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Caretto AA, Tartaglione G, Ieria FP, Colavincenzo C, Gentileschi S. Concordance between preoperative imaging methods in patients with limb lymphedema undergoing supermicrosurgical lymphaticovenular anastomosis. J Vasc Surg Venous Lymphat Disord 2024:101891. [PMID: 38631506 DOI: 10.1016/j.jvsv.2024.101891] [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: 12/05/2023] [Revised: 03/01/2024] [Accepted: 04/04/2024] [Indexed: 04/19/2024]
Abstract
OBJECTIVE Supermicrosurgical lymphaticovenular anastomosis (LVA) is increasingly being recognized as a first-line treatment of limb lymphedema because it is minimally invasive and highly effective. Lymphoscintigraphy and indocyanine green (ICG) lymphography are the two most commonly performed diagnostic imaging examinations to establish the indication and plan the procedure for patients affected by limb lymphedema. In a small group of patients, the information between these two imaging tools can be discordant, showing different anatomical drainage pathways or the absence of drainage and dermal backflow in one examination and valid drainage pathways in the other. The purpose of this study is to examine the types of possible discrepancies between lymphoscintigraphy of the superficial system and ICG lymphography and to describe the surgical outcomes after LVA for patients presenting with such discrepancies. METHODS We retrospectively reviewed the data of all patients who underwent LVA for upper or lower limb lymphedema between July 2015 and July 2023. From this series, we identified a group of patients with nonconcordant imaging results from lymphoscintigraphy and ICG lymphography before lymphatic surgery. Nonconcordant findings were described in terms of "pattern discordance" and "pathway discordance." The surgical outcome was measured by the change in the mean circumference of the limb after surgery. The changes between the preoperative and postoperative limb measures were analyzed using the Student t test. P values < .05 were considered significant. RESULTS A total of 28 patients with limb lymphedema exhibited inconsistencies between preoperative lymphoscintigraphy of the superficial system and ICG lymphography. Among these patients, 14 experienced pattern discordance, 13 had pathway discordance, and 1 patient had both. After LVA, we observed a significant reduction in the average circumference of the affected limb in the analyzed group. CONCLUSIONS The discrepancy in the information between lymphoscintigraphy and ICG lymphography in the preoperative study of patients affected by limb lymphedema is rare but possible. This phenomenon is still not fully explained; however, our results suggest that it does not correlate with the outcome of supermicrosurgical LVAs.
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Affiliation(s)
- Anna Amelia Caretto
- Unità di Chirurgia Plastica, Dipartimento Scienze Della Salute Della Donna E Del Bambino E Di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | | | - Chiara Colavincenzo
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Stefano Gentileschi
- Unità di Chirurgia Plastica, Dipartimento Scienze Della Salute Della Donna E Del Bambino E Di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy.
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Mestre S, Vignes S, Malloizel-Delaunay J, Abba S, Villet S, Picolet A, Vicaut E, Quéré I. Positive Impact of a New Compressive Garment in Patients with Genital Lymphedema: OLYMPY Study. Lymphat Res Biol 2024; 22:138-146. [PMID: 38563697 PMCID: PMC11044870 DOI: 10.1089/lrb.2023.0055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024] Open
Abstract
Purpose: Genital lymphedema is a chronic debilitating condition associated with highly impaired health-related quality of life (QoL). This prospective multicenter study evaluated the use of a new compressive garment in patients with secondary and primary genital lymphedema. Methods: Thirty-two patients prospectively enrolled were advised to wear the compressive garment for 12 weeks (day and night). The primary endpoint was change in patient-reported QoL at 12 weeks via the patient global impression of change (PGI-C) instrument. Secondary outcomes included change in other QoL measures at 12 weeks (visual analog scale, Lymphedema Quality of Life Inventory [LyQLI], and EQ-5D questionnaires), lymphedema severity (genital lymphedema score [GLS]), and physician assessment (Clinical Global Impression-Improvement [CGI-I]). Safety and tolerability were also assessed. Results: After 12 weeks, improvement was reported in 78.6% of patients (PGI-C). Physician assessment (CGI-I) indicated clinical improvement in 82.8% of patients. Patient assessment of lymphedema symptoms showed a significant decrease in discomfort (p = 0.02) and swelling (p = 0.01). Significant declines in the mean global GLS (p < 0.0001), and in the proportion of patients reporting heaviness, tightness, swelling, or urinary dysfunction (p < 0.05 for all), were also observed. LyQLI scores decreased (indicating improved QoL) in each of the physical, psychosocial (p = 0.05), and practical domains. The compressive garment was well tolerated with high compliance, and adverse events (due to swelling or discomfort) led to permanent discontinuation in only three patients. Conclusion: The use of a new genital compression garment over 12 weeks improves the QoL and clinical measures in patients with genital lymphedema (ClinicalTrials.gov ID: NCT04602559; Registration: October 20, 2020).
