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Will P, Dragu A, Zuther J, Heil J, Chang DH, Traber J, Hirche C. [Evidence of modern diagnostic, conservative, and surgical therapy of secondary lymphoedema]. HANDCHIR MIKROCHIR P 2024; 56:291-300. [PMID: 38914123 DOI: 10.1055/a-2322-1325] [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: 06/26/2024] Open
Abstract
BACKGROUND Secondary lymphoedema (SL) is one of the most common and, at the same time, most significant consequences and complications of modern oncological therapy. Although a thorough patient history and physical examination are sufficient to substantiate a suspicion, it is essential to perform functional imaging of the lymphatic system for a targeted diagnosis and determination of severity. For this purpose, techniques such as MR and ICG lymphography as well as ultra-high-frequency ultrasound examinations have been developed and validated in recent years. The selective use of these techniques has allowed for individualized indications and successful stage-dependent treatment using (super)microsurgical techniques to restore regional lymphatic drainage in the context of intensified conservative therapy. METHOD Systematic review of the literature on the diagnosis and treatment of SL with subsequent analysis and classification of the results into evidence levels according to the Oxford Centre for Evidence-Based Medicine and the GRADE Scale. RESULTS The established and validated diagnosis of SL includes imaging (ICG fluorescence lymphography, MR lymphography and Tc-99 functional lymphoscintigraphy) in case of a clinical suspicion and in high-risk patients. Complex physical decongestion therapy (CPE) is superior to physical therapy or compression alone. (Super)microsurgery of SL allows for a postoperative reduction in the frequency of CPE, a reduction of erysipelas rates, a volume reduction of the lymphomatous extremity and, if carried out prophylactically, a lower incidence of SL. Suction-assited lipectomy can produce long-term, stable reductions in circumference and an improvement in quality of life. CONCLUSION Patients with SL benefit from conservative therapy with regular re-evaluation. Patients with a high risk for SL or with clinical deterioration or persistent symptoms under guideline-based conservative therapy can benefit from (super)microsurgical therapy after an individualized functional diagnostic evaluation of the lymphatic system. Excisional dermolipectomies or lympholiposuctions are available and effective for advanced and refractory stages.
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Affiliation(s)
- Patrick Will
- Klinik für Plastische und Handchirurgie, Universitätsklinikum Carl Gustav Carus, Dresden, Germany
| | - Adrian Dragu
- Klinik für Plastische und Handchirurgie, Universitätsklinikum Carl Gustav Carus, Dresden, Germany
| | - Joachim Zuther
- Lymphatic Unit, Academy of Lymphatic Studies, Sebastian, United States
| | - Jörg Heil
- Brustzentrum Heidelberg, St. Elisabeth Klinik, Heidelberg, Germany
| | - De-Hua Chang
- Klinik für diagnostische und interventionelle Radiologie, UniversitätsKlinikum Heidelberg, Heidelberg, Germany
| | - Jürg Traber
- Gefäßchirurgische Klinik, Venenklinik Bellvue Kreuzlingen, Kreuzlingen, Switzerland
| | - Christoph Hirche
- Klinik für Plastische Chirurgie, Hand- und Rekonstruktive Mikrochirurgie, Handtrauma- und Replantationszentrum, BG Unfallklinik Frankfurt am Main, Frankfurt am Main, Germany
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Brahma B, Yamamoto T, Panigoro SS, Haryono SJ, Yusuf PA, Priambodo PS, Harimurti K, Taher A. Supermicrosurgery lymphaticovenous and lymphaticolymphatic anastomosis: Technical detail and short-term follow-up for immediate lymphatic reconstruction in breast cancer treatment-related lymphedema prevention. J Vasc Surg Venous Lymphat Disord 2024; 12:101863. [PMID: 38428499 DOI: 10.1016/j.jvsv.2024.101863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Revised: 02/05/2024] [Accepted: 02/12/2024] [Indexed: 03/03/2024]
Abstract
OBJECTIVE We describe the feasibility and short-term outcome of our surgical technique to repair the lymph vessel disruption directly after axillary lymph node dissection during breast cancer surgery. This procedure is called immediate lymphatic reconstruction to prevent breast cancer treatment-related lymphedema (BCRL), which frequently occurs after axillary lymph node dissection. The surgical technique consisted of lymphaticovenous anastomosis (LVA) or lymphaticolymphatic anastomosis. We named the procedure lymphatic bypass supermicrosurgery (LBS). METHODS This study used a retrospective cohort design of patients with breast cancer between May 2020 and February 2023. LBS was performed by making an intima-to-intima coaptation between afferent lymph vessels and the recipient's veins (LVA) or efferent lymph vessels lymphaticolymphatic anastomosis. RESULTS A total of 82 patients underwent lymphatic bypass. The mean age of patients was 50 ± 12 years, and most had stage III breast cancer (n = 59 [72%]). LVA was the most common type of lymphatic bypass (94.6%). The median number of LVA was 1 (range, 1-4) and 1 (range, 1-3) for lymphaticolymphatic anastomosis. The median follow-up time was 12.5 months (range, 1-33 months). The 50 patients who had postoperative indocyanine green lymphography described arm dermal backflow stage 0 in 20 (40%), stage 1 in 19 (38%), stage 2 in 2 (4%), and stage 3 in 9 (18%) cases. The proportion of BCRL was 11 (22%), and subclinical lymphedema was 19 (38%) in this period. Most cases were in stable subclinical lymphedema (10, 58.8%). The 1-year and 2-year BCRL rates were 14% (95% confidence interval, 4%-23.9%) and 22% (95% confidence interval, 10.1%-33.9%), respectively. CONCLUSIONS Along with the emerging immediate lymphatic reconstruction, LBS is a feasible supermicrosurgery technique that may have a potential role in BCRL prevention. A randomized controlled study would confirm the effectiveness of the technique.
