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Will PA, Taqatqeh F, Fricke F, Berner JE, Lindenblatt N, Kneser U, Hirche C. Tissue-engineered cellulose tubes for microvascular and lymphatic reconstruction: A translational and feasibility study. J Plast Reconstr Aesthet Surg 2024; 97:200-211. [PMID: 39168030 DOI: 10.1016/j.bjps.2024.05.043] [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: 10/14/2023] [Revised: 04/07/2024] [Accepted: 05/24/2024] [Indexed: 08/23/2024]
Abstract
BACKGROUND Lymphedema microsurgery is an emerging treatment modality, with dissimilar long-term outcomes. One of the main technical challenges in lymphatic microsurgery is the identification and availability of suitable donor vessels for anastomosis. Tissue engineering using biomaterials has demonstrated promise in addressing vessel quality issues in other fields, but its application in microsurgery is still limited. METHODS Decellularized cellulose tubes were developed and bioengineered by decellularizing stems of Taraxacum-Ruderalia. The microscopic structure, mechanical properties, and residual DNA content of the cellulose tubes were evaluated. Human and murine skin fibroblasts and dermal lymphatic endothelial cells were isolated and cultured for recellularization studies. Biocompatibility, proliferative capacity, and ex-vivo endothelialization of the cellulose tubes were assessed as potential interposition grafts. Finally, the engineered cellulose tubes were assessed as interposing xenografts for lymphovenous anastomoses (LVA) in an ex-vivo swine limb model. RESULTS The decellularized cellulose tubes exhibited a suitable microscopic structure, mechanical properties, and low residual DNA content. The tubes showed adequate biocompatibility, supported cell proliferation, and facilitated spontaneous ex-vivo endothelialization of lymphatic endothelial cells. In the swine limb model, LVA using the engineered cellulose tubes was successfully performed. CONCLUSION This translational study presents the use of decellularized cellulose tubes as an adjunct for micro and supermicrosurgical reconstruction. The developed tubes demonstrated favorable structural, mechanical, and biocompatible properties, making them a potential candidate for improving long-term outcomes in lymphedema surgical treatment. The next translational step would be trialing the obtained tubes in a microsurgical in-vivo model.
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Affiliation(s)
- P A Will
- Department of Plastic and Hand Surgery, Faculty of Medicine and University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany; Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Centre BG Klinik Ludwigshafen, Ludwigshafen, Germany; Plastic Surgery and Hand Surgery, University Heidelberg, Heidelberg, Germany.
| | - F Taqatqeh
- Department of Plastic and Hand Surgery, Faculty of Medicine and University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - F Fricke
- Applied Tumor Biology, German Cancer Research Center, Heidelberg, Germany
| | - J E Berner
- Kellogg College, University of Oxford, Oxford, United Kingdom; Department of Plastic Surgery, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, United Kingdom
| | - N Lindenblatt
- Department of Plastic Surgery and Hand Surgery, Lymphatic Network of Excellence, University Hospital Zurich, Zurich, Switzerland
| | - U Kneser
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Centre BG Klinik Ludwigshafen, Ludwigshafen, Germany; Plastic Surgery and Hand Surgery, University Heidelberg, Heidelberg, Germany
| | - C Hirche
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Centre BG Klinik Ludwigshafen, Ludwigshafen, Germany; Plastic Surgery and Hand Surgery, University Heidelberg, Heidelberg, Germany; Department of Plastic, Hand, and Reconstructive Microsurgery, Hand-Trauma and Replantation Center, BG Unfallklinik Frankfurt am Main, Affiliated Hospital of Goethe-University, Frankfurt am Main, Germany
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Brahma B, Yamamoto T, Panigoro SS, Haryono SJ, Yusuf PA, Priambodo PS, Harimurti K, Taher A. Supermicrosurgery lymphaticovenous and lymphaticolymphatic anastomosis: Technical detail and short-term follow-up for immediate lymphatic reconstruction in breast cancer treatment-related lymphedema prevention. J Vasc Surg Venous Lymphat Disord 2024; 12:101863. [PMID: 38428499 DOI: 10.1016/j.jvsv.2024.101863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Revised: 02/05/2024] [Accepted: 02/12/2024] [Indexed: 03/03/2024]
Abstract
OBJECTIVE We describe the feasibility and short-term outcome of our surgical technique to repair the lymph vessel disruption directly after axillary lymph node dissection during breast cancer surgery. This procedure is called immediate lymphatic reconstruction to prevent breast cancer treatment-related lymphedema (BCRL), which frequently occurs after axillary lymph node dissection. The surgical technique consisted of lymphaticovenous anastomosis (LVA) or lymphaticolymphatic anastomosis. We named the procedure lymphatic bypass supermicrosurgery (LBS). METHODS This study used a retrospective cohort design of patients with breast cancer between May 2020 and February 2023. LBS was performed by making an intima-to-intima coaptation between afferent lymph vessels and the recipient's veins (LVA) or efferent lymph vessels lymphaticolymphatic anastomosis. RESULTS A total of 82 patients underwent lymphatic bypass. The mean age of patients was 50 ± 12 years, and most had stage III breast cancer (n = 59 [72%]). LVA was the most common type of lymphatic bypass (94.6%). The median number of LVA was 1 (range, 1-4) and 1 (range, 1-3) for lymphaticolymphatic anastomosis. The median follow-up time was 12.5 months (range, 1-33 months). The 50 patients who had postoperative indocyanine green lymphography described arm dermal backflow stage 0 in 20 (40%), stage 1 in 19 (38%), stage 2 in 2 (4%), and stage 3 in 9 (18%) cases. The proportion of BCRL was 11 (22%), and subclinical lymphedema was 19 (38%) in this period. Most cases were in stable subclinical lymphedema (10, 58.8%). The 1-year and 2-year BCRL rates were 14% (95% confidence interval, 4%-23.9%) and 22% (95% confidence interval, 10.1%-33.9%), respectively. CONCLUSIONS Along with the emerging immediate lymphatic reconstruction, LBS is a feasible supermicrosurgery technique that may have a potential role in BCRL prevention. A randomized controlled study would confirm the effectiveness of the technique.
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Affiliation(s)
- Bayu Brahma
- Doctoral Program in Medical Sciences, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia; Department of Surgical Oncology, Dharmais Cancer Hospital-National Cancer Center, Jakarta, Indonesia
| | - Takumi Yamamoto
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan.
| | - Sonar Soni Panigoro
- Oncology Division, Department of Surgery, Faculty of Medicine, Universitas Indonesia - Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
| | - Samuel Johny Haryono
- Department of Surgical Oncology, Dharmais Cancer Hospital-National Cancer Center, Jakarta, Indonesia
| | - Prasandhya Astagiri Yusuf
- Department of Medical Physiology and Biophysics/Medical Technology IMERI, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Purnomo Sidi Priambodo
- Department of Electrical Engineering, Faculty of Engineering, Universitas Indonesia, Jakarta, Indonesia
| | - Kuntjoro Harimurti
- Division of Geriatrics/Clinical Epidemiological Unit, Department of Internal Medicine, Universitas Indonesia - Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
| | - Akmal Taher
- Department of Urology, Faculty of Medicine, Universitas Indonesia - Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
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Hara H, Mihara M. Lymphaticovenous anastomosis map established using lymphatic ultrasound and multi-lymphosome indocyanine green lymphography. J Plast Reconstr Aesthet Surg 2024; 94:223-228. [PMID: 38823078 DOI: 10.1016/j.bjps.2024.05.004] [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: 01/10/2024] [Revised: 04/03/2024] [Accepted: 05/03/2024] [Indexed: 06/03/2024]
Abstract
BACKGROUND Although the usefulness of lymphaticovenous anasotmosis (LVA) for lymphedema has been reported, it is difficult to determine where the LVA is to be performed, especially for inexperienced surgeons. This study aimed to establish a map of the LVA site. METHOD A total of 105 limbs from 64 patients who underwent lower limb LVA were retrospectively reviewed. Multi-lymphosome indocyanine green (ICG) lymphography (in 35 patients) and lymphatic ultrasound (in all patients) were performed preoperatively and the incision site was determined where dilated lymph vessels and appropriate veins were located in close proximity. The LVA location was identified using a post-operative photograph. Additionally, the degree of lymphatic degeneration at the LVA site was recorded based on the normal, ectasis, contraction, and sclerosis type (NECST) classification. RESULT A total of 206 skin incisions were analyzed. Among them, 161 (75.9%) were medial and 45 (21.2%) were lateral. Among the 85 sites on the calf, 52 (61.2%) were medial and 33 (38.8%) were lateral. Among the 117 sites on the thigh, 106 (90.6%) were medial and 11 (9.4%) were lateral. As the severity of lymphedema progressed, the probability of performing LVA on the lateral calf increased. Among the 202 locations where LVA was performed on the thigh and lower leg, ectasis type was found in 164 sites (81.2%). CONCLUSION We established an LVA map of the legs based on multi-lymphosome ICG lymphography and lymphatic ultrasound data. Using this LVA map, surgeons can easily predict the location of lymph vessels, thereby improving the success rate of LVA.
