1
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Meuli JN, Guiotto M, Elmers J, Mazzolai L, di Summa PG. Outcomes after microsurgical treatment of lymphedema: a systematic review and meta-analysis. Int J Surg 2023; 109:1360-1372. [PMID: 37057889 PMCID: PMC10389392 DOI: 10.1097/js9.0000000000000210] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 01/03/2023] [Indexed: 04/15/2023]
Abstract
BACKGROUND Microsurgical treatment options for lymphedema consist mainly of lymphovenous anastomosis (LVA) and vascularized lymph node transfers (VLNTs). There are no standard measurements of the effectiveness of these interventions and reported outcomes vary among studies. METHODS A systematic review and meta-analysis were performed based on a structured search in Embase, Medline, PubMed, Cinahl, Cochrane, and ProQuest in October 2020, with an update in February 2022. Firstly, a qualitative summary of the main reported outcomes was performed, followed by a pooled meta-analysis of the three most frequently reported outcomes using a random effects model. Randomized controlled trials, prospective cohorts, retrospective cohorts, and cross-sectional and case-control studies that documented outcomes following microsurgery in adult patients were included. Studies of other surgical treatments (liposuction, radical excision, lymphatic vessel transplantation) or without reported outcomes were excluded. The study protocol was registered on PROSPERO (International Prospective Register of Systematic Reviews) (ID: CRD42020202417). No external funding was received for this review. RESULTS One hundred fifty studies, including 6496 patients, were included in the systematic review. The qualitative analysis highlighted the three most frequently reported outcomes: change in circumference, change in volume, and change in the number of infectious episodes per year. The overall pooled change in excess circumference across 29 studies, including 1002 patients, was -35.6% [95% CI: -30.8 to -40.3]. The overall pooled change in excess volume across 12 studies including 587 patients was -32.7% [95% CI: -19.8 to -45.6], and the overall pooled change in the number of cutaneous infections episodes per year across 8 studies including 248 patients was -1.9 [95% CI: -1.4 to -2.3]. The vast majority of the studies included were case series and cohorts, which were intrinsically exposed to a risk of selection bias. CONCLUSION The currently available evidence supports LVA and vascularized lymph node transfers as effective treatments to reduce the severity of secondary lymphedema. Standardization of staging method, outcomes measurements, and reporting is paramount in future research in order to allow comparability across studies and pooling of results.
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Affiliation(s)
| | | | | | - Lucia Mazzolai
- Angiology Division, Heart and Vessel Department, Lausanne University Hospital, University of Lausanne, Switzerland
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2
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Verhey EM, Kandi LA, Lee YS, Morris BE, Casey WJ, Rebecca AM, Marks LA, Howard MA, Teven CM. Outcomes of Lymphovenous Anastomosis for Lower Extremity Lymphedema: A Systematic Review. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2022; 10:e4529. [PMID: 36225843 PMCID: PMC9542573 DOI: 10.1097/gox.0000000000004529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 07/27/2022] [Indexed: 06/16/2023]
Abstract
UNLABELLED Lymphovenous anastomosis (LVA) is a microsurgical treatment for lymphedema of the lower extremity (LEL). This study systematically reviews the most recent data on outcomes of various LVA techniques for LEL in diverse patients. METHODS A comprehensive literature search was conducted in the Ovid MEDLINE, Ovid EMBASE, and Scopus databases to extract articles published through June 2021. Studies reporting data on objective postoperative improvement in lymphedema and/or subjective improvement in quality of life for patients with LEL were included. Extracted data comprised demographics, number of patients and lower limbs, duration of symptoms before LVA, surgical technique, duration of follow-up, and objective and subjective outcomes. RESULTS A total of 303 articles were identified and evaluated, of which 74 were ultimately deemed eligible for inclusion in this study, representing 6260 patients and 2554 lower limbs. The average patient age ranged from 22.6 to 76.14 years. The duration of lymphedema before LVA ranged from 12 months to 11.4 years. Objective rates of improvement in lymphedema ranged from 23.3% to 100%, with the greatest degree of improvement seen in patients with early-stage LEL. CONCLUSIONS LVA is a safe and effective technique for the treatment of LEL of all stages. Several emerging techniques and variations may lead to improved patient outcomes.