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Affiliation(s)
- Bayu Brahma
- Doctoral Program in Medical Sciences, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia; Department of Surgical Oncology, Dharmais Cancer Hospital-National Cancer Center, Jakarta, Indonesia
| | - Takumi Yamamoto
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan.
| | - Sonar Soni Panigoro
- Oncology Division, Department of Surgery, Faculty of Medicine, Universitas Indonesia - Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
| | - Samuel Johny Haryono
- Department of Surgical Oncology, Dharmais Cancer Hospital-National Cancer Center, Jakarta, Indonesia
| | - Prasandhya Astagiri Yusuf
- Department of Medical Physiology and Biophysics/Medical Technology IMERI, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Purnomo Sidi Priambodo
- Department of Electrical Engineering, Faculty of Engineering, Universitas Indonesia, Jakarta, Indonesia
| | - Kuntjoro Harimurti
- Division of Geriatrics/Clinical Epidemiological Unit, Department of Internal Medicine, Universitas Indonesia - Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
| | - Akmal Taher
- Department of Urology, Faculty of Medicine, Universitas Indonesia - Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
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Cauley RP, Rahmani B, Adebagbo OD, Park J, Garvey SR, Chen A, Nickman S, Tobin M, Valentine L, Weidman AA, Singhal D, Dowlatshahi A, Lin SJ, Lee BT. Optimizing Surgical Outcomes and the Role of Preventive Surgery: A Scoping Review. J Reconstr Microsurg 2024. [PMID: 38782025 DOI: 10.1055/a-2331-7885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
BACKGROUND Plastic and reconstructive surgeons are often presented with reconstructive challenges as a sequela of complications in high-risk surgical patients, ranging from exposure of hardware, lymphedema, and chronic pain after amputation. These complications can result in significant morbidity, recovery time, resource utilization, and cost. Given the prevalence of surgical complications managed by plastic and reconstructive surgeons, developing novel preventative techniques to mitigate surgical risk is paramount. METHODS Herein, we aim to understand efforts supporting the nascent field of Preventive Surgery, including (1) enhanced risk stratification, (2) advancements in postoperative care. Through an emphasis on four surgical cohorts who may benefit from preventive surgery, two of which are at high risk of morbidity from wound-related complications (patients undergoing sternotomy and spine procedures) and two at high risk of other morbidities, including lymphedema and neuropathic pain, we aim to provide a comprehensive and improved understanding of preventive surgery. Additionally, the role of risk analysis for these procedures and the relationship between microsurgery and prophylaxis is emphasized. RESULTS (1) medical optimization and prehabilitation, (2) surgical mitigation techniques. CONCLUSION Reconstructive surgeons are ideally placed to lead efforts in the creation and validation of accurate risk assessment tools and to support algorithmic approaches to surgical risk mitigation. Through a paradigm shift, including universal promotion of the concept of "Preventive Surgery," major improvements in surgical outcomes may be achieved.
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Affiliation(s)
- Ryan P Cauley
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Benjamin Rahmani
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Oluwaseun D Adebagbo
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
- Department of Surgery, Tufts University School of Medicine, Boston, Massachusetts
| | - John Park
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Shannon R Garvey
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Amy Chen
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Sasha Nickman
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Micaela Tobin
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Lauren Valentine
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Allan A Weidman
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Dhruv Singhal
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Arriyan Dowlatshahi
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Samuel J Lin
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Bernard T Lee
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Attalla P, Becker M, Clark RC, Reid CM, Brazio PS. We Are Not Speaking the Same Language: Current Procedural Terminology Coding and Provision of Care in Lymphatic Reconstruction. Ann Plast Surg 2024; 92:S310-S314. [PMID: 38689411 DOI: 10.1097/sap.0000000000003823] [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: 05/02/2024]
Abstract
INTRODUCTION Current Procedural Terminology (CPT) codes provide a uniform language for medical billing, but specific codes have not been assigned for lymphatic reconstruction techniques. The authors hypothesized that inadequate codes would contribute to heterogeneous coding practices and reimbursement challenges, ultimately limiting surgeons' ability to treat patients. METHODS A 22-item virtual questionnaire was offered to 959 members of the American Society of Reconstructive Microsurgeons to assess the volume of lymphatic reconstruction procedures performed, CPT codes used for each procedure, and challenges related to coding and providing care. RESULTS The survey was completed by 66 board-certified/board-eligible plastic surgeons (6.9%), who unanimously agreed that lymphatic surgery is integral to cancer care, with 86.4% indicating that immediate lymphatic reconstruction should be offered after lymphadenectomy. Most performed lymphovenous bypass, immediate lymphatic reconstruction, liposuction, and vascularized lymph node transfer.Respondents reported that available CPT codes failed to reflect procedural scope. A wide variety of CPT codes was used to report each type of procedure. Insurance coverage problems led to 69.7% of respondents forgoing operations and 32% reducing treatment offerings. Insurance coverage and CPT codes were identified as significant barriers to care by 98.5% and 95.5% of respondents, respectively. CONCLUSIONS Respondents unanimously agreed on the importance of lymphatic reconstruction in cancer care, and most identified inadequate CPT codes as causing billing issues, which hindered their ability to offer surgical treatment. Appropriate and specific CPT codes are necessary to ensure accuracy and consistency of reporting and ultimately to improve patient access to care.