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Affiliation(s)
- Hisako Hara
- Department of Lymphatic and Reconstructive Surgery, JR Tokyo General Hospital, Tokyo, Japan; Lymphedema Clinic Tokyo, Tokyo, Japan
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Weber WP, Hanson SE, Wong DE, Heidinger M, Montagna G, Cafferty FH, Kirby AM, Coles CE. Personalizing Locoregional Therapy in Patients With Breast Cancer in 2024: Tailoring Axillary Surgery, Escalating Lymphatic Surgery, and Implementing Evidence-Based Hypofractionated Radiotherapy. Am Soc Clin Oncol Educ Book 2024; 44:e438776. [PMID: 38815195 DOI: 10.1200/edbk_438776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Abstract
The management of axillary lymph nodes in breast cancer is continually evolving. Recent data now support omitting axillary lymph node dissection (ALND) in most patients with metastases in up to two sentinel lymph nodes (SLNs) during upfront surgery and those with residual isolated tumor cells after neoadjuvant chemotherapy (NACT). In the upfront surgery setting, ALND is still indicated, however, in patients with clinically node-positive breast cancer or more than two positive SLNs and, after NACT, in case of residual micrometastases and macrometastases. Omission of the sentinel lymph node biopsy (SLNB) can be considered in many postmenopausal patients with small luminal breast cancer, particularly when axillary ultrasound is negative. Several randomized controlled trials (RCTs) are currently aiming at eliminating the remaining indications for ALND and also establishing omission of SLNB in a broader patient population. The movement to deescalate axillary staging is in part because of the association between ALND and lymphedema, which is swelling of an extremity because of lymphatic damage and obstructed lymphatic drainage. To reduce the risk of developing this condition, patients undergoing ALND can undergo reverse mapping of the axilla and immediate reconstruction or bypass of the lymphatics from the involved extremity. Decongestion and compression are the foundation of conservative treatment for established lymphedema, while lymphovenous bypass and lymph node transfer are surgical procedures to address the physiologic dysfunction. Radiotherapy is an essential component of breast locoregional therapy: more than three decades of radiation research has optimized treatment according to patient's risk of local recurrence while substantially reducing the number of treatment visits. High-quality RCTs have shown the efficacy and safety of hypofractionation-more than 2Gy radiation dose per treatment (fraction)-significantly reducing the burden of radiotherapy treatment for many patients with breast cancer. In 2024, guidelines recommend no more than 15-16 fractions for whole-breast and nodal radiotherapy, with some recommending five fractions for whole-breast radiotherapy. In addition, simultaneous integrated boost (SIB) has been shown to be noninferior to sequential boost with regards to ipsilateral breast tumor recurrence with similar or reduced long-term side effects, also reducing overall treatment length. Further RCTs are underway investigating other indications for five fractions, including SIB and regional node irradiation, such that, in future, it may be possible for the majority of breast radiotherapy patients to be treated with a 1-week course. This manuscript serves to outline the latest updates on axillary surgical staging, lymphatic surgery, and evidence-based radiotherapy in the treatment of breast cancer.
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Affiliation(s)
- Walter Paul Weber
- Breast Clinic, University Hospital Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Summer E Hanson
- Plastic and Reconstructive Surgery, The University of Chicago Medicine and Biological Sciences Division, Chicago, IL
| | - Daniel E Wong
- Plastic and Reconstructive Surgery, The University of Chicago Medicine and Biological Sciences Division, Chicago, IL
| | - Martin Heidinger
- Breast Clinic, University Hospital Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Giacomo Montagna
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Fay H Cafferty
- Institute of Cancer Research Clinical Trials and Statistics Unit, London, United Kingdom
| | - Anna M Kirby
- Institute of Cancer Research and Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Charlotte E Coles
- Department of Oncology, University of Cambridge, Cambridge, United Kingdom
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Ahmed S, Imeokparia FO, Hassanein AH. Surgical management of lymphedema: prophylactic and therapeutic operations. CURRENT BREAST CANCER REPORTS 2024; 16:185-192. [PMID: 38988994 PMCID: PMC11233112 DOI: 10.1007/s12609-024-00543-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2024] [Indexed: 07/12/2024]
Abstract
Purpose of Review Lymphedema is chronic limb swelling from lymphatic dysfunction and is currently incurable. Breast-cancer related lymphedema (BCRL) affects up to 5 million Americans and occurs in one-third of breast cancer survivors following axillary lymph node dissection. Compression remains the mainstay of therapy. Surgical management of BCRL includes excisional procedures to remove excess tissue and physiologic procedures to attempt improve fluid retention in the limb. The purpose of this review is to highlight surgical management strategies for preventing and treating breast cancer-related lymphedema. Recent findings Immediate lymphatic reconstruction (ILR) is a microsurgical technique that anastomoses disrupted axillary lymphatic vessels to nearby veins at the time of axillary lymph node dissection (ALND) and has been reported to reduce lymphedema rates from 30% to 4-12%. Summary Postsurgical lymphedema remains incurable. Surgical management of lymphedema includes excisional procedures and physiologic procedures using microsurgical technique. Immediate lymphatic reconstruction has emerged as a prophylactic strategy to prevent lymphedema in breast cancer patients.
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Affiliation(s)
- Shahnur Ahmed
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Folasade O Imeokparia
- Division of Surgical Oncology, Indiana University School of Medicine, Indianapolis, IN
| | - Aladdin H Hassanein
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, IN
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Finkelstein ER, Clark M, Ha M, Singh D, Xu KY, Mella-Catinchi J, Rasko Y. Lymphedema Surgical Education and Faculty Demographics in United States Plastic Surgery Residency Programs. J Reconstr Microsurg 2024; 40:348-356. [PMID: 37751881 DOI: 10.1055/a-2182-1315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Abstract
BACKGROUND Recent advancements in supermicrosurgery and promising preliminary outcomes have led to a surge in physiologic lymphedema surgery. This study is the first to evaluate lymphedema surgical education among U.S. plastic surgery residency programs, along with the background and experience of plastic surgeons subspecializing in the field. METHODS Cross-sectional evaluation of 103 accredited U.S. plastic surgery residency programs was performed in January 2023. Web-based searches of program curricula, faculty profiles, and main institutional pages indicated whether a program provided nonclinical or clinical exposure to lymphedema surgery. Review of online faculty profiles, surname searches, Doximity, and Scopus determined the perceived demographics, academic productivity, and procedures performed by lymphedema surgeons. RESULTS Compared with the 11 programs that incorporated lymphedema surgery into their online curriculum, 67 programs had a rotation site with a surgeon performing lymphedema procedures. Of the 33 programs without evidence of clinical exposure, 76% (n = 25) did not provide or specify providing elective time. Faculty perceived to be female or a race underrepresented in plastic surgery had significantly more assistant professor titles (p < 0.0214) and significantly fewer years of experience (p < 0.0293) than their counterparts. CONCLUSION Great variation in lymphedema surgical education exists among U.S. plastic surgery residency programs. While few programs incorporate lymphedema surgery into their advertised curriculum, programs without clinical exposure frequently did not provide elective time to obtain it. Faculty that were female or a race underrepresented in plastic surgery were most often early in their career, suggesting lymphedema surgeons may grow increasingly diverse in years to come.
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Affiliation(s)
- Emily R Finkelstein
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Meaghan Clark
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Michael Ha
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | - Devinder Singh
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Kyle Y Xu
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Juan Mella-Catinchi
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Yvonne Rasko
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Maryland Medical Center, Baltimore, Maryland
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Ng ZY, Chalhoub X, Furniss D. Surgical Treatment of Lymphedema in the Upper Extremity. Hand Clin 2024; 40:283-290. [PMID: 38553099 DOI: 10.1016/j.hcl.2023.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
The advent of supermicrosurgery has led to an increasing interest in the surgical management of lymphedema through the reconstruction of the lymphatic network, that is, the physiologic approach. Broadly, this can be divided into 2 main techniques: lymphaticovenous anastomosis and lymph node transfer. In the United Kingdom, the British Lymphology Society does not provide any recommendations on surgical management. Moreover, surgical treatment of lymphedema is not widely practiced within the National Health Service due to low-certainty evidence. Herein, we discuss our experience in physiologic reconstruction for lymphedema.