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Affiliation(s)
- Erik M. Verhey
- From the Mayo Clinic Alix School of Medicine, Mayo Clinic, Scottsdale, Ariz
| | - Lyndsay A. Kandi
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Mayo Clinic, Phoenix, Ariz
| | - Yeonsoo S. Lee
- From the Mayo Clinic Alix School of Medicine, Mayo Clinic, Scottsdale, Ariz
| | - Bryn E. Morris
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Mayo Clinic, Phoenix, Ariz
| | - William J. Casey
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Mayo Clinic, Phoenix, Ariz
| | - Alanna M. Rebecca
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Mayo Clinic, Phoenix, Ariz
| | - Lisa A. Marks
- Mayo Clinic Libraries, Mayo Clinic, Scottsdale, Ariz
| | - Michael A. Howard
- Division of Plastic Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Chad M. Teven
- Division of Plastic Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill
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3
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Luzardo González A, Planas Balagué R, Gómez Cuba M, Fernández Mariscal E, Arencibia Domínguez A, Salinas Huertas S. [Rehabilitation in lymphedema surgery]. Rehabilitacion (Madr) 2022; 56:215-225. [PMID: 35527077 DOI: 10.1016/j.rh.2021.12.002] [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: 09/28/2021] [Revised: 11/29/2021] [Accepted: 12/11/2021] [Indexed: 01/25/2023]
Abstract
Conservative treatment of lymphedema usually includes complex decongestive therapy in order to reduce the volume of the lymphedema, and compression garments in the maintenance phase. Follow-up is carried out in the Rehabilitation Services. Surgical treatment of lymphedema is a therapeutic option, the interest of which has increased in recent years, although there is no current evidence that it can cure lymphedema and it is always accompanied by conservative treatment. Most studies focus on results according to the type of surgery and there is no standardized protocol for conservative treatment before or after surgery. The objective of this work is to prepare a compendium about the most frequent lymphedema surgeries and their indications, focusing on the rehabilitation treatment for each surgery.
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Affiliation(s)
- A Luzardo González
- Medicina Física y Rehabilitación, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, España.
| | - R Planas Balagué
- Medicina Física y Rehabilitación, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, España; Universitat de Barcelona, Barcelona, España
| | - M Gómez Cuba
- Medicina Física y Rehabilitación, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, España; Universitat de Barcelona, Barcelona, España
| | - E Fernández Mariscal
- Medicina Física y Rehabilitación, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, España
| | - A Arencibia Domínguez
- Medicina Física y Rehabilitación, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, España
| | - S Salinas Huertas
- Medicina Física y Rehabilitación, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, España
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4
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Jørgensen MG, Toyserkani NM, Jensen CH, Andersen DC, Sheikh SP, Sørensen JA. Adipose-derived regenerative cells and lipotransfer in alleviating breast cancer-related lymphedema: An open-label phase I trial with 4 years of follow-up. Stem Cells Transl Med 2021; 10:844-854. [PMID: 33594819 PMCID: PMC8133335 DOI: 10.1002/sctm.20-0394] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 01/04/2021] [Accepted: 01/07/2021] [Indexed: 12/14/2022] Open
Abstract
Patients with breast cancer‐related lymphedema (BCRL) have reduced quality of life and arm function. Current treatments are palliative, and treatments improving lymphedema are lacking. Preclinical studies have suggested that adipose‐derived regenerative cells (ADRCs) can alleviate lymphedema. We, therefore, aimed to assess whether ADRCs can alleviate lymphedema in clinical reality with long‐term follow‐up. We treated 10 patients with BCRL using ADRCs and a scar‐releasing lipotransfer to the axillary region, and all patients were followed 1, 3, 6, 12, and 48 months after treatment. The primary endpoint was change in arm volume. Secondary endpoints were safety, change in lymphedema symptoms, quality of life, lymphedema‐associated cellulitis, and conservative treatment use. There was no significant decrease in BCRL volume after treatment. However, self‐reported upper extremity disability and arm heaviness and tension improved. Six patients reduced their use of conservative BCRL treatment. Five patients felt that their BCRL had improved substantially, and four of these would redo the treatment. We did not observe any cases of locoregional breast cancer recurrence. In this phase I study with 4 years of follow‐up, axillary delivered ADRCs and lipotransfer were safe and feasible and improved BCRL symptoms and upper extremity function. Randomized controlled trials are needed to confirm the results of this study.