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Affiliation(s)
- Sandrine Mestre
- Department of Vascular Medicine, Montpellier University, Montpellier, France
- UA11 INSERM–UM Institut Desbrest d'Épidémiologie et de Santé Publique (IDESP), Montpellier, France
| | - Stéphane Vignes
- Department of Lymphology, Referral Center for Rare Vascular Diseases, Cognacq-Jay Hospital, Paris, France
| | | | - Sarah Abba
- Department of Lymphology, Referral Center for Rare Vascular Diseases, Cognacq-Jay Hospital, Paris, France
| | | | | | - Eric Vicaut
- Clinical Research Unit, Saint-Louis, Lariboisière, Fernand-Widal Hospital, Paris, France
| | - Isabelle Quéré
- Department of Vascular Medicine, Montpellier University, Montpellier, France
- UA11 INSERM–UM Institut Desbrest d'Épidémiologie et de Santé Publique (IDESP), Montpellier, France
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Bolletta A, Losco L, Cigna E. Editorial for the Special Issue "Vasorum Lymphaticorum: From the Discovery of the Lymphatic System to the New Perspectives in Microsurgical Reconstruction and Patient Rehabilitation". MEDICINA (KAUNAS, LITHUANIA) 2024; 60:307. [PMID: 38399594 PMCID: PMC10890691 DOI: 10.3390/medicina60020307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Accepted: 02/07/2024] [Indexed: 02/25/2024]
Abstract
Lymphedema is a complex clinical condition that appears as a result of the failure of the lymphatic system function, and it is characterized by edema, fibrosis, and adipose deposition [...].
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Affiliation(s)
- Alberto Bolletta
- Plastic Surgery and Microsurgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy
| | - Luigi Losco
- Plastic Surgery Unit, Department of Medicine, Surgery and Dentistry, University of Salerno, 84081 Salerno, Italy
| | - Emanuele Cigna
- Plastic Surgery and Microsurgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy
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Cuccurullo V, Rapa M, Catalfamo B, Gatta G, Di Grezia G, Cascini GL. The Role of Imaging of Lymphatic System to Prevent Cancer Related Lymphedema. Bioengineering (Basel) 2023; 10:1407. [PMID: 38135998 PMCID: PMC10740912 DOI: 10.3390/bioengineering10121407] [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: 10/20/2023] [Revised: 12/02/2023] [Accepted: 12/06/2023] [Indexed: 12/24/2023] Open
Abstract
Lymphedema is a progressive chronic condition affecting approximately 250 million people worldwide, a number that is currently underestimated. In Western countries, the most common form of lymphedema of the extremities is cancer-related and less radical surgical intervention is the main option to prevent it. Standardized protocols in the areas of diagnosis, staging and treatment are strongly required to address this issue. The aim of this study is to review the main diagnostic methods, comparing new emerging procedures to lymphoscintigraphy, considered as the golden standard to date. The roles of Magnetic Resonance Lymphangiography (MRL) or indocyanine green ICG lymphography are particularly reviewed in order to evaluate diagnostic accuracy, potential associations with lymphoscintigraphy, and future directions guided by AI protocols. The use of imaging to treat lymphedema has benefited from new techniques in the area of lymphatic vessels anatomy; these perspectives have become of value in many clinical scenarios to prevent cancer-related lymphedema.
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Affiliation(s)
- Vincenzo Cuccurullo
- Department of Precision Medicine, Università della Campania “Luigi Vanvitelli”, 80131 Napoli, Italy; (M.R.); (G.G.)
| | - Marco Rapa
- Department of Precision Medicine, Università della Campania “Luigi Vanvitelli”, 80131 Napoli, Italy; (M.R.); (G.G.)
| | - Barbara Catalfamo
- Nuclear Medicine Unit, Department of Diagnostic Imaging, Magna Graecia University of Catanzaro, 88100 Catanzaro, Italy; (B.C.); (G.L.C.)
| | - Gianluca Gatta
- Department of Precision Medicine, Università della Campania “Luigi Vanvitelli”, 80131 Napoli, Italy; (M.R.); (G.G.)
| | | | - Giuseppe Lucio Cascini
- Nuclear Medicine Unit, Department of Diagnostic Imaging, Magna Graecia University of Catanzaro, 88100 Catanzaro, Italy; (B.C.); (G.L.C.)