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Affiliation(s)
- Zhi Yang Ng
- Department of Plastic and Reconstructive Surgery, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Headley Way, Headington, Oxford, OX3 9DU, United Kingdom
| | - Xavier Chalhoub
- Department of Plastic and Reconstructive Surgery, The Royal Free Hospital, Royal Free London NHS Foundation Trust, Pond Street, London, NW3 2QG, United Kingdom
| | - Dominic Furniss
- Department of Plastic and Reconstructive Surgery, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Windmill Road, Oxford, OX3 7LD, United Kingdom.
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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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Myung Y, Yun J, Beom J, Hayashi A, Lee WW, Song YS, Park JKH. Evaluating the Surgical Outcome of Lymphovenous Anastomosis in Breast Cancer-Related Lymphedema Using Tc-99m Phytate Lymphoscintigraphy: Preliminary Results. Lymphat Res Biol 2024; 22:124-130. [PMID: 38265788 DOI: 10.1089/lrb.2023.0036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2024] Open
Abstract
Background: Breast cancer-related lymphedema (BCRL) remains a significant postcancer treatment challenge with no definitive cure. Recent supermicrosurgical treatments, such as lymphovenous anastomosis (LVA), have shown promise but lack established objective indicators for outcome evaluation. We investigated the utility of Technetium-99m (Tc-99m) lymphoscintigraphy, an imaging technique providing objective information on lymphatic fluid flow, for assessing LVA surgical outcomes. Methods and Results: A retrospective cohort analysis of patients undergoing LVA for BCRL was conducted. Lymphoscintigraphy images pre- and 1-year postsurgery were compared to determine changes in lymphatic fluid flow of 18 patients based on newly defined parameters "uptake ratio" and "washout rates." Statistically significant reduction in the uptake ratio was observed in the forearm at 30 and 60 minutes postinjection phases. In addition, the forearm showed higher washout rate, indicating an improved lymphatic function in the forearm. Conclusion: Tc-99m lymphoscintigraphy can provide valuable objective data for evaluating LVA surgical outcomes in BCRL patients. However, site-specific differences in outcomes highlight the need for individualized surgical planning. Further large-scale studies are necessary to validate these preliminary findings and develop a standardized approach for LVA assessment.
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Affiliation(s)
- Yujin Myung
- Department of Plastic and Reconstructive Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
| | - Junseo Yun
- Department of Plastic and Reconstructive Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
| | - Jaewon Beom
- Department of Rehabilitation Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
| | | | - Won Woo Lee
- Department of Nuclear Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
| | - Yoo Sung Song
- Department of Nuclear Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
| | - Joseph Kyu-Hyung Park
- Department of Plastic and Reconstructive Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
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Nishiyama M, Sakaguchi Y, Morito S, Nagase K, Sakumoto T, Yamashita K, Hashiguchi M, Fukuda M, Toda S, Aoki S. A new lymphedema treatment using pyro-drive jet injection. Hum Cell 2024; 37:465-477. [PMID: 38218753 DOI: 10.1007/s13577-023-01021-2] [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: 10/09/2023] [Accepted: 12/07/2023] [Indexed: 01/15/2024]
Abstract
Lymphedema, resulting from impaired lymphatic drainage, causes inflammation, fibrosis and tissue damage leading to symptoms such as limb swelling and restricted mobility. Despite various treatments under exploration, no standard effective therapy exists. Here a novel technique using the pyro-drive jet injection (PJI) was used to create artificial clefts between collagen fibers, which facilitated the removal of excess interstitial fluid. The PJI was used to deliver a mixture of lactated Ringer's solution and air into the tail of animals with secondary skin edema. Edema levels were assessed using micro-CT scanning. Histopathological changes and neovascularization were evaluated on the injury-induced regenerative tissue. Regarding tissue remodeling, we focused on connective tissue growth factor (CTGF) and vascular endothelial growth factor (VEGF)-C. PJI markedly diminished soft tissue volume in the experimental lymphedema animals compared to the non-injected counterparts. The PJI groups exhibited a significantly reduced proportion of inflammatory granulation tissue and an enhanced density of lymphatic vessels and α-smooth muscle actin (αSMA)-positive small vessels in the fibrous granulation tissue compared to the controls. In addition, PJI curtailed the prevalence of CTGF- and VEGF-C-positive cells in regenerative tissue. In a lymphedema animal model, PJI notably ameliorated interstitial edema, promoted lymphatic vessel growth, and bolstered αSMA-positive capillaries in fibrous granulation tissue. PJI's minimal tissue impact post-lymph node dissection indicates significant potential as an early, standard preventative measure. Easily applied in general clinics without requiring specialized training, it offers a cost-effective and highly versatile solution to the management of lymphedema.
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Affiliation(s)
- Megumi Nishiyama
- Division of Pathology, Department of Pathology and Microbiology, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga, Saga, 849-8501, Japan
| | - Yuko Sakaguchi
- Medical Device Division Life Sciences SBU, Daicel Corporation, Osaka, Japan
| | - Sayuri Morito
- Division of Pathology, Department of Pathology and Microbiology, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga, Saga, 849-8501, Japan
| | - Kei Nagase
- Department of Urology, Faculty of Medicine, Saga University, Saga, Japan
| | - Takehisa Sakumoto
- Division of Pathology, Department of Pathology and Microbiology, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga, Saga, 849-8501, Japan
| | - Kunihiko Yamashita
- Medical Device Division Life Sciences SBU, Daicel Corporation, Osaka, Japan
| | - Mariko Hashiguchi
- Division of Pathology, Department of Pathology and Microbiology, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga, Saga, 849-8501, Japan
| | - Makoto Fukuda
- Division of Nephrology, Department of Internal Medicine, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga, 849-8501, Japan
| | - Shuji Toda
- Department of Pathology, Takagi Hospital, 141-11 Sakemi, Okawa, Fukuoka, 831-0016, Japan
| | - Shigehisa Aoki
- Division of Pathology, Department of Pathology and Microbiology, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga, Saga, 849-8501, Japan.
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11
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Gaxiola-García MA, Escandón JM, Manrique OJ, Skinner KA, Kushida-Contreras BH. Surgical Treatment for Primary Lymphedema: A Systematic Review of the Literature. Arch Plast Surg 2024; 51:212-233. [PMID: 38596145 PMCID: PMC11001464 DOI: 10.1055/a-2253-9859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 11/30/2023] [Indexed: 04/11/2024] Open
Abstract
This is a retrospective review of surgical management for primary lymphedema. Data were extracted from 55 articles from PubMed MEDLINE, Web of Science, SCOPUS, and Cochrane Central Register of Controlled Trials between the database inception and December 2022 to evaluate the outcomes of lymphaticovenous anastomosis (LVA) and vascularized lymph node transfer (VLNT), and outcomes of soft tissue extirpative procedures such as suction-assisted lipectomy (SAL) and extensive soft tissue excision. Data from 485 patients were compiled; these were treated with LVA ( n = 177), VLNT ( n = 82), SAL ( n = 102), and excisional procedures ( n = 124). Improvement of the lower extremity lymphedema index, the quality of life (QoL), and lymphedema symptoms were reported in most studies. LVA and VLNT led to symptomatic relief and improved QoL, reaching up to 90 and 61% average circumference reduction, respectively. Cellulitis reduction was reported in 25 and 40% of LVA and VLNT papers, respectively. The extirpative procedures, used mainly in patients with advanced disease, also led to clinical improvement from the volume reduction, as well as reduced incidence of cellulitis, although with poor cosmetic results; 87.5% of these reports recommended postoperative compression garments. The overall complication rates were 1% for LVA, 13% for VLNT, 11% for SAL, and 46% for extirpative procedures. Altogether, only one paper lacked some kind of improvement. Primary lymphedema is amenable to surgical treatment; the currently performed procedures have effectively improved symptoms and QoL in this population. Complication rates are related to the invasiveness of the chosen procedure.