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Affiliation(s)
- Mads Gustaf Jørgensen
- Department of Plastic Surgery, Research Unit for Plastic Surgery, Odense University Hospital, Odense, Denmark.,Clinical Institute, University of Southern Denmark, Odense, Denmark
| | - Navid Mohamadpour Toyserkani
- Department of Plastic Surgery, Research Unit for Plastic Surgery, Odense University Hospital, Odense, Denmark.,Department of Plastic Surgery and Burns Treatment, Rigshospitalet, Copenhagen, Denmark
| | - Charlotte Harken Jensen
- Laboratory of Molecular and Cellular Cardiology, Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark
| | - Ditte Caroline Andersen
- Clinical Institute, University of Southern Denmark, Odense, Denmark.,Laboratory of Molecular and Cellular Cardiology, Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark
| | - Søren Paludan Sheikh
- Clinical Institute, University of Southern Denmark, Odense, Denmark.,Laboratory of Molecular and Cellular Cardiology, Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark
| | - Jens Ahm Sørensen
- Department of Plastic Surgery, Research Unit for Plastic Surgery, Odense University Hospital, Odense, Denmark.,Clinical Institute, University of Southern Denmark, Odense, Denmark
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5
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Evaluation and selection of lower limb lymphedema patients for lymphaticovenular anastomosis: A prospective study. Injury 2020; 51 Suppl 4:S108-S113. [PMID: 32209243 DOI: 10.1016/j.injury.2020.02.110] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 02/20/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Lymphaticovenular anastomosis (LVA) with supramicrosurgical technique has recently gained popularity as a treatment method for patients with lymphedema. The aim of this study was to prospectively evaluate objective changes in leg volume in patients operated with LVA for lymphedema in the lower extremity, and to find positive predictors for the treatment method to facilitate the location of the venules and lymphatic vessels. PATIENTS & METHODS 31 consecutive patients with lymphedema in the lower extremity and positive pitting test were examined with lymphoscintigraphy and indocyanine green (ICG) lymphography. The causes of the lymphedema were either cancer or unknown cause/primary lymphedema. Fourteen of the patients with pathological lymphangiographic patterns were chosen for surgery and 12 of them were operated with one to four LVAs each. The lymphedema volume in the lower extremity was measured preoperatively, 6- and 12 months after surgery according to the truncated cone formula with the patient´s contralateral leg used as control. Ten patients had unilateral lymphedema and two patients had bilateral lymphedema. RESULTS Five of 12 patients showed between 1-8% edema reductions in the lower extremity after 12 months. With examination considering edema duration, number of anastomoses, radiotherapy and lymph node dissection we found a 6,2% difference in edema reduction between patients who had undergone lymph node dissection and those who had not (p = 0.03). CONCLUSIONS The current study indicates that supramicrosurgery with LVA may reduce edema volumes, where the most distinctive positive predictor for edema reduction with LVAs was previous lymph node dissection.
