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Ogura A, Miyazaki T. Strategy for Indocyanine Green Injection to Identify Lymphatic Vessels in Groin Territory. J Reconstr Microsurg 2024. [PMID: 39303741 DOI: 10.1055/s-0044-1791254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2024]
Affiliation(s)
- Ayaka Ogura
- Department of Medical Education, National Center for Global Health and Medicine, Tokyo, Japan
| | - Toko Miyazaki
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
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2
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Li Y, Tang J, Mao D, Dragomir MP, Li Y, Sun K, Lv Z, Liu X, Meng X, Lu K. MRI-CEUS fusion-guided lymphatic mapping as a preoperative strategy for lymphedema patients undergoing lymphaticovenous anastomosis surgery. J Vasc Surg Venous Lymphat Disord 2024; 12:101907. [PMID: 38759752 DOI: 10.1016/j.jvsv.2024.101907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 04/06/2024] [Accepted: 05/03/2024] [Indexed: 05/19/2024]
Abstract
OBJECTIVE Contrast-enhanced ultrasound (CEUS) is useful in mapping lymphatic vessels in upper limb lymphedema; this study was aimed to evaluate its efficiency in lower limb lymphedema and investigate whether magnetic resonance lymphangiography (MRL) enhance the efficiency of CEUS. METHODS This retrospective study enrolled 48 patients with lymphedema undergoing lymphaticovenous anastomosis (LVA) surgery who received MRL and/or CEUS in addition to conventional indocyanine green (ICG) lymphangiography. The number of anastomotic sites and the duration per site (DPS) for LVA surgery were described and compared. RESULTS Among the 48 patients subjected to analysis, it was observed that 12 (25%), 20 (41.67%), and 16 (33.33%) of them received ICG, ICG+CEUS, and ICG+CEUS+MRL, respectively. The ICG+CEUS group demonstrated a significant increase in the number of LVAs (median, 5; range, 4-7), compared with the ICG group (median, 2; range, 1-4) (P < .001). Moreover, the ICG+CEUS+MRL group exhibited a higher number of LVAs (median, 8; range, 7-8.25) compared with both the ICG+CEUS and ICG groups (P < .001). For lower limb lymphedema, the ICG+CEUS+MRL group displayed an elevated number of LVAs (median, 8; interquartile range, 7-9) (P = .003), in contrast to the ICG group (median, 3; interquartile range, 1.75-4.25). Furthermore, the DPS in the ICG+CEUS+MRL group (median, 50.56; interquartile range, 48.13-59.29) (P = .005) exhibited a remarkable decrease when compared with the ICG group (median, 131.25; interquartile range, 86.75-198.13]). CONCLUSIONS MRL-CEUS fusion demonstrates superior performance in the identification of lymphatic vessels for lymphedema.
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Affiliation(s)
- Yongfeng Li
- Division of General Surgery, Cancer Center, Department of Breast Surgery, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, China
| | - Jinglan Tang
- Cancer Center, Department of Ultrasound Medicine, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, China
| | - Dewang Mao
- Cancer Center, Department of Radiology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, China
| | - Mihnea P Dragomir
- Institute of Pathology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu, Berlin, Germany; German Cancer Consortium (DKTK), Partner Site Berlin, and German Cancer Research Center (DKFZ), Heidelberg, Germany; Berlin Institute of Health, Berlin, Germany
| | - Ying Li
- Division of General Surgery, Cancer Center, Department of Breast Surgery, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, China
| | - Kewang Sun
- Division of General Surgery, Cancer Center, Department of Breast Surgery, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, China
| | - Zhenye Lv
- Division of General Surgery, Cancer Center, Department of Breast Surgery, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, China
| | - Xiaozhen Liu
- Division of General Surgery, Cancer Center, Department of Breast Surgery, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, China
| | - Xuli Meng
- Division of General Surgery, Cancer Center, Department of Breast Surgery, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, China
| | - Kefeng Lu
- Cancer Center, Department of Ultrasound Medicine, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, China.
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3
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Frosolini A, Benedetti S, Catarzi L, Massarelli O, Gennaro P, Gabriele G. Exoscope and Supermicrosurgery: Pros and Cons of 3D Innovation in Lymphatic Surgery. J Clin Med 2024; 13:4974. [PMID: 39274187 PMCID: PMC11396241 DOI: 10.3390/jcm13174974] [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: 07/16/2024] [Revised: 08/16/2024] [Accepted: 08/19/2024] [Indexed: 09/16/2024] Open
Abstract
Background: The surgical treatment of lymphedema has seen advancements in recent years, with supramicrosurgical lymphaticovenular anastomosis (sLVA) gaining global acceptance. The integration of 3D exoscopes into microsurgery offers potential ergonomic and educational benefits. However, systematic evaluation of their efficacy in sLVA remains limited. Methods: A retrospective cross-sectional study was conducted comparing the use of 3D exoscopes to conventional operating microscopes (OM) in sLVA surgeries. Patient data from January 2019 to January 2024 were reviewed, with demographic, clinical, and surgical outcome variables analyzed. Ergonomic assessments were performed using Rapid Entire Body Assessment (REBA) and Rapid Upper Limb Assessment (RULA), while surgeon satisfaction was evaluated through the Microsurgical Intraoperative Satisfaction and Comfort questionnaire (MISCq). Results: An analysis of 25 patients (OM group: n = 14; exoscope group: n = 11) revealed no significant differences in age, sex, etiology, or surgical site between the two groups. Surgical time, number of incisions, and number of anastomoses showed nonsignificant variations between the OM and exoscope groups. Ergonomic assessments indicated potential benefits with exoscope use, particularly for the assistant surgeon. Survey results demonstrated comparable levels of surgeon satisfaction with both instruments, with no significant differences in image quality, contrast, illumination, magnification, visual field, ergonomic maintenance, or stereoscopic orientation. Conclusions: The study suggests that 3D exoscopes are a valuable tool for sLVA supermicrosurgery, offering comparable outcomes to traditional microscopes with potential ergonomic advantages. Their integration into microsurgical practice may contribute to improved surgical comfort and team performance. Further research is warranted to confirm these findings and explore additional factors such as cost-effectiveness and long-term patient outcomes.
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Affiliation(s)
- Andrea Frosolini
- Maxillofacial Surgery Unit, Department of Medical Biotechnology, S. Maria alle Scotte University Hospital of Siena, 53100 Siena, Italy
| | - Simone Benedetti
- Maxillofacial Surgery Unit, Department of Medical Biotechnology, S. Maria alle Scotte University Hospital of Siena, 53100 Siena, Italy
| | - Lisa Catarzi
- Maxillofacial Surgery Unit, Department of Medical Biotechnology, S. Maria alle Scotte University Hospital of Siena, 53100 Siena, Italy
| | - Olindo Massarelli
- Maxillofacial Surgery Unit, Department of Medical Biotechnology, S. Maria alle Scotte University Hospital of Siena, 53100 Siena, Italy
| | - Paolo Gennaro
- Maxillofacial Surgery Unit, Department of Medical Biotechnology, S. Maria alle Scotte University Hospital of Siena, 53100 Siena, Italy
| | - Guido Gabriele
- Maxillofacial Surgery Unit, Department of Medical Biotechnology, S. Maria alle Scotte University Hospital of Siena, 53100 Siena, Italy
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Campos JL, Suominen S, Pons G, Al-Sakkaf AM, Lusetti IL, Sirota M, Vela FJ, Pires L, Sánchez-Margallo FM, Abellán E, Masiá J. Lymphatic Patterns in the Superficial Circumflex Iliac Artery Perforator Flap. J Reconstr Microsurg 2024. [PMID: 38848754 DOI: 10.1055/a-2340-9629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2024]
Abstract
BACKGROUND Lymphedema is a chronic condition, characterized by fluid buildup and tissue swelling and is caused by impairment of the lymphatic system. The lymph interpositional flap transfer technique, in which lymph flow is restored with a flap that includes subdermal lymphatic channels, is an option for surgical reconstruction. The superficial circumflex iliac artery perforator (SCIP) flap can be used for this purpose. This study aimed to describe and characterize the lymphatic patterns within the vascular territory of the SCIP flap. METHODS This cross-sectional multicenter study involved 19 healthy volunteers aged ≥18 years of both sexes assessing the bilateral SCIP flap zone. Superficial lymphatic patterns were evaluated at 4-, 14-, and 24 minutes after indocyanine green (ICG) lymphography injection. Standardized procedures were implemented for all participants in both hospitals. RESULTS The linear pattern was predominant bilaterally. The median number of lymphatic vessels and their length increased over time. Most lymphatic vessels in the SCIP flap were oriented toward the inguinal lymph node (ILN). However, the left SCIP zone lymphatic vessels were directed opposite to the ILN. CONCLUSION The two sides SCIP zones were not significantly different. The primary direction of the bilateral lymphatic vessels was toward the ILN, although only single-side lymphatic vessels were in the opposite direction. These findings emphasize the importance of assessing lymphatic axiality and coherent lymphatic patterns prior to undertaking the SCIP as an interposition flap, to ensure effective restoration of lymphatic flow.