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Affiliation(s)
| | - Miriam Becker
- UC San Diego School of Medicine, Division of Plastic Surgery, La Jolla
| | | | - Chris M Reid
- UC San Diego School of Medicine, Division of Plastic Surgery, La Jolla
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Allan AY, Mughal M, Mohanna PN, Roblin P. Lymphovenous anastomosis using the venous coupler: Primary prevention of lymphoedema. J Plast Reconstr Aesthet Surg 2024; 92:282-284. [PMID: 38583370 DOI: 10.1016/j.bjps.2024.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 03/08/2024] [Accepted: 03/18/2024] [Indexed: 04/09/2024]
Affiliation(s)
- Anna Yarlini Allan
- Department of Plastic Surgery, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London SE1 7EH, United Kingdom.
| | - Maleeha Mughal
- Department of Plastic Surgery, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London SE1 7EH, United Kingdom
| | - Pari-Naz Mohanna
- Department of Plastic Surgery, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London SE1 7EH, United Kingdom
| | - Paul Roblin
- Department of Plastic Surgery, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London SE1 7EH, United Kingdom
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Copeland-Halperin LR, Hyland CJ, Gadiraju GK, Xiang DH, Bellon JR, Lynce F, Dey T, Troll EP, Ryan SJ, Nakhlis F, Broyles JM. Preoperative Risk Factors for Lymphedema in Inflammatory Breast Cancer. J Reconstr Microsurg 2024; 40:311-317. [PMID: 37751880 DOI: 10.1055/a-2182-1015] [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: 09/28/2023]
Abstract
BACKGROUND Prophylactic lymphatic bypass or LYMPHA (LYmphatic Microsurgical Preventive Healing Approach) is increasingly offered to prevent lymphedema following breast cancer treatment, which develops in up to 47% of patients. Previous studies focused on intraoperative and postoperative lymphedema risk factors, which are often unknown preoperatively when the decision to perform LYMPHA is made. This study aims to identify preoperative lymphedema risk factors in the high-risk inflammatory breast cancer (IBC) population. METHODS Retrospective review of our institution's IBC program database was conducted. The primary outcome was self-reported lymphedema development. Multivariable logistic regression analysis was performed to identify preoperative lymphedema risk factors, while controlling for number of lymph nodes removed during axillary lymph node dissection (ALND), number of positive lymph nodes, residual disease on pathology, and need for adjuvant chemotherapy. RESULTS Of 356 patients with IBC, 134 (mean age: 51 years, range: 22-89 years) had complete data. All 134 patients underwent surgery and radiation. Forty-seven percent of all 356 patients (167/356) developed lymphedema. Obesity (body mass index > 30) (odds ratio [OR]: 2.7, confidence interval [CI]: 1.2-6.4, p = 0.02) and non-white race (OR: 4.5, CI: 1.2-23, p = 0.04) were preoperative lymphedema risk factors. CONCLUSION Patients with IBC are high risk for developing lymphedema due to the need for ALND, radiation, and neoadjuvant chemotherapy. This study also identified non-white race and obesity as risk factors. Larger prospective studies should evaluate potential racial disparities in lymphedema development. Due to the high prevalence of lymphedema, LYMPHA should be considered for all patients with IBC.
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Affiliation(s)
| | - Colby J Hyland
- Department of Surgery, Mass General Brigham, Boston, Massachusetts
| | | | | | - Jennifer R Bellon
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Filipa Lynce
- Department of Medicine, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Tanujit Dey
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Elizabeth P Troll
- Department of Breast Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Sean J Ryan
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Faina Nakhlis
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Justin M Broyles
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
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7
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Poskevicius A, Meroni M, Fuchs B, Scaglioni MF. Combined perforator flaps and lymphatic procedures in reconstructions after sarcoma resection. Microsurgery 2024; 44:e31119. [PMID: 37743714 DOI: 10.1002/micr.31119] [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: 05/03/2023] [Revised: 08/28/2023] [Accepted: 09/14/2023] [Indexed: 09/26/2023]
Abstract
BACKGROUND Soft tissue sarcomas are a subtle category of tumors that often require an extensive surgical resection for definitive treatment. This kind of intervention inevitably leads to large tissue damage and, when regions with rich lymphatic network are involved, postoperative complications such as lymphocele or lymphedema are quite common. In this report we present our experience with the combination of lymphatic procedures with perforator flaps for defects reconstruction and lymphatic complications preventions after sarcoma resection throughout the body. METHODS Between 2019 and 2021, 15 patients underwent a surgical resection of soft tissue sarcoma, also including bone tissue in 2 cases, requiring soft tissue reconstruction. A perforator flap reconstruction surgery was performed in all cases. The median age was 59.8 years old (ranging 23-84), 8 patients were females and 7 were males. The lymphovenous anastomosis (LVA) surgery concept was applied to all cases, while other additional lymphatic procedures were chosen individually for every patient. RESULTS All patients were successfully treated without any perioperative complications. In 3 cases infected seroma was encountered in the acceptor site and then successfully treated by means of debridement and vacuum assisted closure (VAC) therapy. 2 patients experienced postoperative lymphedema in the acceptor site which was managed by secondary procedures. Good functional and aesthetic outcomes were achieved in all cases. The mean follow-up was 19.6 months (range 10-33 months). CONCLUSIONS Different combinations of modern lymphatic procedures can be created to find the best solution and tailor the treatment to the patient's needs. Preventative measures regarding lymphatic complications can be highly effective and should be taken into consideration in every reconstructive approach following large soft tissue defects with impairment of the lymphatic network.