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Ehrl D, Heidekrueger PI, Giunta RE, Wachtel N. Giant Penoscrotal Lymphedema-What to Do? Presentation of a Curative Treatment Algorithm. J Clin Med 2023; 12:7586. [PMID: 38137655 PMCID: PMC10743533 DOI: 10.3390/jcm12247586] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 11/26/2023] [Accepted: 12/06/2023] [Indexed: 12/24/2023] Open
Abstract
BACKGROUND While rare, penoscrotal lymphedema (PL) is accompanied with devastating effects on the quality of life of patients. Moreover, especially for patients with excessive (giant) PL, no standardized curative treatment has been defined. This article therefore retrospectively evaluates the authors' surgical treatment approach for giant PL, which includes resection alone or in combination with a free vascularized lymph node transfer (VLNT). METHODS A total of ten patients met the inclusion criteria. One patient dropped out of the study before therapy commenced. Eight of the nine remaining patients presented with end-stage (giant) PL. One patient presented with manifest pitting edema. All patients were treated with penoscrotal resection and reconstruction. Additionally, five patients received VLNT into the groin or scrotum. RESULTS The extent of the lymphedema was specified with a treatment-oriented classification system. The median follow-up was 49.0 months. No patient showed a recurrence. Patients who received VLNT into the scrotum displayed a significantly improved lymphatic transport of the scrotum. CONCLUSIONS Advanced PL should be treated in a standardized surgical fashion as suggested by our proposed algorithm. VLNT from the lateral thoracic region into the scrotum must be considered. If treated correctly, surgical intervention of end-stage PL leads to good results with a low recurrence rate.
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Affiliation(s)
- Denis Ehrl
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, 80336 Munich, Germany
| | - Paul I. Heidekrueger
- Centre of Plastic, Aesthetic, Hand and Reconstructive Surgery, University of Regensburg, 93053 Regensburg, Germany
| | - Riccardo E. Giunta
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, 80336 Munich, Germany
| | - Nikolaus Wachtel
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, 80336 Munich, Germany
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Pirincci CS, Cihan E, Ünüvar BS, Gerçek H, Aytar A, Borman P. Investigation of physical activity, fear of falling, and functionality in individuals with lower extremity lymphedema. Support Care Cancer 2023; 31:360. [PMID: 37247048 DOI: 10.1007/s00520-023-07825-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 05/21/2023] [Indexed: 05/30/2023]
Abstract
PURPOSE To investigate the fear of falling, physical activity, and functionality in patients with lymphedema in the lower extremities. METHODS Sixty-two patients who developed stage 2-3 lymphedema in the lower extremities due to primary or secondary causes (age: 56.03 ± 7.83 years) and 59 healthy controls (age: 54.61 ± 5.43 years) were included in the study. The sociodemographic and clinical characteristics of all individuals included in the study were recorded. In both groups, fear of falling was evaluated with the Tinetti Falls Efficacy Scale (TFES), lower extremity functionality with the Lower Extremity Functional Scale (LEFS), and physical activity with the International Physical Activity Questionnaire-Short Form (IPAQ-SF). RESULTS There was no statistically significant difference between the demographic characteristics of the groups (p > 0.05). The primary and secondary lymphedema groups had similar LEFS (p = 0.207, d = 0.16), IPAQ (p = 0.782, d = 0.04), and TFES (p = 0.318, d = 0.92) scores. However, the TFES score of the lymphedema group was significantly higher than that of the control group (p < 0.01, d = 0.52), while the LEFS (p < 0.01, d = 0.77) and IPAQ scores (p = 0.001, d = 0.30) were significantly higher in the latter. There was a negative correlation between LEFS and TFES (r = -0.714, p < 0.001) and between TFES and IPAQ (r = -0.492, p < 0.001). LEFS and IPAQ were positively correlated (r = 0.619, p < 0.001). CONCLUSION It was determined that individuals with lymphedema developed a fear of falling, and their functionality was negatively affected. This negative effect on functionality can be attributed to reduced physical activity and an increased fear of falling.
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Affiliation(s)
- Cansu Sahbaz Pirincci
- Gulhane Faculty of Physiotherapy and Rehabilitation, University of Health Sciences, Ankara, Turkey.