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Affiliation(s)
- José Luis Campos
- Department of Microsurgery, Jesús Usón Minimally Invasive Surgery Centre, Cáceres, Spain
| | - Sinikka Suominen
- Department of Plastic and Reconstructive Surgery, Helsinki University Central Hospital, Helsinki, Finland
| | - Gemma Pons
- Department of Plastic Surgery, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Ali M Al-Sakkaf
- Department of Plastic Surgery, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Irene Laura Lusetti
- Department of Plastic Surgery, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Max Sirota
- Department of Plastic Surgery, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Francisco Javier Vela
- Department of Microsurgery, Jesús Usón Minimally Invasive Surgery Centre, Cáceres, Spain
| | - Laura Pires
- Department of Microsurgery, Jesús Usón Minimally Invasive Surgery Centre, Cáceres, Spain
| | | | - Elena Abellán
- Department of Microsurgery, Jesús Usón Minimally Invasive Surgery Centre, Cáceres, Spain
| | - Jaume Masiá
- Department of Plastic Surgery, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
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5
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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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6
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Karakama R, Miyazaki T. Considerations on minimally invasiveness and long-term efficacy of lymphaticovenular anastomosis for primary lymphedema. J Plast Reconstr Aesthet Surg 2024; 93:60-61. [PMID: 38657555 DOI: 10.1016/j.bjps.2024.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Accepted: 04/05/2024] [Indexed: 04/26/2024]
Affiliation(s)
- Reo Karakama
- Department of Medical Education, National Center for Global Health and Medicine, Tokyo, Japan
| | - Toko Miyazaki
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan.
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7
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Campos JL, Pires L, Vela FJ, Pons G, Al-Sakkaf AM, Sánchez-Margallo FM, Abellán E, Masiá J. Lymphaticovenous anastomosis in rabbits: A novel live experimental animal model for supermicrosurgical training. J Plast Reconstr Aesthet Surg 2024; 93:290-298. [PMID: 38754281 DOI: 10.1016/j.bjps.2024.04.023] [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: 12/05/2023] [Revised: 03/12/2024] [Accepted: 04/05/2024] [Indexed: 05/18/2024]
Abstract
BACKGROUND Lymphaticovenous anastomosis is widely used in lymphedema management. Although its effectiveness in reducing edema in patients can be clinically observed, evaluating the long-term outcomes of this technique can be complex. This study established an animal model to assess the outcomes of lymphaticovenous anastomosis technique at 15 and 30-days post-surgery using indocyanine green lymphography, Patent Blue V dye injection, and histopathological examination. METHODS An experimental model was established in the hindlimbs of 10 rabbits using the popliteal vein and afferent lymphatic vessels in the popliteal area. The subjects were divided into two groups: the first group (n = 5) underwent patency assessment at 0 and 15 days, and the second group (n = 5) at 0 and 30-days, resulting in 20 anastomoses. Patency was verified at 0, 15, and 30-days using indocyanine green lymphography and Patent Blue V injection. Histopathological examinations were performed on the collected anastomosis samples. RESULTS The patency rate was 90% (19/20) initially, 60% (6/10) at 15 days post-surgery, and 80% (8/10) at 30-days. The average diameter of lymphatic vessels and veins was 1.0 mm and 0.8 mm, respectively. The median number of collateral veins was 3; the median surgical time was 65.8 min. Histopathology revealed minimal endothelial damage and inflammatory responses due to the surgical sutures, with vascular inflammation and thrombosis in a single case. Local vascular neoformations were observed. CONCLUSION This study highlights the reliability and reproducibility of using rabbits as experimental models for training in lymphaticovenous anastomosis technique owing to the accessibility of the surgical site and dimensions of their popliteal vasculature.
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Affiliation(s)
- José L Campos
- Department of Microsurgery, Jesús Usón Minimally Invasive Surgery Centre, Cáceres, Spain.
| | - Laura Pires
- Department of Microsurgery, Jesús Usón Minimally Invasive Surgery Centre, Cáceres, Spain
| | - Francisco J Vela
- Department of Microsurgery, Jesús Usón Minimally Invasive Surgery Centre, Cáceres, Spain
| | - Gemma Pons
- Department of Plastic Surgery, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Ali M Al-Sakkaf
- Department of Plastic Surgery, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | | | - Elena Abellán
- Department of Microsurgery, Jesús Usón Minimally Invasive Surgery Centre, Cáceres, Spain
| | - Jaume Masiá
- Department of Plastic Surgery, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
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8
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Lin CH, Yamamoto T. Supermicrosurgical lymphovenous anastomosis. J Chin Med Assoc 2024; 87:455-462. [PMID: 38517403 DOI: 10.1097/jcma.0000000000001088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2024] Open
Abstract
Lymphedema impairs patients' function and quality of life. Currently, supermicrosurgical lymphovenous anastomosis (LVA) is regarded as a significant and effective treatment for lymphedema. This article aims to review recent literature on this procedure, serving as a reference for future research and surgical advancements. Evolving since the last century, LVA has emerged as a pivotal domain within modern microsurgery. It plays a crucial role in treating lymphatic disorders. Recent literature discusses clinical imaging, surgical techniques, postoperative care, and efficacy. Combining advanced tools, precise imaging, and surgical skills, LVA provides a safer and more effective treatment option for lymphedema patients, significantly enhancing their quality of life. This procedure also presents new challenges and opportunities in the realm of microsurgery.
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Affiliation(s)
- Chih-Hsun Lin
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Surgery, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Takumi Yamamoto
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
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9
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Padungyotee K, Tsukuura R. Letter to the editor regarding ''Comparative study of conservative treatment and lymphaticovenular anastomosis with compression therapy for early-stage breast cancer-related lymphedema''. J Plast Reconstr Aesthet Surg 2024; 92:299-300. [PMID: 38603964 DOI: 10.1016/j.bjps.2024.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 02/01/2024] [Indexed: 04/13/2024]
Affiliation(s)
- Kawinee Padungyotee
- Department of Medicine, Thammasat University Hospital, Pratumthani, Thailand
| | - Reiko Tsukuura
- Department of Plastic and Reconstructive Surgery, Center Hospital of National Center for Global Health and Medicine, Tokyo, Japan.
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10
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Seidenstuecker K, Fertsch S, Ghazaleh AA, Fabi A, Stoffel J, Bukowiecki J, Wolter A, Aghlmandi S, Nadella A, Halbeisen FS, Andree C, Haug MD, Schaefer DJ, Handschin TM, Kappos EA. Improving quality of life after breast cancer: a comparison of two microsurgical treatment options for breast cancer-related lymphedema (BCRL). Clin Exp Med 2024; 24:82. [PMID: 38653874 DOI: 10.1007/s10238-024-01344-w] [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: 01/02/2024] [Accepted: 04/02/2024] [Indexed: 04/25/2024]
Abstract
PURPOSE Vascularized lymph node transfer (VLNT) entails the autologous relocation of lymph nodes to a lymphedematous region of the body, whereas lymphaticovenous anastomosis (LVA) creates a direct bypass between the lymphatic and venous system. Both techniques are meant to lastingly bolster the local lymphatic drainage capacity. This study compared safety and effectiveness of VLNT and LVA in patients with chronic breast cancer related lymphedema (BCRL). METHODS A retrospective cohort study was conducted using data from our encrypted database composed of patients with chronic BCRL who were treated with either VLNT or LVA and had a minimum follow-up of two years. Patient-specific variables analyzed included pre- and postoperative arm circumferences, lymphedema stages and postoperative complications. RESULTS A total of 105 patients met the inclusion criteria, of which 96 patients demonstrated a complete follow-up period of two years. The VLNT group displayed larger preoperative circumferential measurements, evident in both in the isolated examination of the affected arm, as well as when adjusted for the contralateral unaffected arm. Significant reduction in arm volume was achieved by both groups. However, VLNT demonstrated superior relative reduction rates than LVA, neutralizing any significant arm size disparities after 24 months. Surgery duration was slightly longer for VLNT than LVA. Postoperative complications, predominantly minor, were exclusively observed in the VLNT group. CONCLUSIONS Both VLNT and LVA offer significant improvement for patients suffering from chronic BCRL. VLNT shows an even greater potential for improvement in more severe cases of BCRL, but involves a higher risk for (mostly minor) complications.
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Affiliation(s)
- Katrin Seidenstuecker
- Department of Plastic, Reconstructive and Aesthetic Surgery, Sana Hospital Düsseldorf, Düsseldorf, Germany
- Breast Center, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Sonia Fertsch
- Department of Plastic, Reconstructive and Aesthetic Surgery, Sana Hospital Düsseldorf, Düsseldorf, Germany
- Faculty of Health, University Witten-Herdecke, Witten, Germany
| | - Alina A Ghazaleh
- Department of Plastic, Reconstructive and Aesthetic Surgery, Sana Hospital Düsseldorf, Düsseldorf, Germany
| | - Adriano Fabi
- Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital of Basel, Spitalstrasse 21, 4031, Basel, Switzerland
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
| | - Julia Stoffel
- Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital of Basel, Spitalstrasse 21, 4031, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Julia Bukowiecki
- Department of Plastic, Reconstructive and Aesthetic Surgery, Sana Hospital Düsseldorf, Düsseldorf, Germany
| | - Andreas Wolter
- Department of Plastic, Reconstructive and Aesthetic Surgery, Sana Hospital Düsseldorf, Düsseldorf, Germany
- Faculty of Health, University Witten-Herdecke, Witten, Germany
| | - Soheila Aghlmandi
- Surgical Outcome Research Center, Department of Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Anshoo Nadella
- Surgical Outcome Research Center, Department of Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Florian S Halbeisen
- Surgical Outcome Research Center, Department of Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Christoph Andree
- Department of Plastic, Reconstructive and Aesthetic Surgery, Sana Hospital Düsseldorf, Düsseldorf, Germany
| | - Martin D Haug
- Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital of Basel, Spitalstrasse 21, 4031, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Dirk J Schaefer
- Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital of Basel, Spitalstrasse 21, 4031, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Tristan M Handschin
- Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital of Basel, Spitalstrasse 21, 4031, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Elisabeth A Kappos
- Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital of Basel, Spitalstrasse 21, 4031, Basel, Switzerland.