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Affiliation(s)
- Audrius Poskevicius
- Department of Hand- and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
- Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Matteo Meroni
- Department of Hand- and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Bruno Fuchs
- Department of Orthopedic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Mario F Scaglioni
- Department of Hand- and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
- Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
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Deldar R, Spoer D, Gupta N, Towfighi P, Boisvert M, Wehner P, Greenwalt IT, Wisotzky EM, Power K, Fan KL, Tom LK. Prophylactic Lymphovenous Bypass at the Time of Axillary Lymph Node Dissection Decreases Rates of Lymphedema. ANNALS OF SURGERY OPEN 2023; 4:e278. [PMID: 37601478 PMCID: PMC10431289 DOI: 10.1097/as9.0000000000000278] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 03/12/2023] [Indexed: 08/22/2023] Open
Abstract
Background Breast cancer-related lymphedema impacts 30% to 47% of women who undergo axillary lymph node dissection (ALND). Studies evaluating the effectiveness of prophylactic lymphovenous bypass (LVB) at the time of ALND have had small patient populations and/or short follow-up. The aim of this study is to quantitatively and qualitatively evaluate prophylactic LVB in patients with breast cancer. Methods A retrospective review of patients who underwent ALND from 2018 to 2022 was performed. Patients were divided into cohorts based on whether they underwent prophylactic LVB at the time of ALND. Primary outcomes included 30-day complications and lymphedema. Lymphedema was quantitatively evaluated by bioimpedance analysis, with L-dex scores >7.1 indicating lymphedema. Results One-hundred five patients were identified. Sixty-four patients (61.0%) underwent ALND and 41 patients (39.0%) underwent ALND+LVB. Postoperative complications were similar between the cohorts. At a median follow-up of 13.3 months, lymphedema occurred significantly higher in the ALND only group compared with ALND+LVB group (50.0% vs 12.2%; P < 0.001). ALND without LVB was an independent risk factor for lymphedema development (odds ratio, 4.82; P = 0.003). Conclusions Prophylactic LVB decreases lymphedema and is not associated with increased postoperative complications. A multidisciplinary team approach is imperative to decrease lymphedema development in this patient population.
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Affiliation(s)
- Romina Deldar
- From the Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, DC
| | - Daisy Spoer
- From the Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, DC
| | - Nisha Gupta
- Georgetown University School of Medicine, DC
| | | | - Marc Boisvert
- Division of Breast Surgery, Department of Surgery, MedStar Washington Hospital Center, DC
| | - Patricia Wehner
- Division of Breast Surgery, Department of Surgery, MedStar Washington Hospital Center, DC
| | - Ian T. Greenwalt
- Division of Breast Surgery, Department of Surgery, MedStar Washington Hospital Center, DC
| | - Eric M. Wisotzky
- Department of Physical Medicine and Rehabilitation, MedStar National Rehabilitation Hospital, DC
| | - Katherine Power
- Department of Physical Medicine and Rehabilitation, MedStar National Rehabilitation Hospital, DC
| | - Kenneth L. Fan
- From the Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, DC
| | - Laura K. Tom
- From the Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, DC
- Department of Plastic and Reconstructive Surgery, MedStar Washington Hospital Center, DC
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Levy AS, Murphy AI, Ishtihar S, Peysakhovich A, Taback B, Grant RT, Ascherman JA, Feldman S, Rohde CH. Lymphatic Microsurgical Preventive Healing Approach for the Primary Prevention of Lymphedema: A 4-Year Follow-Up. Plast Reconstr Surg 2023; 151:413-420. [PMID: 36696330 DOI: 10.1097/prs.0000000000009857] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Axillary lymph node dissection (ALND) remains the leading cause of lymphedema nationally, and there is still no cure for the disease. The lymphatic microsurgical preventive healing approach (LYMPHA) is a promising option for lymphedema prophylaxis in patients undergoing ALND, but long-term outcomes of the LYMPHA are not well established. METHODS The authors conducted a retrospective review of patients undergoing ALND at their center from November of 2012 to November of 2016 and assembled two cohorts, those who received the LYMPHA and those who did not (non-LYMPHA). Patient data were collected to evaluate lymphedema risk and long-term lymphedema incidence of each group. RESULTS Forty-five women were included in both our LYMPHA and non-LYMPHA cohorts. Mean body mass index (27.7 kg/m2 versus 29.9 kg/m2; P = 0.15) and radiation therapy rates (60.0% versus 68.9%; P = 0.51) did not differ between groups. Non-LYMPHA patients underwent complete mastectomy more frequently than LYMPHA patients (97.8% versus 77.8%; P = 0.007), but had a similar number of nodes removed during ALND (14.4 versus 15.8; P = 0.32). Median follow-up time was greater than 4 years for both LYMPHA and non-LYMPHA groups (57.0 months versus 63.0 months; P = 0.07). Overall, lymphedema incidence was 31.1% in the LYMPHA group and 33.3% in the non-LYMPHA group (P > 0.99). No significant differences in lymphedema incidences were observed between the LYMPHA and non-LYMPHA groups for patients with obesity, patients who received radiation therapy, or patients with obesity who also received radiation therapy (P > 0.05 for all subgroups). CONCLUSIONS The LYMPHA may not prevent lymphedema long-term in patients who undergo ALND. More long-term studies are needed to determine the true potential of the procedure. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Affiliation(s)
- Adam S Levy
- From the Division of Plastic Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles
| | | | | | | | - Bret Taback
- Breast Surgery, Department of Surgery, Columbia University Irving Medical Center/New York-Presbyterian Hospitaland
| | | | | | - Sheldon Feldman
- Division of Breast Surgery, Department of Surgery, Montefiore Medical Center, Albert Einstein College of Medicine
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Scaglioni MF, Meroni M, Fritsche E. Pedicled superficial circumflex iliac artery perforator flap combined with lymphovenous anastomosis between the recipient site lymphatic vessels and flap superficial veins for reconstruction of groin/thigh tissue defect and creation of lymph flow-through to reduce lymphatic complications: A report of preliminary results. Microsurgery 2023; 43:44-50. [PMID: 34779002 DOI: 10.1002/micr.30840] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 08/26/2021] [Accepted: 10/28/2021] [Indexed: 01/12/2023]
Abstract