| | - Emine Cihan
- Vocational School of Health Science Physiotherapy, Selcuk University, Konya, Turkey
| | | | - Hasan Gerçek
- Vocational School of Health Science, KTO Karatay University, Konya, Turkey
| | - Aydan Aytar
- Gulhane Faculty of Physiotherapy and Rehabilitation, University of Health Sciences, Ankara, Turkey
| | - Pınar Borman
- Department of Physical Medicine and Rehabilitation, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
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Istranov AL, Makarov IG, Makarova NV, Tulina I, Ulasov IV, Isakova YI. Combination of conservative and surgical methods in the treatment of giant lymphedema of the scrotum: A case report. Front Surg 2023; 10:1048159. [PMID: 37123541 PMCID: PMC10130451 DOI: 10.3389/fsurg.2023.1048159] [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: 09/19/2022] [Accepted: 02/28/2023] [Indexed: 05/02/2023] Open
Abstract
Objective Genital lymphedema is a severe, disabling condition associated with a malfunction of the lymphatic system. Primary lymphedema of the scrotum is a variant of congenital dysplasia of lymphatic vessels. Secondary genital lymphedema is much more common and can be caused by parasitic invasion (filariasis) or damage to the lymphatic system during the treatment of cancer (radiation therapy, lymphadenectomy). Healthcare providers are frequently unable to detect and treat this illness successfully in ordinary clinical practice. This paper uses the case of a patient with stage 3 secondary lymphedema (unknown genesis) of both lower extremities and lymphedema of the scrotum, complicated by recurrent erysipelas, a history of lymphorrhoea, impaired skin trophic and multiple papillomatosis, to demonstrate the efficacy of a combination of conservative and surgical methods in the treatment of giant lymphedema of the scrotum. Methods In the treatment, the combination of decongestant physical therapy (CDPT, CDT) according to M. Földi was used at pre-surgery and post-surgery stages, combined with a reconstructive operation, including the removal of the affected tissues of the urogenital region, phalloplasty, and scrotoplasty with rotational skin flaps. Results A decrease in the circumference of the lowest extremities in the lower leg area by 68 cm on the right and by 69 cm on the left was achieved by conservative treatment. Due to the combination of conservative and surgical treatment, the patient's body weight decreased by 69.4 kg, and the scrotum decreased by 63 cm. Subsequently, the patient fully recovered his sexual function. Conclusion A combination of complex decongestive physical therapy and surgery is necessary for patients with advanced genital edema. The isolated use of surgical or conservative treatment does not provide a sufficient improvement in the patient's quality of life. Modern plastic surgery technologies enable patients to achieve complete functional and cosmetic recovery, while proper selection and usage of compression hosiery help preserve and improve the outcomes acquired following treatment.
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Affiliation(s)
- Andrey L. Istranov
- Department of Oncology, Radiotherapy and Reconstructive Surgery, Sechenov First Moscow State Medical University, Moscow, Russia
- Correspondence: Andrey L. Istranov Ilya V. Ulasov
| | - Ivan G. Makarov
- Clinical-Research Center for Rehabilitation of Lymphedema Patients “LYMPHA”, Moscow, Russia
| | - Natalya V. Makarova
- Clinical-Research Center for Rehabilitation of Lymphedema Patients “LYMPHA”, Moscow, Russia
| | - Inna Tulina
- Clinic of Colorectal and Minimally Invasive Surgery, Department of Surgery, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Ilya V. Ulasov
- Group of Experimental Biotherapy and Diagnostic, Institute for Regenerative Medicine, Sechenov First Moscow State Medical University, Moscow, Russia
- World-Class Research Center “Digital Biodesign and Personalized Healthcare”, Sechenov First Moscow State Medical University, Moscow, Russia
- Correspondence: Andrey L. Istranov Ilya V. Ulasov
| | - Yuliya I. Isakova
- Department of Oncology, Radiotherapy and Reconstructive Surgery, Sechenov First Moscow State Medical University, Moscow, Russia
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Surgical Treatment and Rehabilitation Strategies for Upper and Lower Extremity Lymphedema: A Comprehensive Review. Medicina (B Aires) 2022; 58:medicina58070954. [PMID: 35888673 PMCID: PMC9324426 DOI: 10.3390/medicina58070954] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 07/10/2022] [Accepted: 07/15/2022] [Indexed: 02/07/2023] Open
Abstract
Lymphedema is a chronic disabling condition affecting a growing number of patients worldwide. Although lymphedema is not life-threatening, several reports underlined detrimental consequences in terms of distress, pain, functional impairment, and infections with a relevant decrease in quality of life. Currently, there is no cure, and the therapeutic management of this condition aims at slowing down the disease progression and preventing secondary complications. Early diagnosis is paramount to enhance the effects of rehabilitation or surgical treatments. On the other hand, a multidisciplinary treatment should be truly integrated, the combination of microsurgical and reductive procedures should be considered a valid strategy to manage extremity lymphedema, and rehabilitation should be considered the cornerstone of the multidisciplinary treatment not only for patients not suitable for surgical interventions but also before and after surgical procedures. Therefore, a specialized management of Plastic Reconstructive Surgeons and Physical and Rehabilitative Medicine physicians should be mandatory to address patients’ needs and optimize the treatment of this disabling and detrimental condition. Therefore, the aim of this review was to characterize the comprehensive management of lymphedema, providing a broad overview of the potential therapy available in the current literature to optimize the comprehensive management of lymphedema and minimize complications.