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Affiliation(s)
- Miguel Angel Gaxiola-García
- Plastic and Reconstructive Surgery Department, Mexico's Children's Hospital (Hospital Infantil de México “Federico Gómez”), Mexico City, Mexico
| | - Joseph M. Escandón
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York
| | - Oscar J. Manrique
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York
| | - Kristin A. Skinner
- Department of Surgical Oncology, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York
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Suzuki Y, Kajita H, Watanabe S, Otaki M, Okabe K, Sakuma H, Imanishi N, Kishi K. Preoperative photoacoustic versus indocyanine green lymphography in lymphaticovenular anastomosis outcomes for lower extremity lymphedema: A pilot study. Microsurgery 2024; 44:e31153. [PMID: 38376254 DOI: 10.1002/micr.31153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 12/22/2023] [Accepted: 02/01/2024] [Indexed: 02/21/2024]
Abstract
BACKGROUND Identification of the proper lymphatics is important for successful lymphaticovenular anastomosis (LVA) for lymphedema; however, visualization of lymphatic vessels is challenging. Photoacoustic lymphangiography (PAL) can help visualize lymphatics more clearly than other modalities. Therefore, we investigated the usefulness of PAL and determined whether the clear and three-dimensional image of PAL affects LVA outcomes. METHODS We recruited 22 female patients with lower extremity lymphedema. The operative time, number of incisions, number of anastomoses, lymphatic vessel detection rate (number of functional lymphatics identified during the operation/number of incisions), and limb volume changes preoperatively and 3 months postoperatively were compared retrospectively. The patients were divided according to whether PAL was performed or not, and results were compared between those undergoing PAL (PAL group; n = 10) and those who did not (near-infrared fluorescence [NIRF] group, n = 12). RESULTS The mean age of the patients was 55.9 ± 15.1 years in the PAL group and 50.7 ± 14.9 years in the NIRF group. One patient in the PAL group and three in the NIRF group had primary lymphedema. Eighteen patients (PAL group, nine; and NIRF group, nine) had secondary lymphedema. Based on preoperative evaluation using the International Society of Lymphology (ISL) classification, eight patients were determined to be in stage 2 and two patients in late stage 2 in the PAL group. In contrast, in the NIRF group, one patient was determined to be in stage 0, three patients each in stage 1 and stage 2, and five patients in late stage 2. Lymphatic vessel detection rates were 93% (42 LVAs and 45 incisions) and 83% (50 LVAs and 60 incisions) in the groups with and without PAL, respectively (p = 0.42). Limb volume change was evaluated in five limbs of four patients and in seven limbs of five patients in the PAL and NIRF groups as 336.6 ± 203.6 mL (5.90% ± 3.27%) and 52.9 ± 260.7 mL (0.71% ± 4.27%), respectively. The PAL group showed a significant volume reduction. (p = .038). CONCLUSIONS Detection of functional lymphatic vessels on PAL is useful for treating LVA.
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Affiliation(s)
- Yushi Suzuki
- Department of Plastic and Reconstructive Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Hiroki Kajita
- Department of Plastic and Reconstructive Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Shiho Watanabe
- Department of Plastic and Reconstructive Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Marika Otaki
- Department of Plastic and Reconstructive Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Keisuke Okabe
- Department of Plastic and Reconstructive Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Hisashi Sakuma
- Department of Plastic and Reconstructive Surgery, Tokyo Dental College Ichikawa General Hospital, Chiba, Japan
| | - Nobuaki Imanishi
- Department of Anatomy, Keio University School of Medicine, Tokyo, Japan
| | - Kazuo Kishi
- Department of Plastic and Reconstructive Surgery, Keio University School of Medicine, Tokyo, Japan
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13
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Zhou X, Ma G, Qi X, Qin A, Liu B. Application of complete decongestive therapy after lymphaticovenular anastomosis of the lower limb combined with liposuction-A retrospective study research. Phlebology 2024; 39:49-57. [PMID: 37897443 DOI: 10.1177/02683555231209056] [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: 10/30/2023]
Abstract
BACKGROUND Complete decongestive therapy (CDT) is a conservative treatment for lymphedema that combines interventions and lifestyle changes. We evaluated the application of CDT after lymphaticovenular anastomosis (LVA) of the lower limb combined with liposuction. METHODS A total of 55 patients who underwent LVA of the lower limb combined with liposuction from January 2021 to July 2022 were enrolled in the study. The patients were divided into groups A (n = 24) and B (n = 31) according to whether they adhered to CDT treatment during the 12-month follow-up. Group A was the non-adherence CDT group and Group B was the adherence CDT group. Lower Extremity Lymphedema Index (LELI) and Lymphoedema Functioning, Disability, and Health Questionnaire for Lower Limb Lymphoedema (Lymph-ICF-LL) were used as prognostic indicators to observe the remission of postoperative lymphedema symptoms in the two groups. RESULTS At 6-month and 12-month follow-up, LELI and the score of Lymph-ICF-LL in group B and group A were lower than before the operation (p < .05). The circumference of the affected limb was reduced, and the quality of life was improved in both groups after the operation. The reduction of LELI and Lymph-ICF-LL in group B was higher than in group A, and the difference was statistically significant (p < .05). CONCLUSION This study preliminarily proves the effectiveness of CDT after LVA of the lower limb combined with liposuction, which can maintain and strengthen the surgical effect. Further, CDT treatment is still needed after the operation, which is necessary to reduce the circumference of the affected limb and improve patients' quality of life.
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Affiliation(s)
- Xuchuan Zhou
- Department of Burn, Plastic and Cosmetic Surgery, Xi'an Central Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Gejia Ma
- Department of Burn, Plastic and Cosmetic Surgery, Xi'an Central Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Xi Qi
- Department of Burn, Plastic and Cosmetic Surgery, Xi'an Central Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Aoshuang Qin
- Department of Burn, Plastic and Cosmetic Surgery, Xi'an Central Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Bin Liu
- Department of Burn, Plastic and Cosmetic Surgery, Xi'an Central Hospital, Xi'an Jiaotong University, Xi'an, China
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Jonis YMJ, Wolfs JAGN, Hummelink S, Tielemans HJP, Keuter XHA, van Kuijk S, Ulrich DJO, van der Hulst RRWJ, Qiu SS. The 6 month interim analysis of a randomized controlled trial assessing the quality of life in patients with breast cancer related lymphedema undergoing lymphaticovenous anastomosis vs. conservative therapy. Sci Rep 2024; 14:2238. [PMID: 38278856 PMCID: PMC10817972 DOI: 10.1038/s41598-024-52489-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 01/19/2024] [Indexed: 01/28/2024] Open
Abstract
Breast cancer related lymphedema (BCRL) is a chronic condition with a detrimental impact on psychosocial and physical well-being. Lymphaticovenous anastomosis has shown promising results in alleviating physical symptoms and increasing quality of life in patients with BCRL. The aim of the study is to evaluate the effect on health related quality of life (HrQol) after LVA surgery versus conservative treatment in patients with BCRL. The study is a prospective, multicenter randomized controlled trial. Adult women with unilateral BCRL, with early stage lymphedema and viable lymphatic vessels were included. The primary outcome measure was HrQol measured by the lymphedema functioning disability and health (Lymph-ICF) questionnaire. The secondary outcomes were volume difference measured by the water displacement method; the Upper Extremity Lymphedema (UEL) index; and daily use of the compression garments after 3 and 6 months. For this interim analysis 46 patients per group were included. There was a significant improvement in the domains in physical and mental function in the Lymph-ICF questionnaire in the LVA group after 6 months, (- 16.46 ± 18.5, p < 0.05, - 10.12 ± 29.5, p < 0.05 respectively). However, there was no statistical difference in the total score of the Lymph-ICF after 6 months in both groups (LVA-group; - 8.57 ± 22.6, p > 0.05, CDT-group; - 2.65 ± 18.2, p < 0.05). Furthermore, there was no significant volume reduction in both groups (LVA-group: 20.04 ± 196.40, p = 0.497, CDT: 33.98 ± 189.87, p = 0.236). In the LVA group, 41% partially of completely stopped wearing the compression garments after six months whereas in the CDT group 0% discontinued to use of compression garments. LVA resulted in improvement of the domains physical and mental function of the Lymph-ICF. Limb volume did not significantly improve after 6 months. However, around 42% could completely or partially stopped with the use of compression garments in the LVA group. The current results are promising, however longer follow up is required to assess long term effect of LVA for secondary lymphedema. Clinical Trial Registration: NCT02790021 registered on 03/06/2016.
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Affiliation(s)
- Y M J Jonis
- Department of Plastic, Reconstructive, and Hand Surgery, Maastricht University Medical Center, 6229HX, Maastricht, The Netherlands
| | - J A G N Wolfs
- Department of Plastic, Reconstructive, and Hand Surgery, Maastricht University Medical Center, 6229HX, Maastricht, The Netherlands
| | - S Hummelink
- Department of Plastic and Reconstructive Surgery, Radboud University Medical Center, 6500 HB, Nijmegen, The Netherlands
| | - H J P Tielemans
- Department of Plastic and Reconstructive Surgery, Radboud University Medical Center, 6500 HB, Nijmegen, The Netherlands
| | - X H A Keuter
- Department of Plastic, Reconstructive, and Hand Surgery, Maastricht University Medical Center, 6229HX, Maastricht, The Netherlands
| | - S van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center, Maastricht, The Netherlands
| | - D J O Ulrich
- Department of Plastic and Reconstructive Surgery, Radboud University Medical Center, 6500 HB, Nijmegen, The Netherlands
| | - R R W J van der Hulst
- Department of Plastic, Reconstructive, and Hand Surgery, Maastricht University Medical Center, 6229HX, Maastricht, The Netherlands
| | - S S Qiu
- Department of Plastic, Reconstructive, and Hand Surgery, Maastricht University Medical Center, 6229HX, Maastricht, The Netherlands.