BACKGROUND Large locoregional defects affecting lymphatic-rich regions may be subject to serious lymphatic complications, such as lymphedema and recurrent lymphocele. In the last few years, a demeaning volume reconstruction combined with lymph flow restoration showed to effectively reduce their incidences. The purpose of this report is to present the preliminary results of the use of pedicled SCIP flap with LVA between the recipient site lymphatic vessels and flap superficial vein for reconstruction of soft tissue defect and creation of lymph flow-through to reduce lymphatic complications. PATIENTS AND METHODS Between 2018 and 2020, 4 patients (2 males and 2 females), with a mean age of 56.5 years (ranging 42-76 years), presented a soft tissue defect with lymphatic drainage damage which was reconstructed by resorting to pedicled SCIP flap. Causes of the defect were tumoral surgical excision in 3 cases and severe trauma in 1 case. The defects were located in the medial thigh in 2 cases and groin area in 2 cases, with sizes ranging from 5 × 19 cm to 8 × 22 cm. The SCIP flap was raised by paying attention to preserve some suitable veins at the distal edge of the skin paddle. The flap was then turned 180 degrees and inset in order to match the direction of the recipient's lymphatic vessels. One or more LVAs were performed between the recipient site damaged lymphatics and a superficial flap's vein. RESULTS The sizes of flaps ranged from 5 × 19 cm to 8 × 22 cm. The mean number of LVAs was 2.2 (ranging from 1 to 3). A minor post-operative complication was encountered (small infected seroma) in 1 case, which was conservatively managed. No secondary procedures were required. In all cases complete range of motion (ROM) of the hip joint and wound coverage at both donor and recipient site were achieved. The mean follow-up was 8 months (ranging 7-10 months). No signs of lymphedema and lymphocele were reported over this time. CONCLUSIONS The pedicled SCIP flap with LVA between the recipient site lymphatic vessels and flap superficial vein may provide a solution for inguinal and upper thigh defects reconstructions that requires a lymphatic drainage restoration. Its superficial veins may be exploited to perform LVAs at recipient site, thus reducing the lymphatic complications in these delicate regions.
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Affiliation(s)
- Mario F Scaglioni
- Depatment of Hand- and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Matteo Meroni
- Depatment of Hand- and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Elmar Fritsche
- Depatment of Hand- and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
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Cook JA, Sinha M, Lester M, Fisher CS, Sen CK, Hassanein AH. Immediate Lymphatic Reconstruction to Prevent Breast Cancer-Related Lymphedema: A Systematic Review. Adv Wound Care (New Rochelle) 2022; 11:382-391. [PMID: 34714158 DOI: 10.1089/wound.2021.0056] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Significance: Lymphedema is chronic limb swelling from lymphatic dysfunction. The condition affects up to 250 million people worldwide. In breast cancer patients, lymphedema occurs in 30% who undergo axillary lymph node dissection (ALND). Recent Advances: Immediate lymphatic reconstruction (ILR), also termed Lymphatic Microsurgical Preventing Healing Approach (LyMPHA), is a method to decrease the risk of lymphedema by performing prophylactic lymphovenous anastomoses at the time of ALND. The objective of this study is to assess the risk reduction of ILR in preventing lymphedema. Critical Issues: Lymphedema has significant effects on the quality of life and morbidity of patients. Several techniques have been described to manage lymphedema after development, but prophylactic treatment of lymphedema with ILR may decrease risk of development to 6.6%. Future Directions: Long-term studies that demonstrate efficacy of ILR may allow for prophylactic management of lymphedema in the patient undergoing lymph node dissection.
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Affiliation(s)
- Julia A. Cook
- Division of Plastic Surgery; Indianapolis, Indiana, USA
| | - Mithun Sinha
- Division of Plastic Surgery; Indianapolis, Indiana, USA
- Indiana Center for Regenerative Medicine, Department of Surgery; Indianapolis, Indiana, USA
| | - Mary Lester
- Division of Plastic Surgery; Indianapolis, Indiana, USA
| | - Carla S. Fisher
- Division of Surgical Oncology; Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Chandan K. Sen
- Division of Plastic Surgery; Indianapolis, Indiana, USA
- Indiana Center for Regenerative Medicine, Department of Surgery; Indianapolis, Indiana, USA
| | - Aladdin H. Hassanein
- Division of Plastic Surgery; Indianapolis, Indiana, USA
- Indiana Center for Regenerative Medicine, Department of Surgery; Indianapolis, Indiana, USA
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Evaluation of Simplified Lymphatic Microsurgical Preventing Healing Approach (SLYMPHA) for the prevention of breast cancer-related lymphedema after axillary lymph node dissection using bioimpedance spectroscopy. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2022; 48:1713-1717. [DOI: 10.1016/j.ejso.2022.04.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Revised: 04/13/2022] [Accepted: 04/27/2022] [Indexed: 01/19/2023]
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13
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Scaglioni MF, Meroni M, Fritsche E, Fuchs B. Lymphatic Complications Prevention and Soft Tissue Reconstruction after Soft Tissue Sarcoma Resection in the Limbs. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58010067. [PMID: 35056375 PMCID: PMC8780159 DOI: 10.3390/medicina58010067] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 12/29/2021] [Accepted: 12/31/2021] [Indexed: 04/10/2023]
Abstract
Background and Objectives: The definitive treatment of soft tissue sarcomas (STS) requires a radical surgical removal of the tumor, which often leads to large soft tissue defects. When they are located in the limbs, significant damage to the lymphatic pathways is not uncommon. In the present article, we present different techniques aimed at both reconstructing the defect and restoring sufficient lymph drainage, thus preventing short- and long-term lymphatic complications. Materials and Methods: Between 2018 and 2020, 10 patients presenting a soft tissue defect with lymphatic impairment received a locoregional reconstruction by means of either pedicled or free SCIP flap. Seven patients required a second flap to reach a good dead space obliteration. In six cases, we performed an interpositional flap, namely a soft tissue transfer with lymphatic tissue preservation, and in four cases a lymphatic flow-through flap. In all cases, the cause of the defect was STS surgical excision. The average age was 60.5 years old (ranging 39-84), seven patients were females and six were males. Results: All the patients were successfully treated. In two cases, minor post-operative complications were encountered (infected seroma), which were conservatively managed. No secondary procedures were required. The average follow-up was 8.9 months (ranging 7-12 months). No signs of lymphedema were reported during this time. In all cases, complete range of motion (ROM) and a good cosmetic result were achieved. Conclusions: A reconstructive procedure that aims not only to restore the missing volume, but also the lymphatic drainage might successfully reduce the rate of postoperative complications. Both lymphatic interpositional flaps and lymphatic flow-through flaps could be effective, and the right choice must be done according to each patient's needs.