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Treatment of Early-Stage Gynecological Cancer-Related Lower Limb Lymphedema by Lymphaticovenular Anastomosis-The Triple Incision Approach. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58050631. [PMID: 35630048 PMCID: PMC9143574 DOI: 10.3390/medicina58050631] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 04/23/2022] [Accepted: 04/26/2022] [Indexed: 11/17/2022]
Abstract
Background and Objectives: Lower extremity lymphedema (LEL) is one of the most relevant chronic and disabling sequelae after gynecological cancer therapy involving pelvic lymphadenectomy (PL). Supermicrosurgical lymphaticovenular anastomosis (LVA) is a safe and effective procedure to treat LEL, particularly indicated in early-stage cases when conservative therapies are insufficient to control the swelling. Usually, preoperative assessment of these patients shows patent and peristaltic lymphatic vessels that can be mapped throughout the limb to plan the sites of skin incision to perform LVA. The aim of this study is to report the efficacy of our approach based on planning LVA in three areas of the lower limb in improving early-stage gynecological cancer-related lymphedema (GCRL) secondary to PL. Materials and Methods: We retrospectively reviewed the data of patients who underwent LVA for the treatment of early-stage GCRL following PL. Patients who had undergone groin dissection were excluded. Our preoperative study based on indocyanine green lymphography (ICG-L) and color doppler ultrasound (CDU) planned three incision sites located in the groin, in the medial surface of the distal third of the thigh, and in the upper half of the leg, to perform LVA. The primary outcome measure was the variation of the mean circumference of the limb after surgery. The changes between preoperative and postoperative limbs’ measures were analyzed by Student’s t-test. p values < 0.05 were considered significant. Results: Thirty-three patients were included. In every patient, three incision sites were employed to perform LVA. A total of 119 LVA were established, with an average of 3.6 for each patient. The mean circumference of the operated limb showed a significant reduction after surgery, decreasing from 37 cm ± 4.1 cm to 36.1 cm ± 4.4 (p < 0.01). Conclusions: Our results suggest that in patients affected by early-stage GCRL secondary to PL, the placement of incision sites in all the anatomical subunits of the lower limb is one of the key factors in achieving good results after LVA.
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Russo R, Carrizzo A, Barbato A, Rasile BR, Pentangelo P, Ceccaroni A, Marra C, Alfano C, Losco L. Clinical Evaluation of the Efficacy and Tolerability of Rigenase ® and Polyhexanide (Fitostimoline ® Plus) vs. Hyaluronic Acid and Silver Sulfadiazine (Connettivina ® Bio Plus) for the Treatment of Acute Skin Wounds: A Randomized Trial. J Clin Med 2022; 11:2518. [PMID: 35566643 PMCID: PMC9105357 DOI: 10.3390/jcm11092518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 04/13/2022] [Accepted: 04/27/2022] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES Compare the efficacy and tolerability of Connettivina® Bio Plus (Group A) gauze and cream, and Fitostimoline® Plus (Group B) gauze and cream for the treatment of acute superficial skin lesions. DESIGN Single-center, parallel, randomized trial. A block randomization method was used. SETTING University of Salerno-AOU San Giovanni di Dio e Ruggi d'Aragona. PARTICIPANTS Sixty patients were enrolled. All patients fulfilled the study requirements. INTERVENTION One application of the study drugs every 24 h, and a six-week observation period. MAIN OUTCOME MEASURES Efficacy and tolerability of the study drugs. RESULTS In total, 60 patients (Group A, n = 30; Group B, n = 30) were randomized; mean age was 58.5 ± 15.8 years. All patients were included in the outcome analysis. Total wound healing was achieved in 17 patients undergoing treatment with Connettivina® Bio Plus and 28 patients undergoing treatment with Fitostimoline® Plus. The greater effectiveness of the latter was significant (p = 0.00104). In Group B, a significantly greater degree of effectiveness was observed in reducing the fibrin in the wound bed (p = 0.04746). Complications or unexpected events were not observed. CONCLUSIONS Both Connettivina® Bio Plus and Fitostimoline® Plus are secure and effective for treating acute superficial skin lesions. Fitostimoline® Plus was more effective than Connettivina® Bio Plus in wound healing of acute superficial skin lesions, especially if fibrin had been observed in the wound bed.