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Iwao A, Ikari N, Higashi A, Moriuchi Y, Akashi R, Asabe K, Kashiyama K, Kitajima Y, Tanaka K. A case of inguinal lymphaticovenular anastomosis for refractory lymphatic ascites after uterine cancer surgery. Case Reports Plast Surg Hand Surg 2024; 11:2304617. [PMID: 38250331 PMCID: PMC10798289 DOI: 10.1080/23320885.2024.2304617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 01/08/2024] [Indexed: 01/23/2024]
Abstract
We herein report a case of refractory lymphatic ascites after uterine cancer surgery treated with bilateral inguinal lymphaticovenular anastomosis (LVA). LVA was performed four months after the uterine cancer surgery in a patient with refractory ascites that had developed one month after the gynecologic surgery. One year and eight months after LVA, there was no recurrence of ascites accumulation.
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Affiliation(s)
- Atsuhiko Iwao
- Department of Plastic and Reconstructive Surgery, Nagasaki University Hospital, Nagasaki, Japan
| | - Noriko Ikari
- Department of Plastic and Reconstructive Surgery, Nagasaki University Hospital, Nagasaki, Japan
| | - Akihito Higashi
- Department of Plastic and Reconstructive Surgery, Nagasaki University Hospital, Nagasaki, Japan
| | - Yuki Moriuchi
- Department of Plastic and Reconstructive Surgery, Nagasaki University Hospital, Nagasaki, Japan
| | - Rina Akashi
- Department of Plastic and Reconstructive Surgery, Nagasaki University Hospital, Nagasaki, Japan
| | - Koumei Asabe
- Department of Plastic and Reconstructive Surgery, Nagasaki University Hospital, Nagasaki, Japan
| | - Kazuya Kashiyama
- Department of Plastic and Reconstructive Surgery, Nagasaki University Hospital, Nagasaki, Japan
| | - Yuriko Kitajima
- Department of Obstetrics and Gynecology, Nagasaki University Hospital, Nagasaki, Japan
| | - Katsumi Tanaka
- Department of Plastic and Reconstructive Surgery, Nagasaki University Hospital, Nagasaki, Japan
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Shimbo K, Kawamoto H, Koshima I. Comparative study of conservative treatment and lymphaticovenular anastomosis with compression therapy for early-stage breast cancer-related lymphoedema. J Plast Reconstr Aesthet Surg 2024; 88:390-396. [PMID: 38086324 DOI: 10.1016/j.bjps.2023.11.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 11/11/2023] [Accepted: 11/22/2023] [Indexed: 01/02/2024]
Abstract
This single-centre retrospective cohort study aimed to clarify the superiority of treatment by comparing the outcomes of lymphaticovenular anastomosis with compression therapy and conservative treatment centred on compression therapy in the early stage of breast cancer-related lymphoedema. Data were collected from all patients treated for breast cancer-related lymphoedema between January 2015 and December 2022. The patients were classified into conservative treatment and surgical treatment groups. The upper extremity lymphoedema index value was calculated, based on five circumference values of the upper extremity and body mass index, to compare the 6-, 12-, 18- and 24-month outcomes between the groups. Of 101 patients with breast cancer-related lymphoedema, 81 (conservative treatment: 52; surgical treatment: 29) were included in the analysis. The therapeutic effect was significantly higher in the surgical treatment group than in the conservative treatment group, when comparing the rate of change in oedema at 6 (-6.6% ± 7.3% vs. 0.9% ± 7.5%; p < 0.001), 12 (-7.3% ± 6.2% vs. 2.9% ± 8.6%; p < 0.001), 18 (-7.6% ± 8.0% vs. 3.9% ± 9.2%; p < 0.001) and 24 (-5.6% ± 6.0% vs. 4.4% ± 10.7%; p < 0.001) months. The incidence of cellulitis increased in the conservative treatment group (from 9.6% to 15.4%), whereas it was suppressed in the surgical treatment group (from 13.8% to 0%). Conservative treatment centred on compression therapy increased oedema over time; however, lymphaticovenular anastomosis with compression therapy effectively reduced oedema.
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Affiliation(s)
- Keisuke Shimbo
- Department of Plastic and Reconstructive Surgery, Hiroshima Prefectural Hospital, Hiroshima, Japan.
| | - Haruka Kawamoto
- Department of Plastic and Reconstructive Surgery, Hiroshima Prefectural Hospital, Hiroshima, Japan.
| | - Isao Koshima
- Department of Plastic and Reconstructive Surgery, Hiroshima University Hospital, Hiroshima, Japan; International Center for Lymphedema, Hiroshima University Hospital, Hiroshima, Japan.
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17
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Karlsson T, Hoffner M, Ohlin K, Svensson B, Brorson H. Complete Reduction of Leg Lymphedema after Liposuction: A 5-Year Prospective Study in 67 Patients without Recurrence. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5429. [PMID: 38074499 PMCID: PMC10703118 DOI: 10.1097/gox.0000000000005429] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 10/05/2023] [Indexed: 09/07/2024]
Abstract
BACKGROUND Lymphedema leads to adipose tissue deposition that cannot be removed using conservative methods. Previous studies have shown a complete reduction in excess volume in limbs with lymphedema when treated with liposuction and controlled compression therapy (CCT). We present the long-term outcomes of all patients treated with liposuction and CCT for lower extremity lymphedema (LEL) who were followed up for 5 years. METHODS Sixty-seven LEL patients underwent liposuction and CCT. Thirty-six patients had primary lymphedema and 31 patients had secondary lymphedema. The outcomes included excess leg volume over a follow-up period of 5 years. Any association between patient characteristics and treatment outcomes was analyzed. RESULTS The preoperative excess volume prior was 3515 mL [interquartile range (IQR): 2225-5455 mL], and the volume ratio to the unaffected leg was 1.35 (IQR: 1.25-1.53). One year after treatment, the excess volume decreased by 101% (IQR: 84-116). The decrease in excess volume continued during the 5-year follow-up, and at the end of the study, the excess volume had decreased by 115% (IQR: 98-124). No major complications were noted. CONCLUSIONS Liposuction and CCT are safe and effective procedures for removing excess adipose tissue and normalizing the leg volume in patients with late-stage LEL. When no satisfactory results are obtained with conservative methods, such as complex decongestive therapy, and there is no or minimal pitting on limb examination, excess adipose tissue is present, and liposuction can be considered.
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Affiliation(s)
- Tobias Karlsson
- From the Department of Clinical Sciences, Malmö, Lund University, Lund, Sweden
- Australian Lymphoedema Education Research Treatment (ALERT) Program, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
- Department of Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, Sweden
| | - Mattias Hoffner
- From the Department of Clinical Sciences, Malmö, Lund University, Lund, 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
| | - Håkan Brorson
- From the Department of Clinical Sciences, Malmö, Lund University, Lund, Sweden
- Department of Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, Sweden
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Garza RM, Wong D, Chang DW. Optimizing Outcomes in Lymphedema Reconstruction. Plast Reconstr Surg 2023; 152:1131e-1142e. [PMID: 38019691 DOI: 10.1097/prs.0000000000010965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Describe current surgical techniques for treating primary and secondary lymphedema. 2. Optimize the surgical care of patients with lymphedema. SUMMARY Over the past decade, significant advances have been made in the surgical treatment of lymphedema. The most notable changes have been the reintroduction and evolution of physiologic techniques, including lymphovenous bypass-sometimes referred to as lymphovenous anastomosis in the literature-and vascularized lymph node transplant. These surgical modalities are now often used as first-line surgical options or may be combined with nonphysiologic approaches, including direct excision and suction-assisted lipectomy. Surgeons continue to debate the most appropriate sequence and combination of surgical treatment, particularly for patients at both extremes of the severity spectrum. Furthermore, debate remains around the need to apply different treatment approaches for patients with upper versus lower extremity involvement and primary versus secondary cause. In this article, we provide a summary of the surgical techniques currently used for both primary and secondary lymphedema and provide our recommendations for optimizing the surgical care of patients with lymphedema.