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Affiliation(s)
- Mario F. Scaglioni
- Clinic of Hand-and Plastic Surgery, Department of Surgery, Luzerner Kantonsspital, 6000 Lucerne, Switzerland; (M.M.); (E.F.)
- Correspondence:
| | - Matteo Meroni
- Clinic of Hand-and Plastic Surgery, Department of Surgery, Luzerner Kantonsspital, 6000 Lucerne, Switzerland; (M.M.); (E.F.)
| | - Elmar Fritsche
- Clinic of Hand-and Plastic Surgery, Department of Surgery, Luzerner Kantonsspital, 6000 Lucerne, Switzerland; (M.M.); (E.F.)
| | - Bruno Fuchs
- Clinic of Orthopedic Surgery, Department of Surgery, Luzerner Kantonsspital, 6000 Lucerne, Switzerland;
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14
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Management of Lymphoedema in Breast Cancer. Breast Cancer 2022. [DOI: 10.1007/978-981-16-4546-4_25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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15
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Shah J, Zhao R, Yi J, Otterburn D, Patel A, Szpalski C, Tanna N, Taub PJ, Weichman KE, Ricci JA. Novel Quantification of Real-Time Lymphatic Clearance: Immediate Lymphatic Reconstruction in a Large-Animal Model. Plast Reconstr Surg 2022; 149:130-141. [PMID: 34936612 PMCID: PMC8691163 DOI: 10.1097/prs.0000000000008631] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 05/19/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND The real-time quantification of lymphatic flow remains elusive. Efforts to provide a metric of direct lymphatic function are not clinically translatable and lack reproducibility. Early reports demonstrate the promise of immediate lymphatic reconstruction (immediate lymphovenous bypass after lymphadenectomy) to reduce the risk of lymphedema development. However, there remains a heightened need to appraise this technique in a clinically translatable large-animal model. The aim of the authors' experiment was to evaluate the role of molecular imaging in the quantification of real-time lymphatic flow after lymphadenectomy, and lymphadenectomy with lymphovenous bypass using novel fluorophores in a swine model. METHODS A lymphadenectomy or lymphadenectomy with subsequent lymphovenous bypass was performed in 10 female swine. After subdermal fluorophore injection, near-infrared molecular imaging of blood samples was used to evaluate change in lymphatic flow after lymphadenectomy versus after lymphadenectomy with lymphovenous bypass. Continuous imaging evaluating fluorescence of the superficial epigastric vein in the torso and adjacent skin was performed throughout all experiments. Findings between modalities were correlated. RESULTS The near-infrared dye signal in central and peripheral blood samples was often difficult to separate from background and proved challenging for reliable quantification. Venous and skin near-infrared imaging demonstrated a lymphatic clearance rate decrease of 70 percent after lymphadenectomy versus a decrease by only 30 percent after lymphadenectomy with immediate lymphovenous bypass. CONCLUSIONS In this article, the authors describe a noninvasive, swine, large-animal model to quantify lymphatic clearance using skin imaging. The authors' findings were consistent with results yielded from real-time imaging of the vein. The authors believe this model may have important implications for eventual direct translation to the clinical setting.