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Affiliation(s)
- Raffaele Russo
- Plastic Surgery Unit, Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, 84081 Salerno, Italy; (R.R.); (A.C.); (B.R.R.); (P.P.); (A.C.); (C.M.)
| | - Albino Carrizzo
- Plastic Surgery Unit, Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, 84081 Salerno, Italy; (R.R.); (A.C.); (B.R.R.); (P.P.); (A.C.); (C.M.)
- Vascular Physiopathology Unit, IRCCS Neuromed, 86077 Pozzilli, Italy
| | - Alfonso Barbato
- U.O.C. di Chirurgia Plastica Ricostruttiva, Azienda Ospedaliera Universitaria OO.RR. San Giovanni di Dio e Ruggi d’Aragona, Via S. Leonardo 1, 84131 Salerno, Italy;
| | - Barbara Rosa Rasile
- Plastic Surgery Unit, Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, 84081 Salerno, Italy; (R.R.); (A.C.); (B.R.R.); (P.P.); (A.C.); (C.M.)
| | - Paola Pentangelo
- Plastic Surgery Unit, Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, 84081 Salerno, Italy; (R.R.); (A.C.); (B.R.R.); (P.P.); (A.C.); (C.M.)
| | - Alessandra Ceccaroni
- Plastic Surgery Unit, Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, 84081 Salerno, Italy; (R.R.); (A.C.); (B.R.R.); (P.P.); (A.C.); (C.M.)
| | - Caterina Marra
- Plastic Surgery Unit, Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, 84081 Salerno, Italy; (R.R.); (A.C.); (B.R.R.); (P.P.); (A.C.); (C.M.)
| | - Carmine Alfano
- Plastic Surgery Unit, Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, 84081 Salerno, Italy; (R.R.); (A.C.); (B.R.R.); (P.P.); (A.C.); (C.M.)
| | - Luigi Losco
- Plastic Surgery Unit, Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, 84081 Salerno, Italy; (R.R.); (A.C.); (B.R.R.); (P.P.); (A.C.); (C.M.)
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Wigg J. Genital lymphoedema and its hidden impact: a treatment guide. Br J Community Nurs 2022; 27:S32-S38. [PMID: 35373617 DOI: 10.12968/bjcn.2022.27.sup4.s32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Genital lymphoedema is recognised as a rare consequence of cancer surgery or its treatment, which also occurs with primary lymphoedema. Over recent years, there has been an increased understanding of the condition; however, good assessment, early recognition and effective management are crucial to prevent the progression and improve the lives of those with this condition. Treatment needs to be individualised and the psychosocial and emotional aspects of the condition need to be carefully considered to ensure that the patient can achieve successful outcomes with realistic expectations.
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Affiliation(s)
- Jane Wigg
- Clinical Nurse Consultant, LymphVision, and Director, Lymphoedema Training Academy
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12
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Lymphatic Function of the Lower Limb after Groin Dissection for Vulvar Cancer and Reconstruction with Lymphatic SCIP Flap. Cancers (Basel) 2022; 14:cancers14041076. [PMID: 35205824 PMCID: PMC8870617 DOI: 10.3390/cancers14041076] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 02/14/2022] [Accepted: 02/16/2022] [Indexed: 01/27/2023] Open
Abstract
Inguinofemoral lymphadenectomy, frequently performed for vulvar cancer, is burdened with substantial immediate and long-term morbidity. One of the most disabling treatment-related sequelae is lower limb lymphedema (LLL). The present study aims to describe the wound complications and the severity of LLL in patients who have undergone groin dissection for vulvar cancer and immediate inguinal reconstruction with the Lymphatic Superficial Circumflex Iliac Perforator flap (L-SCIP). We retrospectively reviewed the data of patients who underwent bilateral groin dissection and unilateral inguinal reconstruction with the L-SCIP. The presence and severity of postoperative LLL during the follow-up period were assessed by lymphoscintigraphy and limbs' volume measurement. In addition, immediate complications at the level of the inguinal area were registered. The changes between preoperative and postoperative limb volumes were analyzed by Student's t test. p values < 0.05 were considered significant. Thirty-one patients were included. The mean variation of volume was 479 ± 330 cc3 in the side where groin reconstruction had been performed, and 683 ± 425 cc3 in the contralateral side, showing smaller variation in the treated side (p = 0.022). Lymphoscintigraphy confirmed the clinical findings. Based on our results, inguinal reconstruction with L-SCIP performed at the same time of groin dissection in patients treated for vulvar cancer can provide a significant protective effect on LLL.