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6
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Yabuki Y, Maegawa J, Shibukawa N, Kagimoto S, Kitayama S, Matsubara S, Mikami T. A Novel Approach to Subcutaneous Collecting Lymph Ducts Using a Small Diameter Wire in Animal Experiments and Clinical Trials. Lymphat Res Biol 2020; 19:73-79. [PMID: 32721266 DOI: 10.1089/lrb.2019.0047] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: While performing microsurgery, including lymphaticovenous anastomosis (LVA) for chronic limb lymphedema, it is a common procedure to identify the subcutaneous collecting lymph ducts with near-infrared fluorescence lymphangiography (NIR) using indocyanine green. However, due to limitations such as minimum observable depth, only a few lymphatic ducts can be identified with this procedure. Hence, we developed a new smaller-diameter "lymphatic wire" (LW) that could be inserted directly into lymphatic collecting ducts of the limbs, enabling accurate identification and localization. Methods and Results: First, used the LW on the hind limbs of 6 swine, and 36 porcine lymphatic collecting ducts were identified, the outer diameter of which varied from 0.3-0.7 mm (mean 0.41 ± 0.11 mm). We could insert the LW after creating a side opening in 30 of these ducts. We encountered no difficulties during the procedure. In the pathological examination, adverse events such as valve dysfunction and perforation were not identified. Based on the results, a clinical evaluation of the LW was performed in two patients with lower extremity lymphedema, and the LW helped us identify lymphatic ducts in the subcutaneous layer, even at the sites where the NIR had proved ineffective. Conclusion: Based on our results, we suggest that the procedure for identifying lymphatic vessels using the newly developed LW is a useful technique that can be utilized before performing a LVA for lymphedema. However, further clinical study is required to develop this device and technique, for wider clinical application in the future.
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Affiliation(s)
- Yuichiro Yabuki
- Department of Plastic and Reconstructive Surgery, Yokohama City University School of Medicine, Yokohama, Kanagawa, Japan
| | - Jiro Maegawa
- Department of Plastic and Reconstructive Surgery, Yokohama City University School of Medicine, Yokohama, Kanagawa, Japan
| | - Naohiko Shibukawa
- Department of Plastic and Reconstructive Surgery, Yokohama City University School of Medicine, Yokohama, Kanagawa, Japan
| | - Shintaro Kagimoto
- Department of Plastic and Reconstructive Surgery, Yokohama City University School of Medicine, Yokohama, Kanagawa, Japan
| | - Shinya Kitayama
- Department of Plastic and Reconstructive Surgery, Yokohama City University School of Medicine, Yokohama, Kanagawa, Japan
| | - Shinobu Matsubara
- Department of Plastic and Reconstructive Surgery, Yokohama City University School of Medicine, Yokohama, Kanagawa, Japan
| | - Taro Mikami
- Department of Plastic and Reconstructive Surgery, Yokohama City University School of Medicine, Yokohama, Kanagawa, Japan
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7
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Forte AJ, Khan N, Huayllani MT, Boczar D, Saleem HY, Lu X, Manrique OJ, Ciudad P, McLaughlin SA. Lymphaticovenous Anastomosis for Lower Extremity Lymphedema: A Systematic Review. Indian J Plast Surg 2020; 53:17-24. [PMID: 32367914 PMCID: PMC7192660 DOI: 10.1055/s-0040-1709372] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Background
Lymphedema is an accumulation of protein-rich fluid in the interstitial spaces resulting from impairment in the lymphatic circulation that can impair quality of life and cause considerable morbidity. Lower extremity lymphedema (LEL) has an overall incidence rate of 20%. Conservative therapies are the first step in treatment of LEL; however, they do not provide a cure because they fail to address the underlying physiologic dysfunction of the lymphatic system. Among several surgical alternatives, lymphaticovenous anastomosis (LVA) has gained popularity due to its improved outcomes and less invasive approach. This study aims to review the published literature on LVA for LEL treatment and to analyze the surgical outcomes.
Methods
PubMed database was used to perform a comprehensive literature review of all articles describing LVA for treatment of LEL from Novemeber 1985 to June 2019. Search terms included “lymphovenous” OR “lymphaticovenous” AND “bypass” OR “anastomosis” OR “shunt” AND “lower extremity lymphedema.”
Results
A total of 95 articles were identified in the initial query, out of which 58 individual articles were deemed eligible. The studies included in this review describe notable variations in surgical techniques, number of anastomoses, and supplementary interventions. All, except one study, reported positive outcomes based on limb circumference and volume changes or subjective clinical improvement. The largest reduction rate in limb circumference and volume was 63.8%.