- Faculty of Medicine, University of Basel, Basel, Switzerland.
- Breast Center, University Hospital of Basel, Basel, Switzerland.
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11
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Kageyama T, Shiko Y, Kawasaki Y, Miyazaki T, Sakai H, Tsukuura R, Yamamoto T. Three-dimensional non-contrast magnetic resonance lymphography severity stage for upper extremity lymphedema. Magn Reson Imaging 2024; 107:24-32. [PMID: 38181836 DOI: 10.1016/j.mri.2023.12.007] [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: 09/18/2023] [Revised: 12/17/2023] [Accepted: 12/28/2023] [Indexed: 01/07/2024]
Abstract
PURPOSES Non-contrast magnetic resonance lymphography (NMRL) has recently shown the capability of evaluating anatomical fluid distribution in upper extremity lymphedema (UEL). However, there is still a lack of knowledge about the correlation between the characteristic three-dimensional (3D) NMRL findings and the indocyanine green lymphography (ICG-L) findings. Our goal was to clarify the relationship between the 3D NMRL findings and the ICG-L findings. METHODS Medical charts of patients with secondary UEL who underwent NMRL and ICG-L between January 2018 to October 2021 were reviewed. The upper extremities were divided into 6 regions; the hand, elbow, and the radial and ulnar aspects of the forearm and the upper arm. We investigated the prevalence of characteristic 3D NMRL patterns (Mist/Spray/Inky) in each region based on the ICG-L stage. We also examined the association between the 3D NMRL stage which we proposed and the ICG-L stage, and other clinical factors. RESULTS A total of 150 regions of 25 patients with upper extremities lymphedema were enrolled in the study. All of the characteristic patterns increased significantly as the ICG-L stage advanced (p < 0.001, < 0.001, and < 0.001, respectively). The predominant NMRL patterns changed significantly from the Early pattern (Mist pattern) to the Advanced pattern (Inky/Spray pattern) as the ICG-L stage progressed (p < 0.001). The higher Stage of 3D NMRL was significantly associated with the progression of the ICG-L stage (rs = 0.80, p < 0.001). CONCLUSIONS Characteristic 3D NMRL patterns and the 3D NMRL Stage had a significant relationship with the ICG-L stage and other clinical parameters. This information may be an efficient tool for a more precise and objective evaluation of various treatments for UEL patients.
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Affiliation(s)
- Takashi Kageyama
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan; Department of Emergency and Critical Care Medicine, Saitama Medical Center, Saitama, Japan
| | - Yuki Shiko
- Research Administration Center, Saitama Medical University, Saitama, Japan
| | - Yohei Kawasaki
- Research Administration Center, Saitama Medical University, Saitama, Japan
| | - Toko Miyazaki
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Hayahito Sakai
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Reiko Tsukuura
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Takumi Yamamoto
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan.
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12
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Devoogdt N, Thomis S, Belva F, Dickinson-Blok J, Fourgeaud C, Giacalone G, Karlsmark T, Kavola H, Keeley V, Marques ML, Mansour S, Nissen CV, Nørregaard S, Oberlin M, Ručigaj TP, Somalo-Barranco G, Suominen S, Van Duinen K, Vignes S, Damstra R. The VASCERN PPL working group patient pathway for primary and paediatric lymphoedema. Eur J Med Genet 2024; 67:104905. [PMID: 38143023 DOI: 10.1016/j.ejmg.2023.104905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 12/18/2023] [Indexed: 12/26/2023]
Abstract
Lymphoedema is caused by an imbalance between fluid production and transport by the lymphatic system. This imbalance can be either caused by reduced transport capacity of the lymphatic system or too much fluid production and leads to swelling associated with tissue changes (skin thickening, fat deposition). Its main common complication is the increased risk of developing cellulitis/erysipelas in the affected area, which can worsen the lymphatic function and can be the cause of raised morbidity of the patient if not treated correctly/urgently. The term primary lymphoedema covers a group of rare conditions caused by abnormal functioning and/or development of the lymphatic system. It covers a highly heterogeneous group of conditions. An accurate diagnosis of primary lymphoedema is crucial for the implementation of an optimal treatment plan and management, as well as to reduce the risk of worsening. Patient care is diverse across Europe, and national specialised centres and networks are not available everywhere. The European Reference Network on Rare Multisystemic Vascular Diseases (VASCERN) gathers the best expertise in Europe and provide accessible cross-border healthcare to patients with rare vascular diseases. There are six different working groups in VASCERN, which focus on arterial diseases, hereditary haemorrhagic telangiectasia, neurovascular diseases, lymphoedema and vascular anomalies. The working group Paediatric and Primary Lymphedema (PPL WG) gathers and shares knowledge and expertise in the diagnosis and management of adults and children with primary and paediatric lymphoedema. The members of PPL WG have worked together to produce this opinion statement reflecting strategies on how to approach patients with primary and paediatric lymphoedema. The objective of this patient pathway is to improve patient care by reducing the time to diagnosis, define the best management and follow-up strategies and avoid overuse of resources. Therefore, the patient pathway describes the clinical evaluation and investigations that lead to a clinical diagnosis, the genetic testing, differential diagnosis, the management and treatment options and the patient follow up at expert and local centres. Also, the importance of the patient group participation in the PPL WG is discussed.
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Affiliation(s)
- Nele Devoogdt
- Centre for Lymphedema, Department of Vascular Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Sarah Thomis
- Centre for Lymphedema, Department of Vascular Surgery, University Hospitals Leuven, Leuven, Belgium
| | | | - Janine Dickinson-Blok
- Expert Center for Lymphovascular Medicine, Nij Smellinghe Hospital, Drachten, the Netherlands
| | - Caroline Fourgeaud
- Department of Lymphology and Reference Center for Rare Vascular Diseases, Cognacq-Jay Hospital, 15, Rue Eugène-Millon, 75015, Paris, France
| | | | - Tonny Karlsmark
- Department of Dermatology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Heli Kavola
- Department of Plastic Surgery, Helsinki University Hospital, Helsinki, Finland
| | - Vaughan Keeley
- Derby Lymphedema Service, University Hospitals of Derby and Burton NHS Trust, Derby, UK
| | | | - Sahar Mansour
- Department of Lymphovascular Medicine, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Christoffer V Nissen
- Department of Dermatology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Susan Nørregaard
- Department of Dermatology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Michael Oberlin
- European Centre for Lymphology, Földi Clinic, Hinterzarten, Germany
| | | | | | - Sinikka Suominen
- Department of Plastic Surgery, Helsinki University Hospital, Helsinki, Finland
| | - Kirsten Van Duinen
- Expert Center for Lymphovascular Medicine, Nij Smellinghe Hospital, Drachten, the Netherlands
| | - Stéphane Vignes
- Department of Lymphology and Reference Center for Rare Vascular Diseases, Cognacq-Jay Hospital, 15, Rue Eugène-Millon, 75015, Paris, France
| | - Robert Damstra
- Expert Center for Lymphovascular Medicine, Nij Smellinghe Hospital, Drachten, the Netherlands.
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13
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Sun JM, Yamamoto T. Lymphovenous shunts in the treatment of lymphedema. J Chin Med Assoc 2024; 87:5-11. [PMID: 37962114 DOI: 10.1097/jcma.0000000000001016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2023] Open
Abstract
Lymphedema is a progressive disease with no known cure. Characterized by the accumulation of lymphatic fluid and subsequent swelling in the affected limbs, it often poses significant challenges to those living with it. Although various conservative treatments have been used to manage lymphedema, such as compression therapy and physical rehabilitation, surgical interventions have emerged as promising avenues for more substantial relief. Lymphovenous shunts have been described since the 1960s and have garnered much attention in the recent two decades due to technological advances in optics, imaging, and surgical instruments. This review article explores the use of different lymphovenous shunts such as lymphatic implantation, lymph node-to-vein anastomoses (LNVAs), dermal-adipose lymphatic flap venous wrapping (DALF-VW), and supermicrosurgical lymphovenous anastomoses (LVAs) as treatment modalities for lymphedema. We will discuss the underlying principles, indications, techniques, and potential benefits. By examining the current state of knowledge and ongoing research in the field, we aim to provide insights into the role of lymphovenous shunts in the comprehensive management of lymphedema and shed light on the prospects for this treatment option.
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Affiliation(s)
- Jeremy Mingfa Sun
- Department of Surgery, Plastic Reconstructive and Aesthetic Surgery Service, Changi General Hospital, Singapore, Singapore
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Takumi Yamamoto
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
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14
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Yoshikawa Y, Sakai H. The ventral metacarpal artery of chicken wings for microsurgery and supermicrosurgery training. J Plast Reconstr Aesthet Surg 2023; 87:316-317. [PMID: 37925921 DOI: 10.1016/j.bjps.2023.10.081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 10/07/2023] [Indexed: 11/07/2023]
Affiliation(s)
- Yuji Yoshikawa
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Hayahito Sakai
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan.