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Affiliation(s)
- Jinesh Shah
- From the Division of Plastic and Reconstructive Surgery, Montefiore Medical Center; Division of Plastic and Reconstructive Surgery, Weill Cornell Medical Center; Division of Plastic and Reconstructive Surgery, Albany Medical Center; Division of Plastic Surgery, St. Joseph’s Health; Division of Plastic and Reconstructive Surgery, Northwell Health; and Division of Plastic and Reconstructive Surgery, Mount Sinai Hospital
| | - Ruya Zhao
- From the Division of Plastic and Reconstructive Surgery, Montefiore Medical Center; Division of Plastic and Reconstructive Surgery, Weill Cornell Medical Center; Division of Plastic and Reconstructive Surgery, Albany Medical Center; Division of Plastic Surgery, St. Joseph’s Health; Division of Plastic and Reconstructive Surgery, Northwell Health; and Division of Plastic and Reconstructive Surgery, Mount Sinai Hospital
| | - Joseph Yi
- From the Division of Plastic and Reconstructive Surgery, Montefiore Medical Center; Division of Plastic and Reconstructive Surgery, Weill Cornell Medical Center; Division of Plastic and Reconstructive Surgery, Albany Medical Center; Division of Plastic Surgery, St. Joseph’s Health; Division of Plastic and Reconstructive Surgery, Northwell Health; and Division of Plastic and Reconstructive Surgery, Mount Sinai Hospital
| | - David Otterburn
- From the Division of Plastic and Reconstructive Surgery, Montefiore Medical Center; Division of Plastic and Reconstructive Surgery, Weill Cornell Medical Center; Division of Plastic and Reconstructive Surgery, Albany Medical Center; Division of Plastic Surgery, St. Joseph’s Health; Division of Plastic and Reconstructive Surgery, Northwell Health; and Division of Plastic and Reconstructive Surgery, Mount Sinai Hospital
| | - Ashit Patel
- From the Division of Plastic and Reconstructive Surgery, Montefiore Medical Center; Division of Plastic and Reconstructive Surgery, Weill Cornell Medical Center; Division of Plastic and Reconstructive Surgery, Albany Medical Center; Division of Plastic Surgery, St. Joseph’s Health; Division of Plastic and Reconstructive Surgery, Northwell Health; and Division of Plastic and Reconstructive Surgery, Mount Sinai Hospital
| | - Caroline Szpalski
- From the Division of Plastic and Reconstructive Surgery, Montefiore Medical Center; Division of Plastic and Reconstructive Surgery, Weill Cornell Medical Center; Division of Plastic and Reconstructive Surgery, Albany Medical Center; Division of Plastic Surgery, St. Joseph’s Health; Division of Plastic and Reconstructive Surgery, Northwell Health; and Division of Plastic and Reconstructive Surgery, Mount Sinai Hospital
| | - Neil Tanna
- From the Division of Plastic and Reconstructive Surgery, Montefiore Medical Center; Division of Plastic and Reconstructive Surgery, Weill Cornell Medical Center; Division of Plastic and Reconstructive Surgery, Albany Medical Center; Division of Plastic Surgery, St. Joseph’s Health; Division of Plastic and Reconstructive Surgery, Northwell Health; and Division of Plastic and Reconstructive Surgery, Mount Sinai Hospital
| | - Peter J. Taub
- From the Division of Plastic and Reconstructive Surgery, Montefiore Medical Center; Division of Plastic and Reconstructive Surgery, Weill Cornell Medical Center; Division of Plastic and Reconstructive Surgery, Albany Medical Center; Division of Plastic Surgery, St. Joseph’s Health; Division of Plastic and Reconstructive Surgery, Northwell Health; and Division of Plastic and Reconstructive Surgery, Mount Sinai Hospital
| | - Katie E. Weichman
- From the Division of Plastic and Reconstructive Surgery, Montefiore Medical Center; Division of Plastic and Reconstructive Surgery, Weill Cornell Medical Center; Division of Plastic and Reconstructive Surgery, Albany Medical Center; Division of Plastic Surgery, St. Joseph’s Health; Division of Plastic and Reconstructive Surgery, Northwell Health; and Division of Plastic and Reconstructive Surgery, Mount Sinai Hospital
| | - Joseph A. Ricci
- From the Division of Plastic and Reconstructive Surgery, Montefiore Medical Center; Division of Plastic and Reconstructive Surgery, Weill Cornell Medical Center; Division of Plastic and Reconstructive Surgery, Albany Medical Center; Division of Plastic Surgery, St. Joseph’s Health; Division of Plastic and Reconstructive Surgery, Northwell Health; and Division of Plastic and Reconstructive Surgery, Mount Sinai Hospital
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16
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Lymphatic Microsurgical Preventive Healing Approach (LYMPHA) for Lymphedema Prevention after Axillary Lymph Node Dissection—A Single Institution Experience and Feasibility of Technique. J Clin Med 2021; 11:jcm11010092. [PMID: 35011833 PMCID: PMC8745451 DOI: 10.3390/jcm11010092] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 12/20/2021] [Accepted: 12/21/2021] [Indexed: 11/17/2022] Open
Abstract
While surgical options exist to treat lymphedema after axillary lymph node dissection (ALND), the lymphatic microsurgical preventive healing approach (LYMPHA) has been introduced as a preventive measure performed during the primary surgery, thus avoiding the morbidity associated with lymphedema. Here, we highlight details of our operative technique and review postoperative outcomes. For our patients, limb measurements and body composition analyses were performed pre- and postoperatively. Intraoperatively, axillary reverse lymphatic mapping was performed with indocyanine green (ICG) and lymphazurin. SPY-PHI imaging was used to visualize the ICG uptake into axillary lymphatics. Cut lymphatics from excised nodes were preserved for lymphaticovenous anastomosis (LVA). At the completion of the microanastomosis, ICG was visualized draining from the lymphatic through the recipient vein. A retrospective review identified nineteen patients who underwent complete or partial mastectomy with ALND and subsequent LYMPHA over 19 months. The number of LVAs performed per patient ranged between 1–4 per axilla. The operating time ranged from 32–95 min. There were no surgical complications, and thus far one patient developed mild lymphedema with an average follow up of 10 months. At the clinic follow up, ICG and SPY angiography were used to confirm intact lymphatic conduits with an uptake of ICG across the axilla. This study supports LYMPHA as a feasible and effective method for lymphedema prevention.