Conclusion
LVA demonstrated a considerable reduction in limb volume and improvement in subjective findings of lymphedema in the majority of patients. The maintained effectiveness of this treatment modality in long-term follow-up suggests great efficacy of LVA in LEL treatment.
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Affiliation(s)
- Antonio J Forte
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, Florida, United States
| | | | - Maria T Huayllani
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, Florida, United States
| | - Daniel Boczar
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, Florida, United States
| | - Humza Y Saleem
- Department of Surgery, Mayo Clinic, Jacksonville, Florida, United States
| | - Xiaona Lu
- Division of Plastic and Reconstructive Surgery, Yale School of Medicine, New Haven, Connecticut, United States
| | - Oscar J Manrique
- Division of Plastic Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Sarah A McLaughlin
- Department of Surgery, Mayo Clinic, Jacksonville, Florida, United States
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8
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Klingelhoefer E, Hesse K, Taeger CD, Prantl L, Stepniewski A, Felmerer G. Factors affecting outcomes after supermicrosurgical lymphovenous anastomosis in a defined patient population. Clin Hemorheol Microcirc 2020; 73:53-63. [PMID: 31561341 DOI: 10.3233/ch-199213] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND The optimal surgical treatment for lymphedema is still subject of intensive research. Therefore, it is vital to investigate what significance lymphovenous anastomosis (LVA) has in this context. OBJECTIVE This study aims to determine the short- and long-term results as well as the most important factors that can improve outcomes after LVA. METHODS This study includes a complete data set of 26 patients who received LVA for a therapy-resistant lymphedema. Patients were followed up for an average of 23 months. RESULTS 50% of the patients reported a subjective improvement. Without conservative treatment after the operation the patients showed significant better results (100% vs. 40.9%, p = 0.030). The localization of lymphedema as well as the region of LVA had a significant influence. In patients with lymphedema affecting the entire leg, symptom improvement was significantly lower (35.3% vs. 77.8%, p = 0.039). Patients who received LVA in an upper limb show a significantly higher improvement in symptoms than patients who received LVA in a lower limb (100% vs. 30%, p = 0.021). CONCLUSIONS We identified factors with a significant influence on the outcome of patients after receiving LVA. Patients with early-stage upper extremity lymphedema seem to benefit most from this procedure.
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Affiliation(s)
- Eric Klingelhoefer
- Division of Plastic Surgery, Department of Trauma Surgery, Orthopedics and Plastic Surgery, University Medical Center Goettingen, Germany
| | - Karl Hesse
- Division of Plastic Surgery, Department of Trauma Surgery, Orthopedics and Plastic Surgery, University Medical Center Goettingen, Germany
| | - Christian D Taeger
- Department of Plastic, Hand- and Reconstructive Surgery, University Hospital Regensburg, Germany
| | - Lukas Prantl
- Department of Plastic, Hand- and Reconstructive Surgery, University Hospital Regensburg, Germany
| | - Adam Stepniewski
- Division of Plastic Surgery, Department of Trauma Surgery, Orthopedics and Plastic Surgery, University Medical Center Goettingen, Germany
| | - Gunther Felmerer
- Division of Plastic Surgery, Department of Trauma Surgery, Orthopedics and Plastic Surgery, University Medical Center Goettingen, Germany
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9
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Sakuma H, Watanabe S, Kono H. A Novel Surgical Approach for Refractory Secondary Lymphedema of the Lower Extremity Accompanying Micro-Arteriovenous Fistula. Ann Vasc Surg 2019; 65:284.e13-284.e18. [PMID: 31705986 DOI: 10.1016/j.avsg.2019.10.098] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 07/17/2019] [Accepted: 10/30/2019] [Indexed: 10/25/2022]
Abstract
Lymphaticovenous anastomosis (LVA) for lymphedema of the lower extremity has been established as a minimally invasive and effective surgical treatment to return static lymph fluid to the vein. However, we often experience cases in which the effect of LVA cannot be obtained sufficiently, or the anastomotic site becomes obstructed and the edema deteriorates over a long term. One of the causes is the combination of local venous hypertension (VT) by micro-arteriovenous fistula (mAVF). We report two cases of refractory lymphedema at the lower extremity caused by mAVF and incompetent perforating vein (IPV). In these cases, surgical ligation and separation of the mAVF and IPV is effective in reducing edema.