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Affiliation(s)
- Rebecca M Garza
- From the Section of Plastic and Reconstructive Surgery, Department of Surgery, The University of Chicago Medicine & Biological Sciences
| | - Daniel Wong
- From the Section of Plastic and Reconstructive Surgery, Department of Surgery, The University of Chicago Medicine & Biological Sciences
| | - David W Chang
- From the Section of Plastic and Reconstructive Surgery, Department of Surgery, The University of Chicago Medicine & Biological Sciences
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Maruccia M, Giudice G, Ciudad P, Manrique OJ, Cazzato G, Chen HC, Elia R. Lymph Node Transfer and Neolymphangiogenesis: From Theory to Evidence. Plast Reconstr Surg 2023; 152:904e-912e. [PMID: 36940155 DOI: 10.1097/prs.0000000000010434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2023]
Abstract
BACKGROUND Vascularized lymph node transfer (VLNT) has proven to be a valuable treatment for patients with advanced stages of lymphedema. Although spontaneous neolymphangiogenesis has been advocated to explain the positive effects of VLNT, there is still a lack of supportive biological evidence. The aim of this study was to demonstrate the postoperative formation of new lymphatic vessels using histologic skin sections from the lymphedematous limb. METHODS Patients with lymphedema of the extremities who had undergone gastroepiploic vascularized lymph node flap surgery between January of 2016 and December of 2018 were identified. Full-thickness 6-mm skin-punch biopsy specimens were obtained from patients at identical sites of the lymphedematous limb during the VLNT surgical procedure (T0) and 1 year later (T1). The histologic samples were immunostained with anti-podoplanin/gp36 antibody. RESULTS A total of 14 patients with lymph node transfer were included. At the 12-month follow-up, the mean circumference reduction rate was 44.3 ± 4.4 at the above-elbow/above-knee level and 60.9 ± 7 at the below-elbow/below-knee level. Podoplanin expression values were, on average, 7.92 ± 1.77 vessels/mm 2 at T0 and 11.79 ± 3.38 vessels/mm 2 at T1. The difference between preoperative and postoperative values was statistically significant ( P = 0.0008). CONCLUSION This study provides anatomic evidence that a neolymphangiogenic process is induced by the VLNT procedure because new functional lymphatic vessels can be detected in close proximity to the transferred lymph nodes. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Affiliation(s)
- Michele Maruccia
- From the Division of Plastic and Reconstructive Surgery, Department of Emergency and Organ Transplantation, University of Bari
| | - Giuseppe Giudice
- From the Division of Plastic and Reconstructive Surgery, Department of Emergency and Organ Transplantation, University of Bari
| | - Pedro Ciudad
- Department of Plastic, Reconstructive, and Burn Surgery, Arzobispo Loayza National Hospital
| | - Oscar J Manrique
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center
| | - Gerardo Cazzato
- Section of Pathology, Department of Emergency and Organ Transplantation, University of Bari "Aldo Moro"
| | - Hung-Chi Chen
- Department of Plastic Surgery, China Medical University Hospital
| | - Rossella Elia
- From the Division of Plastic and Reconstructive Surgery, Department of Emergency and Organ Transplantation, University of Bari
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20
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Shimbo K, Kawamoto H, Koshima I. Conservative treatment versus lymphaticovenular anastomosis for early-stage lower extremity lymphedema. J Vasc Surg Venous Lymphat Disord 2023; 11:1231-1240. [PMID: 37454902 DOI: 10.1016/j.jvsv.2023.06.013] [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: 03/28/2023] [Revised: 06/01/2023] [Accepted: 06/04/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVE Several options for the treatment of lower extremity lymphedema (LEL) can be broadly classified into conservative treatment, such as compression garments and decongestive lymphatic therapy, and surgical treatment, such as lymphaticovenular anastomosis (LVA). The purpose of our study was to clarify the superiority of these treatments by comparing the outcomes of LVA with those of conservative treatment for early-stage LEL. METHODS We performed a single-center, retrospective cohort study. The patients with LEL who presented to our department between January 2015 and December 2022 were identified and classified into two groups: conservative treatment and surgical treatment. The LEL indexes, calculated from the four lower extremity circumferences and the body mass index, were compared at the 6-, 12-, and 24-month follow-up between the two groups. RESULTS Of the 101 patients with LEL, 53 with 72 affected limbs (conservative treatment, 39 patients and 53 affected limbs; surgical treatment, 15 patients and 19 affected limbs) were included in the present analysis. The therapeutic effect for reducing edema, as determined by comparing the corrected LEL index at 12 months (103.7 ± 12.7 vs 91.9 ± 10.7; P = .005) and 24 months (103.1 ± 12.9 vs 83.8 ± 7.2; P < .001), was significantly higher in the surgical treatment group than that in the conservative treatment group. The conservative treatment group showed little change in the corrected LEL index at ≤24 months of follow-up (+3.1%; P = .299). In contrast, the surgical treatment group showed a significant reduction in edema at 24 months according to the corrected LEL index (-16.2%; P = .019). CONCLUSIONS In early-stage LEL, conservative treatment centered on compression therapy alone only maintained edema (ie, edema did not worsen or improve). In contrast, LVA with compression therapy reduced edema.
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Affiliation(s)
- Keisuke Shimbo
- Department of Plastic and Reconstructive Surgery, Hiroshima Prefectural Hospital, Hiroshima, Japan.
| | - Haruka Kawamoto
- Department of Plastic and Reconstructive Surgery, Hiroshima Prefectural Hospital, Hiroshima, Japan
| | - Isao Koshima
- Department of Plastic and Reconstructive Surgery, Hiroshima University Hospital, Hiroshima, Japan; International Center for Lymphedema, Hiroshima University Hospital, Hiroshima, Japan
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21
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Geyik SG, Demirdover C, Arican Alicikus LZ, Karabay N, Geyik A. Experimental Study of the Prevention and Treatment of Lymphoedema in a Rat Hindlimb Model by Applying Cardioperitoneal Catheters and Lacrimal Intubation Tubes in the Inguinoperitoneal Region. Eur J Vasc Endovasc Surg 2023; 66:587-596. [PMID: 37422208 DOI: 10.1016/j.ejvs.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 06/08/2023] [Accepted: 07/03/2023] [Indexed: 07/10/2023]
Abstract
OBJECTIVE Secondary lymphoedema (LE) is a chronic condition with limited surgical treatment options for restoring extremity form and function. This study aimed to establish a reproducible model of secondary LE and evaluate the preventive and corrective effects of fenestrated catheters (FC) and capillary tubes (CT). METHODS Thirty-five rats underwent left hindlimb inguinal and popliteal lymph node dissection, followed by radiotherapy after two weeks. The right hindlimb served as the control. The rats were divided into five groups: sham, two preventive (Group 2 - EFC, Group 3 - ECT), and two corrective (Group 4 - LFC, Group 5 - LCT). Measurements of ankle circumference (AC) and paw thickness (PT) were taken weekly, and imaging modalities were performed. After a 16 week follow up, rats were euthanised for histological examination. RESULTS Data include paw thickness (PT) and ankle circumference (AC) ratios for hindlimbs. In the sham group, AC ratio was 1.08 (p = .002) and PT ratio was 1.11 (p = .020), confirming successful lymphoedema model establishment. Early catheter and tube placement in Groups 2 and 3 prevented AC and PT increase until the 16th week. Group 2: the AC ratio was 0.98 (p = .93), and the PT ratio was 0.98 (p = .61). Group 3: the AC ratio was 0.98 (p = .94) and the PT ratio was 0.99 (p = .11). From the 10th to the 16th week, Groups 4 and 5 exhibited reduced measurements after insertion of catheters and tubes. Computed tomography imaging as an objective examination supported the results obtained from the measurements. The histological findings confirmed the benefits of both FC and CT. CONCLUSION The insights gained from the present study provide a basis for further exploration and refinement of drainage system designs, ultimately leading to improved treatment approaches for individuals suffering from lymphoedema in the future.
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Affiliation(s)
- Selin Guler Geyik
- Department of Plastic, Reconstructive, and Aesthetic Surgery of Dokuz Eylul University, Izmir, Turkey
| | - Cenk Demirdover
- Department of Plastic, Reconstructive, and Aesthetic Surgery of Dokuz Eylul University, Izmir, Turkey
| | | | - Nuri Karabay
- Department of Radiology of Dokuz Eylul University, Izmir, Turkey
| | - Alper Geyik
- Department of Plastic, Reconstructive, and Aesthetic Surgery of Dokuz Eylul University, Izmir, Turkey.