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Pierazzi DM, Arleo S, Faini G. Distally Prophylactic Lymphaticovenular Anastomoses after Axillary or Inguinal Complete Lymph Node Dissection Followed by Radiotherapy: A Case Series. Medicina (B Aires) 2022; 58:medicina58020207. [PMID: 35208531 PMCID: PMC8880594 DOI: 10.3390/medicina58020207] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 12/29/2021] [Accepted: 01/28/2022] [Indexed: 11/16/2022] Open
Abstract
Background and Objectives: Lymphedema is an important and underestimated condition, and this progressive chronic disease has serious implications on patients’ quality of life. The main goal of research would be to prevent lymphedema, instead of curing it. Patients receiving radiotherapy after lymph node dissection have a significantly higher risk of developing lymphedema. Through the prophylactic use of microsurgical lymphaticovenular anastomoses in selected patients, we could prevent the development of lymphedema. Materials and Methods: Six patients who underwent prophylactic lymphaticovenular anastomoses in a distal site to the axillary or groin region after axillary or inguinal complete lymph node dissection followed by radiotherapy were analyzed. Patients characteristics, comorbidities, operative details, postoperative complications and follow-up assessments were recorded. Results: Neither early nor late generic surgical complications were reported. We observed no lymphedema development throughout the post-surgical follow-up. In particular, we observed no increase in limb diameter measured at 1, 3, 6 and 12 months postoperatively. Conclusion: In our experience, performing LVA after axillary or groin lymphadenectomy and after adjuvant radiotherapy, and distally to the irradiated area, allows us to ensure the long-term patency of anastomoses in order to obtain the best results in terms of reducing the risk of iatrogenic lymphedema. This preliminary report is encouraging, and the adoption of our approach should be considered in selected patients.
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Affiliation(s)
- Diletta Maria Pierazzi
- Department of Medicine, Surgery and Neuroscience, Division of Plastic and Reconstructive Surgery, “Santa Maria alle Scotte” Hospital, University of Siena, 53100 Siena, Italy
- Correspondence:
| | - Sergio Arleo
- Department of Plastic Surgery, ASST Spedali Civili di Brescia, 25121 Brescia, Italy;
| | - Gianpaolo Faini
- Operative Unit of Reconstructive Microsurgery, Department of Surgery, ASST Valle Camonica, 25040 Brescia, Italy;
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The Combination of Lymph Node Transfer and Excisional Procedures in Bilateral Lower Extremity Lymphedema: Clinical Outcomes and Quality of Life Assessment with Long-Term Follow-Up. J Clin Med 2022; 11:jcm11030570. [PMID: 35160022 PMCID: PMC8836833 DOI: 10.3390/jcm11030570] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 01/17/2022] [Accepted: 01/21/2022] [Indexed: 02/04/2023] Open
Abstract
Background: Bilateral lower extremity lymphedema is a rare and invalidating condition that poses a great challenge to the scientific community, and deeply affects the quality of life (QoL) of affected patients. A combined protocol consisting of lymph node transfer and a reductive method have never been reported for the treatment of this condition, except for small case series with brief follow-up periods. Methods: This retrospective study analyzed data of 29 patients, mean age 51 ± 17.1 years, who had been diagnosed with bilateral lower extremity lymphedema. Gastroepiploic vascularized lymph node transfer was performed in all the patients, and an excisional procedure was associated according to the clinical stage. Clinical history, circumferential limb measurements, complications, episodes of cellulitis, and responses to the Lymphedema Quality of Life Questionnaire were analyzed. Results: The mean follow-up was 38.4 ± 11.8 months. A significant reduction in the episodes of cellulitis per year was observed (p < 0.001). In our series, BMI and duration of symptoms were significantly related to the development of cellulitis during the postoperative period, p = 0.006 and p = 0.020, respectively. The LYMQoL questionnaire showed a significant quality of life improvement from 3.4 ± 0.9 to 6.2 ± 0.8 (p < 0.05). Conclusions: An integrated approach is essential for the treatment of bilateral lower extremity lymphedema: reductive and reconstructive methods are complementary to achieve a successful outcome. Timely treatment and BMI reduction are relevant in order to decrease the number of episodes of cellulitis. An attentive follow-up is necessary to identify recurrence and treat affected patients in time.