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15
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Banerjee A, Jou E, Wong KY. Supermicrosurgery: past, present and future. Br J Hosp Med (Lond) 2023; 84:1-10. [PMID: 37906072 DOI: 10.12968/hmed.2022.0482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Abstract
Supermicrosurgery was popularised in 1997 and is defined as a technique of microvascular anastomosis for single nerve fascicles and vessels 0.3-0.8 mm in diameter. It requires the use of powerful microscopes, ultradelicate microsurgical instruments and specialist dyes. The development of supermicrosurgery has vastly improved the ability of microsurgeons to create true perforator flaps with minimal donor site morbidity for reconstructive surgery and improved the precision of additional microsurgical techniques. This review outlines the origins and history of supermicrosurgery, its current applications in reconstructive surgery (including fingertip reconstructions, true perforator flap surgery, nerve flaps and lymphoedema surgery), supermicrosurgery training and future directions for the field.
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Affiliation(s)
- Arka Banerjee
- Department of Plastic Surgery, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Eric Jou
- Medical Sciences Division, Oxford University Hospitals, University of Oxford, Oxford, UK
- Kellogg College, University of Oxford, Oxford, UK
| | - Kai Yuen Wong
- Department of Plastic Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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16
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Cheon H, Lee SH, Kim SA, Kim B, Suh HP, Jeon JY. In Vivo Dynamic and Static Analysis of Lymphatic Dysfunction in Lymphedema Using Near-Infrared Fluorescence Indocyanine Green Lymphangiography. Arterioscler Thromb Vasc Biol 2023; 43:2008-2022. [PMID: 37615112 DOI: 10.1161/atvbaha.123.319188] [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: 02/23/2023] [Accepted: 08/02/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND Near-infrared fluorescence indocyanine green lymphangiography, a primary modality for detecting lymphedema, which is a disease due to lymphatic obstruction, enables real-time observations of lymphatics and reveals not only the spatial distribution of drainage (static analysis) but also information on the lymphatic contraction (dynamic analysis). METHODS We have produced total lymphatic obstruction in the upper limbs of 18 Sprague-Dawley rats through the dissection of proximal (brachial and axillary) lymph nodes and 20-Gy radiation (dissection limbs). After the model formation for 1 week, 9 animal models were observed for 6 weeks using near-infrared fluorescence indocyanine green lymphangiography by injecting 6-μL ICG-BSA (indocyanine green-bovine serum albumin) solution of 20-μg/mL concentration. The drainage pattern and leakage of lymph fluid were evaluated and time-domain signals of lymphatic contraction were observed in the distal lymphatic vessels. The obtained signals were converted to frequency-domain spectrums using signal processing. RESULTS The results of both static and dynamic analyses proved to be effective in accurately identifying the extent of lymphatic disruption in the dissection limbs. The static analysis showed abnormal drainage patterns and increased leakage of lymph fluid to the periphery of the vessels compared with the control (normal) limbs. Meanwhile, the waveforms were changed and the contractile signal frequency increased by 58% in the dynamic analysis. Specifically, our findings revealed that regular lymphatic contractions, observed at a frequency range of 0.08 to 0.13 Hz in the control limbs, were absent in the dissection limbs. The contractile regularity was not fully restored for the follow-up period, indicating a persistent lymphatic obstruction. CONCLUSIONS The dynamic analysis could detect the abnormalities of lymphatic circulation by observing the characteristics of signals, and it provided additional evaluation indicators that cannot be provided by the static analysis. Our findings may be useful for the early detection of the circulation problem as a functional evaluation indicator of the lymphatic system.
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Affiliation(s)
- Hwayeong Cheon
- Biomedical Engineering Research Center, Asan Medical Center, Seoul, Republic of Korea (H.C.)
| | - Sang-Hun Lee
- Department of Optical Engineering, Kumoh National Institute of Technology, Gyeongbuk, Republic of Korea (S.-H.L.)
| | - Sang Ah Kim
- Department of Rehabilitation Medicine (S.A.K., B.K., J.Y.J.), Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Bumchul Kim
- Department of Rehabilitation Medicine (S.A.K., B.K., J.Y.J.), Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hyunsuk Peter Suh
- Department of Plastic Surgery (H.P.S.), Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jae Yong Jeon
- Department of Rehabilitation Medicine (S.A.K., B.K., J.Y.J.), Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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17
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Nuri T, Asaka A, Otsuki Y, Ueda K. Modified Preparatory Intravascular Stenting Technique in Super-microsurgical Lymphaticovenular Anastomosis for the Treatment of Lymphedema. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5308. [PMID: 37799441 PMCID: PMC10550024 DOI: 10.1097/gox.0000000000005308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 08/21/2023] [Indexed: 10/07/2023]
Abstract
Clinical studies have reported that lymphaticovenular anastomosis (LVA) is more effective for early-stage lymphedema. However, the diameter of lymphatic vessels in early-stage lymphedema is thin (only about 0.3 mm). In this article, we report a modified preparatory intravascular stenting technique (PIST) for LVA with smaller lymphatic vessels and present the results of its application for the treatment of secondary lymphedema. In this technique, a 9-0 nylon thread is inserted into the target lymphatic vessel. Then, the thread is pulled until its tip has entered the lymphatic vessel. After that, the thread is allowed to proceed into the lumen by pushing it. Finally, with the nylon in place, the lymphatic vessel is transected and the lumen is secured. In this report, we investigated the surgical time for LVA between 10 patients who underwent LVA with modified PIST (group A) and another group of 10 patients who underwent LVA without the technique (group B). Lymphatic lumen was secured at all sites where indocyanine green lymphangiography confirmed lymphatic flow. The average outer diameter of lymphatic vessels in group A and B were 0.36 mm and 0.53 mm, respectively. The average surgical time for LVA in group A was 136 minutes, which was significantly shorter than the 187 minutes in group B. Our results indicated that modified PIST can help secure the lymphatic lumen even when the lymphatic vessels are thin. As a result, this technique can significantly reduce the surgical time for this procedure.
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Affiliation(s)
- Takashi Nuri
- From the Department of Plastic and Reconstructive Surgery, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Akinori Asaka
- From the Department of Plastic and Reconstructive Surgery, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Yuki Otsuki
- From the Department of Plastic and Reconstructive Surgery, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Koichi Ueda
- From the Department of Plastic and Reconstructive Surgery, Osaka Medical and Pharmaceutical University, Osaka, Japan
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18
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Kondo A, Umezawa H, Fukunaga Y, Oshima A, Higashino T, Ogawa R. Supermicrovascular anastomosis training using chicken wings and colored water. J Plast Reconstr Aesthet Surg 2023; 84:531-536. [PMID: 37421676 DOI: 10.1016/j.bjps.2023.06.044] [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: 04/08/2023] [Revised: 05/30/2023] [Accepted: 06/09/2023] [Indexed: 07/10/2023]
Abstract
Plastic surgeons require experience in supermicroscopic vascular anastomosis. Herein, we report a simple, rapid, and cost-effective training method using chicken wings and colored water. The avian ventral metacarpal artery was selected for dissection and anastomosis to mimic supermicrosurgery. Over 14 weeks (one anastomosis per day), the ulnar artery in 100 chicken wings was exposed by dissection, cut proximally, and injected with blue food dye-colored water by an inexperienced surgeon. After ligating the artery branches, it was cut and subjected to end-to-end anastomosis. Next, colored water was injected into the ulnar artery to check for suture sufficiency. The vessel was re-dissected to inspect the lumen and sutures qualitatively. Of the 100 wings, the first and last 20 wings' ventral metacarpal artery dissection, anastomosis times, and leakage frequency were compared. Avian ventral metacarpal artery diameter was recorded, and the cumulative anastomosis time where individual anastomosis times started decreasing was determined. Leakage rates before and after this point were compared. The avian ventral metacarpal artery diameter was 0.7-0.8 mm. The last 20 wings had significantly shorter median dissection times (12:27 vs. 17:45 min), anastomosis times (9:02 vs. 12:29 min), and leakage rates (15% vs. 70%); more even stitching and parallel ligature points; and less vessel layer inversion than the first 20 wings. After a cumulative anastomosis time of 10 h 26 min, individual times sharply decreased, and the leakage rate decreased significantly (58.3% vs. 23.8%). The proposed method significantly improved supermicrosurgical anastomosis. Thus, we believe that this method will help surgeons improve their supermicrosurgical skills.
