatric primary extremity lymphedema. Microsurgery 2020; 40:766-775. [DOI: 10.1002/micr.30622] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 04/15/2020] [Accepted: 05/29/2020] [Indexed: 12/22/2022]
Affiliation(s)
- Ming‐Huei Cheng
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery Chang Gung Memorial Hospital, College of Medicine, Chang Gung University Taoyuan Taiwan
| | - Tiffany Ting‐Fong Liu
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery Chang Gung Memorial Hospital, College of Medicine, Chang Gung University Taoyuan Taiwan
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