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17
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Chun MJ, Saeg F, Meade A, Kumar T, Toraih EA, Chaffin AE, Homsy C. Immediate Lymphatic Reconstruction for Prevention of Secondary Lymphedema: A Meta-Analysis. J Plast Reconstr Aesthet Surg 2021; 75:1130-1141. [PMID: 34955392 DOI: 10.1016/j.bjps.2021.11.094] [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: 11/24/2020] [Revised: 11/06/2021] [Accepted: 11/14/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Secondary lymphedema remains one of the most notorious complications of axillary and pelvic lymph node surgery following mastectomy. There is a lack of high-level evidence found on the effectiveness of immediate lymphatic reconstruction (ILR) in preventing secondary lymphedema. This meta-analysis evaluates the outcomes of ILR for prevention of secondary lymphedema in patients undergoing different surgeries, and provides suggestions for lymphatic microsurgical preventive healing approach (LYMPHA). METHODS A review of PubMed, Embase, and Web of Science was performed according to Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. All English-language studies published from January 1, 2009 to June 1, 2020 were included. We excluded non-ILR interventions, literature reviews/letters/commentaries, and nonhuman or cadaver studies. A total of 789 patients that were enrolled in 13 studies were included in our one-arm meta-analysis. RESULTS A total of 13 studies (n=789) met inclusion criteria: upper extremity ILR (n=665) and lower extremity ILR (n=124). The overall incidence of lymphedema for upper extremity ILR was 2.7% (95%CI: 1.1%-4.4%) and lower extremity ILR was 3.6% (95%CI: 0.3%-10.1%). For upper extremity ILR, the average follow-up time was 11.6 ± 7.8 months and the LE incidence appeared to be the highest approximately 1 to 2 years postoperation. CONCLUSIONS Lymphedema is a common complication in cancer treatment. ILR, especially LYMPHA, may be an effective technique to facilitate lymphatic drainage at the time of the index procedure but future studies will be required to show its short-term efficacy and long-term outcomes.
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Affiliation(s)
- Magnus J Chun
- Division of Plastic and Reconstructive Surgery, Tulane University School of Medicine, New Orleans, LA, 70112
| | - Fouad Saeg
- Division of Plastic and Reconstructive Surgery, Tulane University School of Medicine, New Orleans, LA, 70112
| | - Anna Meade
- Department of Plastic Surgery, University of Texas-Southwestern, Dallas, TX, 75390
| | - Taruni Kumar
- Division of Plastic and Reconstructive Surgery, Tulane University School of Medicine, New Orleans, LA, 70112
| | - Eman A Toraih
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA, 70112; Department of Histology and Cell Biology, Genetics Unit, Faculty of Medicine, Suez Canal University, Ismailia, 41522, Egypt
| | - Abigail E Chaffin
- Division of Plastic and Reconstructive Surgery, Tulane University School of Medicine, New Orleans, LA, 70112
| | - Christopher Homsy
- Division of Plastic and Reconstructive Surgery, Tufts Medical Center, Boston, MA, 02111.
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Abstract
An estimated 250 million people worldwide suffer from lymphedema. In the past, the firstline option for treatment was nonsurgical management, either in the form of compression garments or wrapping, or comprehensive decongestive therapy, with debulking surgery reserved for the more advanced cases. However, with improvements in microsurgical techniques and imaging modalities, surgical intervention is increasingly being utilized. This review highlights recent advancements in the surgical treatment of lymphedema, specifically focusing on improvements in imaging, surgical techniques, and prevention of lymphedema.
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19
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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: 8] [Impact Index Per Article: 2.7] [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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20
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Hanson SE, Chu CK, Chang EI. Surgical Treatment Options of Breast Cancer-Related Lymphedema. CURRENT SURGERY REPORTS 2021. [DOI: 10.1007/s40137-021-00286-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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21
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Abstract
Physiologic surgical interventions, including lymphovenous bypass (LVB) and vascularized lymph node transplant (VLNT), are increasingly being used to treat lymphedema. LVB has been shown to be effective in improving the severity of lymphedema, particularly for patients with still-functional superficial lymphatic vessels that can be identified for bypass. However, in many patients, there is a paucity of functional lymphatic vessels for bypass and, thus, they are not ideal candidates for LVB alone. Unlike LVB, VLNT does not depend on the presence of functioning lymphatic vessels, but the effects of VLNT are delayed, as the proposed mechanisms of action require more time for optimal function. The author has offered a combined approach to microsurgical treatment of lymphedema for both the upper and lower extremities. Simultaneous VLNT and LVB are safe and effective for patients with both early and advanced stages of primary and secondary lymphedema. Our experience shows that a majority of patients can expect some long-term improvement, in both overall limb volume and quality of life, after surgical intervention with LVB and/or VLNT.
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Affiliation(s)
- David W Chang
- Section of Plastic and Reconstructive Surgery, Department of Surgery, The University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
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22
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Abstract
The arm is less often concerned by reconstructive surgeries than more distal parts of the upper extremity. However, when affected, the arm is frequently part of complex mutilating injuries involving composite defects. For a given traumatic or oncologic defect, there are several reconstructive options and choosing the right sequence may pose a challenge even to the most experienced surgeon. The latter must integrate not only functional and esthetic requirements, but also the surgeon's habits, especially in situations of emergency. Once life-threatening conditions are averted, wound debridement, bony stabilization, neurovascular, and cutaneous reconstruction tailored to the defects should be performed in a single-stage procedure. Functionally, prompt bony stabilization is necessary to allow early mobilization. Diaphyseal shortening of the humerus can be a salvage procedure to avoid nerve and vascular grafting, with good biomechanical tolerance up to 5cm. Restoration of adequate elbow motion sometimes requires muscle transfer and should be a main concern, as proper positioning of the hand during daily activities demands a functional elbow joint. Esthetically, the surgeon must choose the most cosmetic skin coverage option whilst limiting morbidity of the donor site area. The flaps vascularized by the sub- scapular or thoraco-dorsal vessels are the most useful flaps for arm reconstruction. This paper discusses the reconstructive sequence of complex defects of the arm and provides a review of commonly used reconstructive techniques supported with illustrative cases.
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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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