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Affiliation(s)
- A Kondo
- Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School, Tokyo, Japan; Department of Plastic and Reconstructive Surgery, National Cancer Center Hospital East, Kashiwa, Japan.
| | - H Umezawa
- Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School, Tokyo, Japan
| | - Y Fukunaga
- Department of Plastic and Reconstructive Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - A Oshima
- Department of Plastic and Reconstructive Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - T Higashino
- Department of Plastic and Reconstructive Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - R Ogawa
- Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School, Tokyo, Japan
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19
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Seki Y, Kajikawa A, Asai R, Tomochika M, Nemoto H, Terashima T, Kurogi N. The Dynamic Lymphaticovenular Anastomosis for Breast Cancer-related Lymphedema without Compression: Salvaging Lymphedema Patients Who Lost Conservative Treatment Opportunity. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5175. [PMID: 37577241 PMCID: PMC10412430 DOI: 10.1097/gox.0000000000005175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 06/22/2023] [Indexed: 08/15/2023]
Abstract
In conservative treatment for breast cancer-related lymphedema (BCRL), compression therapy has a crucial role. However, some BCRL patients are unable to use compression, and then their lymphedema continues to worsen as they miss treatment opportunity. Although lymphaticovenular anastomosis (LVA) is an effective and minimally invasive surgical treatment for BCRL, compression therapy is still important to enhance lymphatic fluid flow in LVA. The authors previously reported the dynamic LVA method for BCRL, in which patient's natural hand movements theoretically propel lymph to the anastomosed vein. This study is conducted to clarify whether dynamic LVA can salvage BCRL patients without pre- and postoperative compression therapy. Methods The study involved 17 BCRL patients, 18 limbs. All patients had International Society of Lymphology stage-2 lymphedema, but they had no compression: six patients had difficulty by other diseases to undergo compression, and other 11 patients refused any compression usage because of the burden of the treatment itself. Three dynamic LVAs were performed in each patient. Results Patients' mean age was 60.4 ± 10.1, and mean body mass index was 24.0 ± 3.3. The mean follow-up period was 25.5 ± 9.2 months. The volume of the lymphedematous limb, according to the upper extremity lymphedema (UEL) index, was reduced in all 18 limbs postoperatively (postoperative UEL index 101.8 ± 9.4 versus preoperative UEL index 116.0 ± 20.1; P < 0.01). Twelve of the 18 limbs were cured without edema. Conclusion Even without compression therapy, International Society of Lymphology stage-2 BCRL patients can be treated by the dynamic LVA method.
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Affiliation(s)
- Yukio Seki
- From the Department of Plastic and Reconstructive Surgery, St. Marianna University School of Medicine, Kawasaki, Kanagawa, Japan
- Department of Plastic and Reconstructive Surgery, Shonan Atsugi Hospital, Atsugi, Kanagawa, Japan
| | - Akiyoshi Kajikawa
- From the Department of Plastic and Reconstructive Surgery, St. Marianna University School of Medicine, Kawasaki, Kanagawa, Japan
| | - Rintaro Asai
- From the Department of Plastic and Reconstructive Surgery, St. Marianna University School of Medicine, Kawasaki, Kanagawa, Japan
- Department of Plastic and Reconstructive Surgery, Shonan Atsugi Hospital, Atsugi, Kanagawa, Japan
| | - Mayo Tomochika
- From the Department of Plastic and Reconstructive Surgery, St. Marianna University School of Medicine, Kawasaki, Kanagawa, Japan
- Department of Plastic and Reconstructive Surgery, Shonan Atsugi Hospital, Atsugi, Kanagawa, Japan
| | - Hitoshi Nemoto
- Department of Plastic Surgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Takahiro Terashima
- Department of General Surgery, Shonan Atsugi Hospital, Atsugi, Kanagawa, Japan
| | - Norimitsu Kurogi
- Department of General Surgery, Shonan Atsugi Hospital, Atsugi, Kanagawa, Japan
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Ochalek K, Kurpiewska J, Gradalski T. Adjustable Compression Wraps (ACW) vs. Compression Bandaging (CB) in the Acute Phase of Breast Cancer-Related Arm Lymphedema Management—A Prospective Randomized Study. BIOLOGY 2023; 12:biology12040534. [PMID: 37106735 PMCID: PMC10135916 DOI: 10.3390/biology12040534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 03/27/2023] [Accepted: 03/30/2023] [Indexed: 04/03/2023]
Abstract
The objective of this study is to compare the effectiveness, comfort and possibilities of the self-application of adjustable compression wraps (ACW) with compression bandaging (CB) in the acute phase of treatment in advanced upper-limb lymphedema. In total, 36 patients who fulfilled the admission criteria were randomly assigned into ACW-Group (18 patients), or CB-Group (18 patients). Treatment in both groups lasted for two weeks. In the first, all patients were educated in applying adjustable compression wraps (ACW-Group) or self-bandaging (CB-Group) and treated by experienced physiotherapists. In the second week, the use of ACW and CB was continued by the patients themselves at home. In both groups, a clinically significant reduction in the affected limb volume was found after the first week (p < 0.001). A further decrease in the affected limb volume within the second week was noted only in the CB-Group (p = 0.02). A parallel trend was found in the percentage reduction in the excess volume after one and two weeks of compression therapy. Within two weeks, both groups achieved a significant improvement in decreasing lymphedema-related symptoms, but women from the ACW-Group reported complications related to carrying out compression more frequently (p = 0.002). ACW can reduce lymphedema and disease-related symptoms, but based on the results it is difficult to recommend this method as an alternative option in the acute phase of CPT among women with advanced arm lymphedema.
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Affiliation(s)
- Katarzyna Ochalek
- Faculty of Motor Rehabilitation, Institute of Clinical Rehabilitation University of Physical Education, 31-571 Krakow, Poland
- Lymphedema Clinic, St. Lazarus Hospice, 31-380 Krakow, Poland
- Correspondence:
| | - Joanna Kurpiewska
- Lymphedema Clinic, St. Lazarus Hospice, 31-380 Krakow, Poland
- Chair of Orthopaedics, Traumatology and Rehabilitation, Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Krakow University, 30-705 Krakow, Poland
| | - Tomasz Gradalski
- Lymphedema Clinic, St. Lazarus Hospice, 31-380 Krakow, Poland
- Chair of Palliative Medicine, Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Krakow University, 30-705 Krakow, Poland
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21
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Suami H. Reply to letter comments on: A new indocyanine green fluorescence lymphography protocol for diagnostic assessment of lower limb lymphoedema. J Plast Reconstr Aesthet Surg 2023; 78:71-72. [PMID: 36827819 DOI: 10.1016/j.bjps.2023.01.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 01/31/2023] [Indexed: 02/11/2023]
Affiliation(s)
- Hiroo Suami
- Australian Lymphoedema Education, Research and Treatment (ALERT), Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia.
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22
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Sakai H, Miyazaki T. Need for better protocol and severity staging system of indocyanine green lymphography. J Plast Reconstr Aesthet Surg 2023; 79:19-20. [PMID: 36841144 DOI: 10.1016/j.bjps.2023.01.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 01/29/2023] [Indexed: 02/11/2023]
Affiliation(s)
- Hayahito Sakai
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan.
| | - Toko Miyazaki
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
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23
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Yamamoto T, Yamamoto N. Office-Based Lymphatic Supermicrosurgery: Supermicrosurgical Lymphaticovenular Anastomosis at an Outpatient Clinic. J Reconstr Microsurg 2023; 39:131-137. [PMID: 35817051 DOI: 10.1055/s-0042-1750123] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Supermicrosurgical lymphaticovenular anastomosis (LVA) has become popular for the treatment of compression-refractory lymphedema. With advancement of navigation tools, LVA can be performed with more ease and safety, allowing office-based LVA at an outpatient clinic. METHODS Office-based LVA was performed on patients with compression-refractory secondary extremity lymphedema by a well-experienced supermicrosurgeon (T.Y.) under local infiltration anesthesia. Indocyanine green (ICG) lymphography and vein visualizer were used to localize vessels preoperatively. A stereoscopic microscope (Leica S6E, Leica Microsystems, Germany) or a relatively small operative microscope (OPMI pico, Carl Zeiss, Germany) was used for LVA. Operative records and postoperative results were reviewed to evaluate feasibility of office-based LVA. RESULTS LVAs were performed on 27 arms and 42 legs, which resulted in 131 anastomoses via 117 incisions. ICG lymphography stage included stage II in 47 limbs, and stage III in 22 limbs. Time required for one LVA procedure (from skin incision to skin closure in one surgical field) ranged from 13 to 37 minutes (average, 24.9 minutes). One year after LVA, all cases showed significant volume reduction (lymphedematous volume reduction; 0.5-23.6%, average 13.23%). No postoperative complication was observed. CONCLUSION LVA can be performed with safety and effectiveness outside an operation theater. Patient selection, precise preoperative mapping, and experience of a surgeon are key to successful office-based LVA.
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Affiliation(s)
- Takumi Yamamoto
- Department of Plastic and Reconstructive Surgery, Center Hospital of the National Center for Global Health and Medicine, Tokyo, Japan.,Department of Plastic Surgery, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Nana Yamamoto
- Department of Plastic and Reconstructive Surgery, Center Hospital of the National Center for Global Health and Medicine, Tokyo, Japan.,Department of Plastic Surgery, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
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24
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Winaikosol K, Surakunprapha P. Lymphaticovenular Anastomosis: Superficial Venous Anatomical Approach. Arch Plast Surg 2022; 49:689-695. [PMID: 36159382 PMCID: PMC9507617 DOI: 10.1055/s-0042-1756348] [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: 10/01/2021] [Accepted: 07/26/2022] [Indexed: 11/17/2022] Open
Abstract
Background
Lymphaticovenular anastomosis (LVA) is an effective, functional treatment for limb lymphedema. This study reports an alternative surgical approach to lymphedema treatment without the use of indocyanine green mapping.
Methods
A retrospective analysis was performed on 29 consecutive lymphedema patients who underwent LVAs from January 2015 to December 2020, whereby incisions were made along the anatomy of the superficial venous systems in both upper and lower extremities around the joint areas. The evaluation included qualitative assessments and quantitative volumetric analyses.
Result
The mean number of anastomoses was 3.07, and the operative time was 159.55 minutes. Symptom improvement was recorded in 86.21% of the patients, with a mean volume reduction of 32.39%. The lymphangitis episodes decreased from 55.17% before surgery to 13.79% after surgery, and the median number of lymphangitis episodes per year decreased from 1 before surgery to 0 after surgery.