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Affiliation(s)
- Hisashi Sakuma
- Department of Plastic and Reconstructive Surgery, Yokohama Citizens' Municipal Hospital, Kanagawa, Japan.
| | - Shiho Watanabe
- Department of Plastic and Reconstructive Surgery, Yokohama Citizens' Municipal Hospital, Kanagawa, Japan
| | - Hikaru Kono
- Department of Plastic and Reconstructive Surgery, Yokohama Citizens' Municipal Hospital, Kanagawa, Japan
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10
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Correlations between Tracer Injection Sites and Lymphatic Pathways in the Leg. Plast Reconstr Surg 2019; 144:634-642. [DOI: 10.1097/prs.0000000000005982] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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11
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Adipose-derived regenerative cells and fat grafting for treating breast cancer-related lymphedema: Lymphoscintigraphic evaluation with 1 year of follow-up. J Plast Reconstr Aesthet Surg 2018; 72:71-77. [PMID: 30293963 DOI: 10.1016/j.bjps.2018.09.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 09/03/2018] [Accepted: 09/10/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND Breast cancer-related lymphedema (BCRL) is a feared late complication. Treatment options are lacking at present. Recent studies have suggested that mesenchymal stromal cells can alleviate lymphedema. Herein, we report the results from the first human pilot study with adipose-derived regenerative cells (ADRCs) for treating BCRL with 1 year of follow-up. MATERIAL AND METHODS We included 10 patients with BCRL. ADRCs were injected directly into the axillary region together with a scar-releasing fat grafting procedure. Primary endpoint was change in arm volume. Secondary endpoints were change in patient-reported outcomes, changes in lymph flow, and safety. RESULTS During follow-up, no significant change in volume was noted. Patient-reported outcomes improved significantly with time. Five patients reduced their use of conservative management. Quantitative lymphoscintigraphy did not improve on the lymphedema-affected arms. ADRCs were well tolerated, and only minor transient adverse events related to liposuction were noted. CONCLUSIONS In this pilot study, a single injection of ADRCs improved lymphedema based on patient-reported outcome measures, and there were no serious adverse events during the follow-up period. Lymphoscintigraphic evaluation showed no improvement after ADRC treatment. There was no change in excess arm volume. Results of this trial need to be confirmed in randomized clinical trials.
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12
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Hoffner M, Ohlin K, Svensson B, Manjer J, Hansson E, Troëng T, Brorson H. Liposuction Gives Complete Reduction of Arm Lymphedema following Breast Cancer Treatment-A 5-year Prospective Study in 105 Patients without Recurrence. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2018; 6:e1912. [PMID: 30324078 PMCID: PMC6181505 DOI: 10.1097/gox.0000000000001912] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 07/05/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND Arm lymphedema is a well-recognized complication after breast cancer surgery that negatively impacts patients' quality of life, both physiologically and psychologically. Lymph stasis and inflammation result in excess formation of adipose tissue, which makes removal of the deposited subcutaneous fat necessary to eliminate the excess volume. Liposuction, combined with postoperative controlled compression therapy (CCT), is the only treatment that gives complete reduction of the excess volume. The aim of this study was to evaluate the 5-year results after liposuction in combination with CCT. METHODS Patients consecutively operated on between 1993 and 2012 were identified from the lymphedema registry, comprising all patients with nonpitting lymphedema treated with liposuction and CCT in our department. Standardized forms were used to collect pre-, peri-, and postoperative data. RESULTS One hundred five women with nonpitting edema were treated. The mean interval between the breast cancer operation and lymphedema start was 2.9 ± 5.0 years, the mean duration of lymphedema was 10 ± 7.4 years, and the preoperative mean excess volume was 1,573 ± 645 ml. The mean volume aspirated was 1,831 ± 599 ml. Postoperative mean reduction 5 years postoperatively was 117% ± 26% as compared with the healthy arm. CONCLUSION Liposuction is an effective method for the treatment of chronic, nonpitting, arm lymphedema resistant to conservative treatment. The volume reduction remains complete after 5 years.