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Prevention of Secondary Lymphedema after Complete Lymph Node Dissection in Melanoma Patients: The Role of Preventive Multiple Lymphatic-Venous Anastomosis in Observational Era. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58010117. [PMID: 35056425 PMCID: PMC8778345 DOI: 10.3390/medicina58010117] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/02/2022] [Accepted: 01/08/2022] [Indexed: 11/16/2022]
Abstract
Background and Objectives: Current guidelines have limited the performance of complete lymph node dissection (CLND) for patients with clinically detectable lymphatic metastases. Despite the limitations of this surgical procedure, secondary lymphedema (SL) is an unsolved problem that affects approximately 20% of patients undergoing CLND. Preventive lymphatic–venous micro-anastomoses (PMLVA) has already demonstrated its efficacy in the prevention of SL in melanoma patients with a positive sentinel lymph node biopsy (SLNB), but the efficacy of this procedure is not demonstrated in patients with clinically detectable lymphatic metastases. Materials and Methods: This retrospective cohort study, was performed in two observation periods. Until March 2018, CLND was proposed to all subjects with positive-SLNB andPMLVA was performed in a subgroup of patients with risk factors for SL (Group 1). From April 2018, according to the modification of melanoma guidelines, all patients with detectable metastatic lymph nodes underwent PMLVA during CLND (Group 2). The frequency of lymphedema in subjects undergoing PMLVA was compared with the control group. Results: Database evaluation revealed 172 patients with melanoma of the trunk with follow-up information for at least 6 mounts. Twenty-three patients underwent PMLVA during CLND until March 2018, 29 from April 2018, and 120 subjects underwent CLND without any preventive surgery (control Group). The frequency of SL was significantly lower in both Group 1 (4.3% vs. 24.2%, p = 0.03) and Group 2 (3.5%, p = 0.01). Patients undergoing PMLVA showed a similar recurrence-free periods and overall survival when compared to the control group. Conclusions: PMLVA significantly reduces the frequency of SL both in immediate and delayed CLND. This procedure is safe and does not lead to an increase in length of hospitalization.
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Suzuki Y, Kajita H, Watanabe S, Otaki M, Okabe K, Sakuma H, Takatsume Y, Imanishi N, Aiso S, Kishi K. Surgical Applications of Lymphatic Vessel Visualization Using Photoacoustic Imaging and Augmented Reality. J Clin Med 2021; 11:jcm11010194. [PMID: 35011933 PMCID: PMC8745664 DOI: 10.3390/jcm11010194] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 12/12/2021] [Accepted: 12/26/2021] [Indexed: 11/16/2022] Open
Abstract
Lymphaticovenular anastomosis (LVA) is a widely performed surgical procedure for the treatment of lymphedema. For good LVA outcomes, identifying lymphatic vessels and venules is crucial. Photoacoustic lymphangiography (PAL) is a new technology for visualizing lymphatic vessels. It can depict lymphatic vessels at high resolution; therefore, this study focused on how to apply PAL for lymphatic surgery. To visualize lymphatic vessels, indocyanine green was injected as a color agent. PAI-05 was used as the photoacoustic imaging device. Lymphatic vessels and veins were visualized at 797- and 835-nm wavelengths. First, it was confirmed whether the branching of the vasculature as depicted by the PAL was consistent with the actual branching of the vasculature as confirmed intraoperatively. Second, to use PAL images for surgical planning, preoperative photoacoustic images were superimposed onto the patient limb through augmented reality (AR) glasses (MOVERIO Smart Glass BT-30E). Lymphatics and venule markings drawn using AR glasses were consistent with the actual intraoperative images obtained during LVA. To anastomose multiple lymphatic vessels, a site with abundant venous branching was selected as the incision site; and selecting the incision site became easier. The anatomical morphology obtained by PAL matched the surgical field. AR-based marking could be very useful in future LVA.
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Affiliation(s)
- Yushi Suzuki
- Department of Plastic and Reconstructive Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan; (H.K.); (S.W.); (M.O.); (K.O.); (K.K.)
- Correspondence: ; Tel.: +81-3-5363-3814
| | - Hiroki Kajita
- Department of Plastic and Reconstructive Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan; (H.K.); (S.W.); (M.O.); (K.O.); (K.K.)
| | - Shiho Watanabe
- Department of Plastic and Reconstructive Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan; (H.K.); (S.W.); (M.O.); (K.O.); (K.K.)
| | - Marika Otaki
- Department of Plastic and Reconstructive Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan; (H.K.); (S.W.); (M.O.); (K.O.); (K.K.)
| | - Keisuke Okabe
- Department of Plastic and Reconstructive Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan; (H.K.); (S.W.); (M.O.); (K.O.); (K.K.)
| | - Hisashi Sakuma
- Department of Plastic and Reconstructive Surgery, Tokyo Dental College Ichikawa General Hospital, Chiba 272-8513, Japan;
| | - Yoshifumi Takatsume
- Department of Anatomy, Keio University School of Medicine, Tokyo 160-8582, Japan; (Y.T.); (N.I.)
| | - Nobuaki Imanishi
- Department of Anatomy, Keio University School of Medicine, Tokyo 160-8582, Japan; (Y.T.); (N.I.)
| | | | - Kazuo Kishi
- Department of Plastic and Reconstructive Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan; (H.K.); (S.W.); (M.O.); (K.O.); (K.K.)
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