Conclusions
The superficial venous anatomical approach is an easy way to start a lymphedema practice using LVA without other advanced surgical equipment. With this reliable technique, microsurgeons can perform LVA procedures and achieve good results.
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Affiliation(s)
- Kengkart Winaikosol
- Plastic and Reconstructive Unit, Department of Surgery, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Palakorn Surakunprapha
- Plastic and Reconstructive Unit, Department of Surgery, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
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25
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Imai H, Yoshida S, Mese T, Roh S, Fujita A, Uchiki T, Sasaki A, Nagamatsu S, Koshima I. Technical Tips for Anastomosis of 0.2-mm Diameter Vessels during Lymphatic Venous Anastomosis. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2022; 10:e4304. [PMID: 35572187 PMCID: PMC9094417 DOI: 10.1097/gox.0000000000004304] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 03/15/2022] [Indexed: 12/04/2022]
Affiliation(s)
- Hirofumi Imai
- From the International Center for Lymphedema, Hiroshima University Hospital, Hiroshima, Japan
| | - Shuhei Yoshida
- From the International Center for Lymphedema, Hiroshima University Hospital, Hiroshima, Japan
| | - Toshiro Mese
- From the International Center for Lymphedema, Hiroshima University Hospital, Hiroshima, Japan
| | - Solji Roh
- From the International Center for Lymphedema, Hiroshima University Hospital, Hiroshima, Japan
| | - Asuka Fujita
- Plastic and Reconstructive Surgery, Hiroshima University Hospital, Hiroshima, Japan
| | - Toshio Uchiki
- Plastic and Reconstructive Surgery, Hiroshima University Hospital, Hiroshima, Japan
| | - Ayano Sasaki
- Plastic and Reconstructive Surgery, Hiroshima University Hospital, Hiroshima, Japan
| | - Shogo Nagamatsu
- Plastic and Reconstructive Surgery, Hiroshima University Hospital, Hiroshima, Japan
| | - Isao Koshima
- From the International Center for Lymphedema, Hiroshima University Hospital, Hiroshima, Japan
- Plastic and Reconstructive Surgery, Hiroshima University Hospital, Hiroshima, Japan
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26
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Sakai H, Kageyama T, Tsukuura R, Yamamoto T. Anatomical Location of Lymphatic Pathways in the Posterior Thigh. Ann Plast Surg 2022; 88:330-334. [PMID: 34387576 DOI: 10.1097/sap.0000000000002968] [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] [Indexed: 11/25/2022]
Abstract
BACKGROUND It is necessary for treating lower extremity lymphedema to understand the lymphatic pathways in the extremities. This study aimed to clarify the anatomical locations of lymph vessels in the posterior thigh using indocyanine green (ICG) lymphography. METHODS Medical records of cancer survivors who underwent ICG lymphography for secondary lymphedema screening from February 2019 to November 2020 were reviewed. Nonlymphedematous limbs without dermal backflow pattern on ICG lymphography (ICG stage 0) were included. Indocyanine green (0.1 mL) was injected intradermally at 2 points in the midlateral thigh, at the levels of one third and two thirds from the popliteal fossa to the gluteal fold in a prone position. Locations of the posterior thigh collecting lymph vessels visualized by ICG lymphography were marked on the skin surface with a pen, and distances from the popliteal fossa to the collecting lymph vessels were measured at the posterior midline in percentage, with the popliteal fossa set as 0% and the gluteal fold as 100%. Based on ICG lymphography findings, the number of the collecting lymph vessels shown as linear pattern and anatomical locations at the posterior thigh midline were investigated. RESULTS Twenty limbs of 20 cancer survivors were included. Linear pattern was identified in all lower extremities; average number was 2.3 ± 0.7 (range, 1-3). Most collecting lymph vessels shown on ICG lymphography, 26.7% (12 of 45) lymph vessels, were located within 40% to 50% of the region, and 24.4% (11 of 45) lymph vessels within 30% to 40% of the region. CONCLUSIONS There are 1 or more collecting lymph vessels in the posterior thigh by midlateral thigh ICG injection, which can be addressed for posterior thigh lymphedema.
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Affiliation(s)
- Hayahito Sakai
- From the Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
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27
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Yamamoto T, Yamamoto N. Indocyanine Green Lymphography for Evaluation of Breast Lymphedema Secondary to Breast Cancer Treatments. J Reconstr Microsurg 2022; 38:630-636. [PMID: 35135031 DOI: 10.1055/s-0042-1742732] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Although breast lymphedema (BL) significantly deteriorates quality of life (QOL) of breast cancer survivors, little is known and pathophysiological severity staging system is yet reported. This study aimed to evaluate usefulness of a novel BL severity staging system based on indocyanine green (ICG) lymphography findings. METHODS Breast cancer survivors with breast symptoms who underwent breast ICG lymphography were included. Breast ICG lymphography stage was determined based on visibility of linear pattern and extension of dermal backflow patterns. Prevalence of breast symptoms and lymphedema QOL score (LeQOLiS) was compared according to the stage. RESULTS Thirty-seven patients were included. Breast ICG lymphography stage included stage 0 in 11 (29.7%) cases, stage I in 3 (8.1%) cases, stage II in 11 (29.7%) cases, stage III in 6 (16.2%) cases, stage IV in 4 (10.8%) cases, and stage V in 2 (5.4%) cases. Higher ICG stages were associated with more frequent prevalence of breast swelling (p = 0.020), breast pain (p = 0.238), and breast cellulitis (p = 0.024), and with higher LeQOLiS (p < 0.001). CONCLUSION ICG lymphography allows clear visualization of superficial lymph circulation in the breast. Higher breast ICG lymphography stages are associated with more frequent prevalence of BL-related symptoms and worse QOL.
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Affiliation(s)
- Takumi Yamamoto
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan.,Department of Plastic Surgery, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan.,Department of Plastic Surgery, Noda Hospital, Chiba, Japan
| | - Nana Yamamoto
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan.,Department of Plastic Surgery, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
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28
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Kageyama T. Characteristic non-contrast magnetic resonance lymphography findings of secondary lower extremity lymphedema. J Plast Reconstr Aesthet Surg 2021; 75:893-939. [PMID: 34866008 DOI: 10.1016/j.bjps.2021.11.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 11/03/2021] [Indexed: 10/19/2022]
Affiliation(s)
- Takashi Kageyama
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo 162-8655, Japan.
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29
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Aso K, Tsukuura R. Re: "Limb Volume Changes and Activities of Daily Living: A Prospective Study" by Park et al. Lymphat Res Biol 2021; 20:441-442. [PMID: 34788136 DOI: 10.1089/lrb.2021.0003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Kenta Aso
- Department of Medical Education and National Center for Global Health and Medicine, Tokyo, Japan
| | - Reiko Tsukuura
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
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30
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Yamamoto T, Yamamoto N, Ishiura R. Free double-paddle superficial circumflex iliac perforator flap transfer for partial maxillectomy reconstruction: A case report. Microsurgery 2021; 42:84-88. [PMID: 34617610 DOI: 10.1002/micr.30824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 06/09/2021] [Accepted: 09/28/2021] [Indexed: 11/10/2022]
Abstract
Partial maxillectomy for maxillary sinus cancer treatment requires soft tissue reconstruction with enough bulk to occupy the large-volume defect. Deep inferior epigastric artery-based flaps and subscapular artery-based flaps are commonly used, but necessitate invasive muscle dissection or position change and a large recipient vessel. The aim of this report was to present a case of partial maxillectomy defect successfully reconstructed with a superficial circumflex iliac artery (SCIA) perforator (SCIP) flap, to address these drawbacks. A 67-year-old female underwent partial maxillectomy for maxillary sinus cancer. The defects included the medial and the caudal aspects of the maxillary sinus with unilateral palate loss. A double-paddle SCIP flap (19 × 9 cm and 10 × 6 cm) was elevated in a free-style manner based on the superficial branches of the SICA. The SCIP and its concomitant vein were anastomosed to a facial artery perforator and the angular vein with supermicrosurgical perforator-to-perforator anastomosis. Two skin paddles were utilized to reconstruct the defects of the nasal wall and the oral aspects of the palate. Postoperative course was uneventful, and the patient could resume normal oral diet 5 days after surgery. Three years after surgery, there was no cancer recurrence or any postoperative complication, and the patient was satisfied with normal speech and diet, and with concealable donor and recipient scars. Double-paddle SCIP flap transfer may be an option for reconstruction of a partial maxillectomy defect.