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Park JKH, Choi N, Beom J, Lim JY, Kang Y, Nam SY, Myung Y. Utilization of Noncontrast Magnetic Resonance Lymphangiography for Selection of Effective Surgical Method in Breast Cancer-Related Lymphedema. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1656. [PMID: 37763775 PMCID: PMC10537151 DOI: 10.3390/medicina59091656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 09/11/2023] [Accepted: 09/12/2023] [Indexed: 09/29/2023]
Abstract
Background and Objectives: When considering surgery for patients with breast cancer-related lymphedema (BCRL), it is crucial to determine which surgery will be most effective for the patient and establish the indications for each surgery. Our study retrospectively compared the results of preoperative noncontrast MR lymphangiography (NMRL) performed on the lymphedematous limb of patients before surgery, with the aim of analyzing whether preoperative NMRL can be used as a criterion for determining the type of surgery. Materials and Methods: From January 2020 to June 2022, a total of 138 patients with lymphedema underwent surgery at Seoul National University Bundang Hospital. All patients underwent preoperative NMRL imaging and were classified into stages 1-3 based on the MRI severity index using the authors' previous reference. Three types of surgery, LVA, LVA + liposuction, and LVA + VLNT, were conducted on all patients. The effectiveness of the surgery was evaluated one year postoperatively using the interlimb volume difference before and after surgery, the fluid volume of the edematous limb measured by bioimpedance spectroscopy, and the subjective satisfaction of the patients through the Lymph Q questionnaire. Results: In this study, out of a total of 138 patients, 26 (19%) were MRI stage 1, 62 (45%) were stage 2, and 50 (36%) were stage 3. Of the 83 patients who underwent LVA surgery, the greatest decrease in interlimb volume difference was observed in stage 2 patients, and subjective satisfaction was also the most effective in stage 2. In the case of LVA + liposuction patients, a significant volume decrease and a high satisfaction were observed in stage 3 patients. In the case of LVA + VLNT patients, there was no difference in volume decrease according to the stage, but a greater decrease in body fluid volume was observed as the MRI severity index score increased through BIA. Conclusions: In conclusion, this study demonstrates that NMRL imaging is a useful modality for determining the most effective surgical method and predicting the surgical outcome in patients with lymphedema. This highlights the importance of using NMRL in the treatment planning of lymphedema patients.
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Affiliation(s)
- Joseph Kyu-hyung Park
- Department of Plastic and Reconstructive Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 300 Gumi-dong, Bundang-gu, Seongnam 07061, Republic of Korea; (J.K.-h.P.)
| | - Nakwon Choi
- Department of Plastic and Reconstructive Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 300 Gumi-dong, Bundang-gu, Seongnam 07061, Republic of Korea; (J.K.-h.P.)
| | - Jaewon Beom
- Department of Rehabilitation Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam 07061, Republic of Korea
| | - Jae-Young Lim
- Department of Rehabilitation Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam 07061, Republic of Korea
| | - Yusuhn Kang
- Department of Radiology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam 07061, Republic of Korea
| | - Sun-Young Nam
- Department of Plastic and Reconstructive Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 300 Gumi-dong, Bundang-gu, Seongnam 07061, Republic of Korea; (J.K.-h.P.)
| | - Yujin Myung
- Department of Plastic and Reconstructive Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 300 Gumi-dong, Bundang-gu, Seongnam 07061, Republic of Korea; (J.K.-h.P.)
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Myung Y, Park JKH, Beom J, Lim JY, Park YS, Ahn SH, Kang E, Shin HC, Kim EK, Nam SY, Heo CY, Jeong JH. Outcome Analysis of Combined Surgical Approaches in Advanced-stage Upper Extremity Breast Cancer-related Lymphedema. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5237. [PMID: 37691707 PMCID: PMC10484372 DOI: 10.1097/gox.0000000000005237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 07/18/2023] [Indexed: 09/12/2023]
Abstract
Background This study aimed to discuss several surgical approaches for advanced-stage breast cancer-related lymphedema and compared their treatment outcomes. Methods The patients who underwent surgery with International Society of Lymphology stage III lymphedema were included in this study. The three surgical methods used here were (1) suction-assisted lipectomy with lymphovenous anastomosis, (2) autologous breast reconstruction with muscle-sparing transverse rectus abdominis muscle flap combined with inguinal lymph node transfer, and (3) vascularized lymph node transfer with free omental flap. Analysis of the postoperative outcomes in the patients was based on the difference in volume between patients pre- and postoperatively, LYMPH-Q questionnaire, and bioelectrical impedance analysis. Results Eighty-seven patients with stage IIb or higher disease underwent surgery. 38 patients underwent suction-assisted lipectomy + lymphovenous anastomosis, 23 underwent autologous breast reconstruction with vascularized lymph node transfer + lymphovenous anastomosis, and 26 underwent right gastroepiploic omental vascularized lymph node transfer with lymphovenous anastomosis. The LYMPH-Q questionnaire, which evaluates patients' subjective satisfaction, showed that the autologous breast reconstruction group showed the greatest improvement, whereas in bioimpedance analysis, the omental flap group demonstrated the greatest postoperative improvement compared with preoperative values. However, suction-assisted lipectomy was considered the most effective surgical method for reducing limb volume in patients with high-stage lymphedema accompanied by fibrosis and volume increase. Conclusions We observed slightly different clinical effects for each surgical method; however, all surgical methods demonstrated a reduction in the degree of edema and an increase in patient satisfaction.
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Affiliation(s)
- Yujin Myung
- From the Department of Plastic and Reconstructive Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Joseph Kyu-hyung Park
- From the Department of Plastic and Reconstructive Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jaewon Beom
- Department of Rehabilitation Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jae-Young Lim
- Department of Rehabilitation Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Young Suk Park
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Sang-Hoon Ahn
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Eunyoung Kang
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hee-Chul Shin
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Eun-Kyu Kim
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Sun-Young Nam
- From the Department of Plastic and Reconstructive Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Chan Yeong Heo
- From the Department of Plastic and Reconstructive Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jae Hoon Jeong
- From the Department of Plastic and Reconstructive Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
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Zhou X, Liu B, Guo X, Tang Y, Ma G. Application of indocyanine green lymphography combined with methylene blue staining in lymphaticovenular anastomosis of lower limb vessels: A prospective study. Phlebology 2023; 38:466-473. [PMID: 37339252 DOI: 10.1177/02683555231185449] [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: 06/22/2023]
Abstract
BACKGROUND Methylene blue (MB) is a conventional lymphatic tracer. We evaluated the application of indocyanine green (ICG) lymphography combined with MB staining in lower limb lymphaticovenular anastomosis (LVA). METHODS A total of 49 patients with lower limb lymphedema were selected as the study subjects and divided into the research (n = 27) and control groups (n = 22). The patients were treated with LVA using ICG lymphography combined with MB staining and simple ICG lymphography as the positioning method, respectively. The number of lymphatic vessels anastomosed and the operating time were compared between the groups. Lower Extremity Lymphedema Index (LEL index) and Lymphoedema Functioning, Disability and Health Questionnaire for Lower Limb Lymphoedema (Lymph-ICF-LL) were used as prognostic indices; 6 months after LVA, both groups were evaluated for the symptomatic relief of lymphedema. RESULTS The number of anastomotic lymphatic vessels in the study group was higher than that in the control group (p < .05), and their procedural time was shorter than that in the control group. The two groups had no significant difference in lymphatic anastomosis time (p > .05). The LEL index and Lymph-ICF-LL of the research and control groups at 6-month follow-up after LVA were lower than those before the operation (p < .05). CONCLUSION The circumference of the affected limb is reduced after LVA in patients with lower extremity lymphedema with a favorable prognosis. ICG lymphography combined with MB staining has the advantages of real-time visualization and accurate localization.