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Affiliation(s)
- Mattias Hoffner
- From the Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Surgery, Blekinge Hospital, Karlskrona, Sweden
| | - Karin Ohlin
- Department of Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, Sweden
| | - Barbro Svensson
- Department of Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, Sweden
| | - Jonas Manjer
- From the Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, Sweden
| | - Emma Hansson
- From the Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Plastic and Reconstructive Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Thomas Troëng
- From the Department of Clinical Sciences, Lund University, Malmö, Sweden
- Section of Vascular Surgery, Uppsala University Hospital, Uppsala, Sweden
| | - Håkan Brorson
- From the Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, Sweden
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13
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Mihara M, Hara H, Kawakami Y, Zhou HP, Tange S, Kikuchi K, Iida T. Multi-site lymphatic venous anastomosis using echography to detect suitable subcutaneous vein in severe lymphedema patients. J Plast Reconstr Aesthet Surg 2018; 71:e1-e7. [DOI: 10.1016/j.bjps.2017.10.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 07/09/2017] [Accepted: 10/04/2017] [Indexed: 12/31/2022]
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Jørgensen MG, Toyserkani NM, Sørensen JA. The effect of prophylactic lymphovenous anastomosis and shunts for preventing cancer-related lymphedema: a systematic review and meta-analysis. Microsurgery 2017; 38:576-585. [PMID: 28370317 DOI: 10.1002/micr.30180] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Revised: 01/27/2017] [Accepted: 03/17/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND Lymphedema is one of the most dreaded side effects to any cancer treatment involving lymphadenectomy. Progressed lymphedema is adversely complex and currently there is no widely acknowledged curative treatment. Therefore recent focus has shifted to risk reduction and prevention. It has been hypothesized that bypassing lymphatic vessels to veins prophylactically, could minimize the lymphatic dysfunction seen following lymphadenectomy. METHODS To investigate this possible future treatment modality, we performed a systematic meta-analysis of studies treating patients with prophylactic lymphovenous analysisstomosis (LVA) for the prevention of secondary lymphedema following lymphadenectomy. A systematic search yielded 12 articles included in the qualitative analysis and four of these were further eligible to be included in the quantitative analysis. RESULTS We found that patients treated with prophylactic LVA had a significant reduction in lymphedema incidence (Relative risk: 0.33, 95%CI: 0.19 to 0.56) when compared to patients receiving no prophylactic treatment (P < 0.0001). CONCLUSION Prophylactic LVA in relation to lymphadenectomy shows promising results, however because of the low number of eligible studies and method heterogeneity between studies, there is an urgent need for uniformly high quality studies, before the treatment can be concluded effective.
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Affiliation(s)
- Mads G Jørgensen
- Department of Plastic Surgery, Odense University Hospital, Denmark
| | | | - Jens A Sørensen
- Department of Plastic Surgery, Odense University Hospital, Denmark
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Winters H, Tielemans HJP, Sprangers PN, Ulrich DJO. Peri-operative care for patients undergoing lymphaticovenular anastomosis: A systematic review. J Plast Reconstr Aesthet Surg 2016; 70:178-188. [PMID: 28025009 DOI: 10.1016/j.bjps.2016.11.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Accepted: 11/22/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Lymphaticovenular anastomosis (LVA) is a supermicrosurgical procedure that involves the anastomosis of a functional lymphatic channel to a venule. Although peri-operative care might be an important contributor to the success of this technique, evidence about optimal peri-operative care seems limited. This review aims to summarize the peri-operative methods used by authors reporting on LVA. METHODS A systematic search of the literature was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Peri-operative care used by authors was summarized and listed in a pre-defined form. Studies were also graded on quality of evidence by the GRADE system and a lymphedema surgery-specific system. RESULTS In total, 22 studies were identified describing peri-operative measures. Although most authors were sparse in their description of peri-operative management, most recommended initiation of conventional compression therapy at 1-4 weeks after surgery. Prophylactic antibiotics, elevation of the affected limb, bandaging, low-molecular-weight heparin, prostaglandin E1, and manual pressure therapy were also described. The quality of evidence of the included studies was low on average. CONCLUSION Although supermicrosurgical LVAs are gaining in popularity, there are no high-quality prospective trials evaluating these new techniques and the description of peri-operative management is scarce. Of the available studies, a peri-operative management consisting of prophylactic antibiotics, elevation of the affected limb during night and hospital stay, and compression therapy 4 weeks post-surgery for 6 months seems to be preferred. Future studies should describe a detailed peri-operative protocol to allow for a better comparison between study results and to determine optimal peri-operative recommendations.