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Affiliation(s)
- Takumi Yamamoto
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine (NCGM), Tokyo, Japan.,Department of Plastic Surgery, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Nana Yamamoto
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine (NCGM), Tokyo, Japan.,Department of Plastic Surgery, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Ryohei Ishiura
- Department of Plastic Surgery, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan.,Department of Plastic and Reconstructive Surgery, Mie University, Mie, Japan
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31
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Radical reduction and reconstruction for male genital elephantiasis: Superficial circumflex iliac artery perforator (SCIP) lymphatic flap transfer after elephantiasis tissue resection. J Plast Reconstr Aesthet Surg 2021; 75:870-880. [PMID: 34756554 DOI: 10.1016/j.bjps.2021.08.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 06/04/2021] [Accepted: 08/26/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Treatment of elephantiasis, the most severe lymphedema, is challenging. Management of male genital elephantiasis (MGE) is even more challenging than extremity elephantiasis due to its complicated shape and high risk of lymphorrhea and cellulitis. Complete resection of fibrous tissue and lymphatic reconstruction is considered to be ideal for the treatment of MGE. The aim of this study was to evaluate the feasibility of radical reduction and reconstruction (3R) for isolated MGE. METHODS Medical charts of patients who underwent 3R were reviewed. The 3R operation consisted of genital fibrous tissue resection and reconstruction of soft tissue and lymphatic structure using superficial circumflex iliac artery perforator (SCIP) lymphatic flap transfer (LFT). No compression was applied postoperatively. Patient and flap characteristics, intraoperative findings, and postoperative results were evaluated. RESULTS Seven patients were included. MGE included isolated scrotal elephantiasis in 4 cases, and scrotal and penile elephantiasis in 3 cases. Resected tissue volume ranged from 609 to 2304 grams (average, 1511.0 grams). SCIP-LFT was performed in all cases; pedicled full-thickness SCIP-LFT for scrotal reconstruction in all cases, and SCIP pure-skin-perforator flap transfer for penile reconstruction in 3 cases. There was no postoperative genital complication or evidence of genital lymphedema recurrence in the mean follow-up period of 22.7 months. Genital lymphedema scores significantly improved postoperatively (6.7 ± 1.8 vs. 0.3 ± 0.5, P <0.001). CONCLUSIONS 3R operation allowed one-stage curative treatment for MGE. LFT has the potential to play an essential role in the prevention of postoperative wound complications and lymphedema recurrence after radical resection of fibrotic tissue.
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32
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Sato F, Sakai H. Improvement of knee Joint's range of motion in a patient with posterior thigh lymphedema by lymphaticovenular anastomosis. Microsurgery 2021; 41:816-817. [PMID: 34462955 DOI: 10.1002/micr.30801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 05/26/2021] [Accepted: 08/19/2021] [Indexed: 11/10/2022]
Affiliation(s)
- Fumiya Sato
- Department of Medical Education, National Center for Global Health and Medicine, Tokyo, Japan
| | - Hayahito Sakai
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
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33
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Kojimahara T, Tsukuura R. Changing the Paradigm: Lymphovenous Anastomosis in Advanced Stage Lower Extremity Lymphedema. Plast Reconstr Surg 2021; 148:320e-321e. [PMID: 34228672 DOI: 10.1097/prs.0000000000008145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
| | - Reiko Tsukuura
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
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34
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Tsukuura R, Yamamoto T. Free medialis tarsus flap transfer for reconstruction of toe necrosis: A case report. Microsurgery 2021; 41:671-675. [PMID: 34156111 DOI: 10.1002/micr.30780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 01/12/2021] [Accepted: 05/28/2021] [Indexed: 10/21/2022]
Abstract
The medial tarsal area is a commonly used donor site for skin grafts to the digits and toes, with good color and texture match as well as a concealable donor site scar. Yet, there has been no report as a perforator free flap donor site. The purpose of this report is to present a new perforator flap harvested from medial tarsal region. We present a case of a soft tissue defect of the fifth toe due to essential thrombocythemia (ET), successfully treated with a free medialis tarsus flap (MTF) transfer. A 62-year-old male with ET suffered from the right fifth toe necrosis caused by digital artery thrombosis. After the manifestation of the necrosis, necrotic tissue was completely debrided, which resulted in a 3 × 1.5 cm skin defect with exposure of the tendon and the phalangeal bone. Sixth days after debridement, a 4.5 × 1.7 cm MTF was harvested transversely and inferiorly to the right medial ankle, locating the preoperatively detected posterior tibial artery perforator (PTAP) in the flap. Perforator-to-perforator anastomosis was done using the dorsal metatarsal artery perforator and the subcutaneous vein as recipient vessels. The donor site was closed primarily. Postoperative course was uneventful, and the reconstruction preserved the toe length and functions of extension and flexion at 9 months postoperatively. The patient could walk with conventional shoes by himself. MTF may be an option for small skin defect in the digits and toes where skin graft is not indicated.
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Affiliation(s)
- Reiko Tsukuura
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Takumi Yamamoto
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
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35
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Sakai H, Tsukuura R, Kageyama T. Injection sites for indocyanine green lymphography to enhance minor forearm lymphatic pathways. Shoulder Elbow 2021; 13:346. [PMID: 34659477 PMCID: PMC8512987 DOI: 10.1177/17585732211008467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Hayahito Sakai
- Hayahito Sakai, Department of Plastic and
Reconstructive Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama
Shinjuku-ku, Tokyo 162-8655, Japan.
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36
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A Case-control Analysis of the Knight's Move Technique in a Chicken Wing Microsurgery Model: Video Article. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3476. [PMID: 33968549 PMCID: PMC8099401 DOI: 10.1097/gox.0000000000003476] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 01/08/2021] [Indexed: 12/29/2022]
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37
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Universal indocyanine green lymphography staging for extremity lymphedema: Universal ICG stage. J Plast Reconstr Aesthet Surg 2021; 74:1931-1971. [PMID: 34154943 DOI: 10.1016/j.bjps.2021.03.130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Accepted: 03/14/2021] [Indexed: 11/24/2022]
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38
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Zocchi ML. Regenerative assisted microsurgery (RAM) and regenerative assisted supermicrosurgery (RASM): the future of microsurgery? EUROPEAN JOURNAL OF PLASTIC SURGERY 2021; 44:389-391. [PMID: 33867686 PMCID: PMC8043839 DOI: 10.1007/s00238-021-01812-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 03/24/2021] [Indexed: 12/15/2022]
Affiliation(s)
- Michele L Zocchi
- Plastic and Reconstructive Surgery Unit, University of Padua, Via Giustiniani 2, 35128 Padua, Italy.,Remix Regeneration Institute, Turin, Italy
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39
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Lymph-interpositional-flap transfer (LIFT) based on lymph-axiality concept: Simultaneous soft tissue and lymphatic reconstruction without lymph node transfer or lymphatic anastomosis. J Plast Reconstr Aesthet Surg 2021; 74:2604-2612. [PMID: 33867280 DOI: 10.1016/j.bjps.2021.03.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 02/01/2021] [Accepted: 03/11/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND Lymphatic system is important to maintain homeostasis. Lymph-axiality concept has been reported, which suggests possibility of lymphatic reconstruction using flap transfer without lymph node or supermicrosurgical lymphatic anastomosis. METHODS Medical charts of 122 free flap reconstruction cases, either with conventional flap transfer (control) or lymph-interpositional-flap transfer (LIFT), for extremity soft tissue defects including lymphatic pathways were reviewed. Lymph vessels' stumps in a flap were placed as close to those in a recipient site as possible under indocyanine green (ICG) lymphography navigation in LIFT group. LIFT group was subdivided into LIFT(+) and LIFT(-) groups; lymph vessels' stumps could be approximated within 2 cm in LIFT(+) group, whereas those could not be in LIFT(-) group. Lymph flow restoration (LFR) and lymphedema development (LED) rates were compared between the groups on postoperative 6 months. RESULTS No flap included lymph node. LFR was observed in 50 cases and LED in 72 cases. LFR rate in LIFT group (n = 75) was significantly higher than that in control group (n = 47) (57.3% vs. 14.9%; P < 0.001). LED rate in LIFT group was significantly lower than that in control group (20.0% vs. 48.9%; P < 0.001). Sub-group analysis showed significantly higher LFR and lower LED rates in LIFT(+) group (n = 44) than those in LIFT(-) group (n = 31; 88.6% vs. 12.9%; P < 0.001, 4.5% vs. 41.9%; P < 0.001). CONCLUSIONS LIFT allows simultaneous soft tissue and lymphatic reconstruction without lymph node transfer or lymphatic anastomosis, which prevents development of secondary lymphedema.
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40
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Brahma B, Putri RI, Reuwpassa JO, Tuti Y, Alifian MF, Sofyan RF, Iskandar I, Yamamoto T. Lymphaticovenular Anastomosis in Breast Cancer Treatment-Related Lymphedema: A Short-Term Clinicopathological Analysis from Indonesia. J Reconstr Microsurg 2021; 37:643-654. [PMID: 33648010 DOI: 10.1055/s-0041-1723940] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Locally advanced breast cancer is commonly found in Indonesia. In this group of patients, aggressive treatment such as axillary lymph nodes dissection (ALND) with or without regional nodal irradiation (RNI) will increase the risk of breast cancer treatment-related lymphedema (BCRL) in our patients. Lymphaticovenular anastomosis (LVA) has been established as a minimally invasive approach in lymphedema surgery. In this study, we report our first experience of LVAs in BCRL patients. METHODS This was a cross-sectional study taken from breast cancer patients receiving ALND with or without RNI. From December 2018 until June 2020, we collected and described general patient information, tumor characteristics, diagnostic methods, and the outcome of LVA. Postoperative subjective symptoms scores (lymphedema quality-of-life score [LeQOLiS]) and lymphedematous volume (upper extremity lymphedema [UEL] index) were compared with preoperative ones. RESULTS Seventy patients experienced BCRL with the mean age of 54.8 (9.4) years and mean body mass index of 28.1 (4.5). ALND was performed in 66 (97.1%) cases and RNI was given in 58 (82.9%) patients. Thirty-one (44.3%) patients were in the International Society of Lymphology stage 1, 24 (34.3%) in stage 2A, and 15 (21.4%) in stage 2B. The mean lymphatic vessel diameter was 0.5 (0.26) mm and 0.80 (0.54) mm for the vein. Lymphosclerosis severity was 7 (4%) in S0 type, 129 (74.1%) in S1 type, 37 (21.3%) in S2 type, and 1 (0.6%) in S3 type. In histopathology examination, S1 types were in lower grade injury, while S2 and S3 types were in the higher grade. Seven (53.8%) cases of S2 type showed severe fibrosis from trichrome staining. Postoperative LeQOLiSs were significantly lower than preoperative ones (5.6 ± 2.4 vs. 3.7 ± 2.6; p = 0.000). With the mean follow-up of 7.4 (3.7) months, the overall UEL index reduction was 9.2%; mean -11 (16.8). Postoperative UEL index was significantly lower than preoperative ones (117.7 ± 26.5 vs. 106.9 ± 18.5; p = 0.000). No complications were observed during this period. CONCLUSION LVA reduced the subjective symptoms and UEL index in BCRL cases. Future studies using updated imaging technologies of the lymphatic system and longer follow-up time are needed to confirm our results.
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Affiliation(s)
- Bayu Brahma
- Department of Surgical Oncology, Dharmais Cancer Hospital-National Cancer Center, Jakarta, Indonesia
| | - Rizky Ifandriani Putri
- Department of Anatomical Pathology, Dharmais Cancer Hospital-National Cancer Center, Jakarta, Indonesia
| | - Jauhari Oka Reuwpassa
- Department of Surgical Oncology, Dharmais Cancer Hospital-National Cancer Center, Jakarta, Indonesia
| | - Yustia Tuti
- Department of Nuclear Medicine, Dharmais Cancer Hospital-National Cancer Center, Jakarta, Indonesia
| | - Muhammad Farid Alifian
- Department of Surgical Oncology, Dharmais Cancer Hospital-National Cancer Center, Jakarta, Indonesia
| | - Rian Fabian Sofyan
- Department of Surgical Oncology, Dharmais Cancer Hospital-National Cancer Center, Jakarta, Indonesia
| | - Iskandar Iskandar
- 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
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41
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Yamamoto N. Tissue hypoxia and frequent cellulitis in lymphedematous limbs. J Plast Reconstr Aesthet Surg 2021; 74:1633-1701. [PMID: 33579640 DOI: 10.1016/j.bjps.2021.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Accepted: 01/24/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Nana Yamamoto
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan; Department of Plastic Surgery, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan.
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42
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Aso K, Tsukuura R. Universal ICG lymphography stage for reproducible severity evaluation of extremity lymphedema. J Plast Reconstr Aesthet Surg 2021; 74:1633-1701. [PMID: 33608237 DOI: 10.1016/j.bjps.2020.12.106] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 12/22/2020] [Indexed: 11/15/2022]
Affiliation(s)
- Kenta Aso
- Department of Medical Education, National Center for Global Health and Medicine, Tokyo, Japan
| | - Reiko Tsukuura
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Toyama 1-21-1, Shinjuku-ku, Tokyo 162-8655, Japan.
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43
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Sato F, Sakai H. Real-time lymph flow projection mapping using near-infrared fluorescence. J Surg Oncol 2020; 123:701-702. [PMID: 33333588 DOI: 10.1002/jso.26326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 11/21/2020] [Indexed: 11/07/2022]
Affiliation(s)
- Fumiya Sato
- Department of Medical Education, National Center for Global Health and Medicine, Tokyo, Japan
| | - Hayahito Sakai
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
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44
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Sumiya R, Tsukuura R, Mihara F, Yamamoto T. Free superficial circumflex iliac artery perforator fascial flap for reconstruction of upper abdominal wall with extensive infected herniation: A case report. Microsurgery 2020; 41:270-275. [PMID: 33314361 DOI: 10.1002/micr.30693] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 09/05/2020] [Accepted: 12/03/2020] [Indexed: 01/30/2023]
Abstract
Complex abdominal wall reconstruction is challenging, and vascularized fascia is preferred for active infection cases. Pedicled tensor fascia lata flap is commonly used for lower abdominal wall reconstruction, and free vascularized fascial flap based on the lateral circumflex femoral artery (LCFA) is used for upper abdominal wall reconstruction. However, LCFA-based flap transfer requires invasive and time-consuming muscle dissection and a large recipient vessel. The purpose of this report was to present a new application of superficial circumflex iliac artery (SCIA) perforator (SCIP)-based fascial flap for upper abdominal wall reconstruction. A 70-year-old male suffered from a long-lasting extensive abdominal wall herniation complicated with mesh infection and cutaneous fistulae following multiple herniation repair with synthetic mesh. After complete debridement of infected tissues, there was a 29 x 26 cm full-thickness abdominal wall defect. Components separation was performed to minimize the defect size, after which 12 x 7 cm defect remained in the upper abdominal wall. A 20 x 10 cm SCIP deep fascial flap was elevated based on the deep branch of the SCIA. The SCIP flap was transferred to the defect to reconstruct the upper abdominal wall. The SCIP was anastomosed to the deep inferior epigastric artery perforator with supermicrosurgical perforator-to-perforator anastomosis. Postoperative course was uneventful with good functional and esthetic results of the donor and recipient sites 11 months after the surgery. Although further studies are required, SCIP fascial flap may be an option for upper abdominal wall reconstruction.
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Affiliation(s)
- Ryusuke Sumiya
- Department of Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Reiko Tsukuura
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Fuminori Mihara
- Department of Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Takumi Yamamoto
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
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Saiga A, Yamamoto M, Akita S, Koizumi J, Kondo H, Uno T. Effectiveness of lymphatic cannulation in case of non-applicable intranodal lymphangiography. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2020; 7:97-99. [PMID: 33718675 PMCID: PMC7921193 DOI: 10.1016/j.jvscit.2020.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 10/01/2020] [Indexed: 11/25/2022]
Abstract
A 78-year-old man presented with lymphatic fluid collections in bilateral inguinal area after bilateral inguinal lymph node dissections. Because no inguinal or popliteal lymph nodes were observed under ultrasound examination, intranodal lymphangiography was not applicable. Although traditional pedal lymphangiography was required, it was difficult to perform this procedure owing to the decreasing frequency over the past 20 years and being unavailable in not only our institution, but also other in institutions. Therefore, we performed catheterization using the 29-guage Argyle PI catheter into the lymphatic duct in lower legs under a microscope and achieved successful percutaneous embolization using N-butyl cyanoacrylate for inguinal lymphatic leakage.
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Affiliation(s)
- Atsushi Saiga
- Department of Radiology, Chiba University Hospital, Chiba, Japan
| | | | - Shinsuke Akita
- Department of Plastic, Reconstructive and Aesthetic Surgery, Chiba University Hospital, Chiba, Japan
| | - Jun Koizumi
- Department of Radiology, Chiba University Hospital, Chiba, Japan
| | - Hiroshi Kondo
- Department of Radiology, Teikyo University Hospital, Tokyo, Japan
| | - Takashi Uno
- Department of Radiology, Chiba University Hospital, Chiba, Japan
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Sumiya R, Fuse Y, Yamamoto T. Distinction between the lymph vessel and the vein on ICG lymphography: Intradermal or subcutaneous ICG injection also enhances the vein. J Plast Reconstr Aesthet Surg 2020; 73:1897-1916. [DOI: 10.1016/j.bjps.2020.03.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 03/25/2020] [Indexed: 10/24/2022]
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Lymphatic anatomy and injection sites for indocyanine green lymphography in the posterior thigh. J Plast Reconstr Aesthet Surg 2020; 74:644-710. [PMID: 32868232 DOI: 10.1016/j.bjps.2020.05.103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 05/09/2020] [Indexed: 11/23/2022]
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Arié A, Yamamoto T. Lymphedema secondary to melanoma treatments: diagnosis, evaluation, and treatments. Glob Health Med 2020; 2:227-234. [PMID: 33330812 PMCID: PMC7731060 DOI: 10.35772/ghm.2020.01022] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 07/22/2020] [Accepted: 07/29/2020] [Indexed: 01/20/2023]
Abstract
Approximately 300,000 new cases of melanoma are annually diagnosed in the world. Advanced stage melanomas require sentinel lymph node biopsy (SLNB), sometimes lymph node dissections (LND). The development rate of lower extremity lymphedema ranges from 7.6% to 35.1% after inguinal SLNB, and from 48.8% to 82.5% after inguinal LND. Development rate of upper extremity lymphedema ranges from 4.4% to 14.6% after axillary LND. Lymphedema management has constantly improved but effective evaluation and surgical management such as supermicrosurgical lymphaticovenular anastomosis (LVA) are becoming common as minimally invasive lymphatic surgery. Diagnosis and new classification using indocyanine green lymphography allowing pre-clinical secondary lymphedema stage management are improving effectiveness of supermicrosurgical LVA and vascularized lymph node transfer. Lymphatic transfer with lymph-interpositional-flap can restore lymph flow after large oncologic excision even without performing lymphatic anastomosis. Since lymphatic reconstructive surgery may affect local to systemic dissemination of remnant tumor cells, careful consideration is required to evaluate indication of surgical treatments.
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Affiliation(s)
- Azuelos Arié
- Department of Plastic, Reconstructive, Aesthetic and Maxillofacial Surgery, Henri Mondor University Hospital, Creteil, France
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Takumi Yamamoto
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
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