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Affiliation(s)
- Harm Winters
- Department of Plastic and Reconstructive Surgery, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Hanneke J P Tielemans
- Department of Plastic and Reconstructive Surgery, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Philippe N Sprangers
- Department of Plastic and Reconstructive Surgery, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Dietmar J O Ulrich
- Department of Plastic and Reconstructive Surgery, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
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Mitra D, Catalano PJ, Cimbak N, Damato AL, Muto MG, Viswanathan AN. The risk of lymphedema after postoperative radiation therapy in endometrial cancer. J Gynecol Oncol 2015; 27:e4. [PMID: 26463430 PMCID: PMC4695454 DOI: 10.3802/jgo.2016.27.e4] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Revised: 08/16/2015] [Accepted: 09/13/2015] [Indexed: 12/20/2022] Open
Abstract
Objective Lower extremity lymphedema adversely affects quality of life by causing discomfort, impaired mobility and increased risk of infection. The goal of this study is to investigate factors that influence the likelihood of lymphedema in patients with endometrial cancer who undergo adjuvant radiation with or without chemotherapy. Methods A retrospective chart review identified all stage I–III endometrial cancer patients who had a hysterectomy with or without complete staging lymphadenectomy and adjuvant radiation therapy between January 2006 and February 2013. Patients with new-onset lymphedema after treatment were identified. Logistic regression was used to find factors that influenced lymphedema risk. Results Of 212 patients who met inclusion criteria, 15 patients (7.1%) developed new-onset lymphedema. Lymphedema was associated with lymph-node dissection (odds ratio [OR], 5.6; 95% CI, 1.01 to 105.5; p=0.048) and with the presence of pathologically positive lymph nodes (OR, 4.1; 95% CI, 1.4 to 12.3; p=0.01). Multivariate logistic regression confirmed the association with lymph-node positivity (OR, 3.2; 95% CI, 1.0007 to 10.7; p=0.0499) when controlled for lymph-node dissection. Median time to lymphedema onset was 8 months (range, 1 to 58 months) with resolution or improvement in eight patients (53.3%) after a median of 10 months. Conclusion Lymph-node positivity was associated with an increased risk of lymphedema in endometrial cancer patients who received adjuvant radiation. Future studies are needed to explore whether node-positive patients may benefit from early lymphedema-controlling interventions.
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Affiliation(s)
- Devarati Mitra
- Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham & Women's Hospital, Boston, MA, USA.
| | - Paul J Catalano
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, MA, USA.,Department of Biostatistics, Harvard School of Public Health, Boston, MA, USA
| | - Nicole Cimbak
- Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham & Women's Hospital, Boston, MA, USA
| | - Antonio L Damato
- Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham & Women's Hospital, Boston, MA, USA
| | - Michael G Muto
- Department of Gynecologic Oncology, Dana-Farber Cancer Institute and Brigham & Women's Hospital, Boston, MA, USA
| | - Akila N Viswanathan
- Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham & Women's Hospital, Boston, MA, USA
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Ramsey K, Mortimer P. Lymphoedema. Plast Reconstr Surg 2015. [DOI: 10.1002/9781118655412.ch47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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