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Affiliation(s)
- Xuchuan Zhou
- Department of Burn, Plastic, and Cosmetic Surgery, Xi'an Central Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Bin Liu
- Department of Burn, Plastic, and Cosmetic Surgery, Xi'an Central Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Xiaowei Guo
- Department of Burn, Plastic, and Cosmetic Surgery, Xi'an Central Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Yueling Tang
- Department of Burn, Plastic, and Cosmetic Surgery, Xi'an Central Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Gejia Ma
- Department of Burn, Plastic, and Cosmetic Surgery, Xi'an Central Hospital, Xi'an Jiaotong University, Xi'an, China
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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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Cornely ME. Lymphological Liposculpture for Secondary Lymphedema after Breast Cancer and Gynecological Tumors: Long-Term Results after 15 Years. Arch Plast Surg 2023; 50:288-304. [PMID: 37256036 PMCID: PMC10226801 DOI: 10.1055/s-0043-1768943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 11/27/2022] [Indexed: 06/01/2023] Open
Abstract
Background Untreated lymphedema of an extremity leads to an increase in volume. The therapy of this condition can be conservative or surgical. Methods "Lymphological liposculpture" is a two-part procedure consisting of resection and conservative follow-up treatment to achieve curative volume adjustment of the extremities in secondary lymphedema. This treatment significantly reduces the need for complex decongestive therapy (CDT). From 2005 to 2020, 3,184 patients with secondary lymphedema after breast cancer and gynecological tumors were treated in our practice and clinic. "Lymphological liposculpture" was applied to 65 patients, and the data were recorded and evaluated by means of perometry and questionnaires. Results The alignment of the sick to the healthy side was achieved in all patients. In 58.42% ( n = 38), the CDT treatment could be completely stopped postoperatively; in another 33.82% ( n = 22) of the patients, a permanent reduction of the CDT was achieved. In 7.69% ( n = 5) patients, the postoperative CDT could not be reduced. A total of 92.30% ( n = 60) of the patients described a lasting significant improvement in their quality of life. Conclusion "Lymphological liposculpture" is a standardized curative sustainable procedure for secondary lymphedema for volume adjustment of the extremities and reduction of postoperative CDT with eminent improvement of the quality of life.
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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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Robotics in Plastic Surgery. CURRENT SURGERY REPORTS 2023. [DOI: 10.1007/s40137-022-00337-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
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Hong JP, Masoodi Z, Tzou CHJ. Attributes of a Good Microsurgeon-A Brief Counsel to the Up-and-Coming Prospects. Arch Plast Surg 2023; 50:130-140. [PMID: 36755651 PMCID: PMC9902200 DOI: 10.1055/s-0042-1759786] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 08/17/2022] [Indexed: 02/09/2023] Open
Abstract
Microsurgery, which deservedly sits on top of the reconstruction ladder, has been a boon to plastic surgery. It is because of this marvelous tool that plastic surgeons the world over have been able to tackle many reconstructive dilemmas, which were once considered to be an improbability. Microsurgery-aided revolutions have rendered a new meaning to all forms of reconstruction-whether it is postoncological, posttraumatic, or postlymphedema reconstruction. As the most advanced reconstructive medium at our disposal that has broadened the horizons of plastic surgery exponentially, it is but obvious that many budding plastic surgeons are drawn toward this subspecialty. In lieu of the aforementioned facts, it is necessary to sensitize all such aspiring surgeons about the various intricacies concerning the field of microsurgery. This article with its focus on the six desirable microsurgical attributes of "Clarity, Curiosity, Perseverance, Passion, An Open Mindset and Action," is meant to be a modest attempt on part of the authors to share their microsurgical insights, procured through their respective journeys, with budding aspirants, hoping to sensitize as well as motivate them for the challenging path that lies ahead.
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Affiliation(s)
- Joon Pio Hong
- Department of Plastic and Reconstructive Surgery, University of Ulsan College of Medicine and Asian Medical Center, Seoul, South Korea,Address for correspondence Joon Pio Hong, MD, PhD, MMM Division of Plastic and Reconstructive Surgery, Department of Plastic Surgery, Asan Medical Center, University of Ulsan88 Olympic-ro 43-gil, Songpa-gu, SeoulSouth Korea
| | - Zulqarnain Masoodi
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Hospital of Divine Savior, Vienna, Austria,Plastic Surgery Division, Florence Hospital, Srinagar, Jammu and Kashmir, India
| | - Chieh-Han John Tzou
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Hospital of Divine Savior, Vienna, Austria,Faculty of Medicine, Sigmund Freud University, Vienna, Austria,TZOU Medical, Vienna, Austria
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Cornely ME. Operative Lymphologie. Therapieoption bei Lymphödem und Lipohyperplasia dolorosa. J Dtsch Dermatol Ges 2023; 21:147-170. [PMID: 36808442 DOI: 10.1111/ddg.14974_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 11/15/2022] [Indexed: 02/22/2023]
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Intensive hands-on microsurgery course provides a solid foundation for performing clinical microvascular surgery. Eur J Trauma Emerg Surg 2023; 49:115-123. [PMID: 35831748 DOI: 10.1007/s00068-022-02040-8] [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: 05/18/2022] [Accepted: 06/26/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Microvascular surgery requires highly specialized and individualized training; most surgical residency training programs are not equipped with microsurgery teaching expertise and/or facilities. The aim of this manuscript was to describe the methodology and clinical effectiveness of an international microsurgery course, currently taught year-round in eight countries. METHODS In the 5-day microsurgery course trainees perform arterial and venous end-to-end, end-to-side, one-way-up, and continuous suture anastomoses and vein graft techniques in live animals, supported by video demonstrations and hands-on guidance by a full-time instructor. To assess and monitor each trainee's progress, the course's effectiveness is evaluated using "in-course" evaluations, and participant satisfaction and clinical relevance are assessed using a "post-course" survey. RESULTS Between 2007 and 2017, more than 600 trainees participated in the microsurgery course. "In-course" evaluations of patency rates revealed 80.3% (arterial) and 39% (venous) performed in end-to-end, 82.7% in end-to-side, 72.6% in continuous suture, and 89.5% (arterial) and 62.5% (venous) one-way-up anastomoses, and 58.1% in vein graft technique. "Post-course" survey results indicated that participants considered the most important components of the microcourse to be "practicing on live animals", followed by "the presence of a full-time instructor". In addition, almost all respondents indicated that they were more confident performing clinical microsurgery cases after completing the course. CONCLUSIONS Microvascular surgery requires highly specialized and individualized training to achieve the competences required to perform and master the delicate fine motor skills necessary to successfully handle and anastomose very small and delicate microvascular structures. The ever-expanding clinical applications of microvascular procedures has led to an increased demand for training opportunities. By teaching time-tested basic motor skills that form the foundation of microsurgical technique this international microsurgery-teaching course is helping to meet this demand.
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Cornely ME. Surgical lymphology. Therapy option for lymphoedema and lipohyperplasia dolorosa. J Dtsch Dermatol Ges 2023; 21:147-168. [PMID: 36808447 DOI: 10.1111/ddg.14974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 11/15/2022] [Indexed: 02/22/2023]
Abstract
The typical therapy in lymphology is conservative. However, reconstructive and resective treatments for primary and secondary lymphoedema as well as resective procedures for lipohyperplasia dolorosa (LiDo) "lipedema" have been available for several decades. Each of these procedures has its clear indication and decades of successful history. These therapies represent a paradigm shift in lymphology. In reconstruction, the basic idea is to restore lymph flow, to bypass the obstacle to drainage in the vascular system. The combination procedures of two-stage application of resection and reconstruction in lymphoedema are just as much a "work in progress" as the concept of prophylactic lymphatic venous anastomosis (LVA). In the case of resective procedures, the focus is not only on improving the silhouette, but also on reducing the complex decongestion therapy (CDT) and - in the case of LiDo - freedom from pain by improving imaging procedures and the early use of surgical therapy options, the development of higher stages of lymphoedema should be a thing of the past. For LiDo, the application of surgical procedures avoids lifelong CDT and achieves painlessness. All surgical procedures, but especially the resection procedures, are now possible in a way that is gentle on the lymphatic vessels and should be offered to patients with lymphoedema or lipohyperplasia dolorosa without reservation if the goals - reduction in circumference, avoidance of lifelong CDT and, in the case of LiDo, painlessness - cannot be achieved by other means.
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Lee CD, Kwiecien G, Wenzinger EJ, Lee I, Cakmakoglu C, Schwarz GS. Long-term efficacy of lymphovenous anastomosis for the treatment of retroperitoneal lymphangiectasia: A case report and a review of literature. Microsurgery 2023; 43:63-67. [PMID: 35014739 DOI: 10.1002/micr.30859] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 09/29/2021] [Accepted: 11/29/2021] [Indexed: 01/12/2023]
Abstract
Lymphovenous anastomosis (LVA) represents an alternative treatment for retroperitoneal lymphangiectasia. In contrast to sclerotherapy or excision, which may risk lymphatic obstruction and subsequent lymphedema, LVA preserves existing lymphatic architecture and transit. This report shows long-term efficacy of LVA for functional decompression of a symptomatic pathologically dilatated retroperitoneal lymphatics. A 47-year-old female with retroperitoneal lymphangiectasia refractory to multiple percutaneous drainages and treatments with sclerosing agents underwent LVA with anastomosis of a dominant segment of retroperitoneal lymphangiectasia to the deep inferior epigastric vein. Postoperative serial magnetic resonance imaging with 3-dimensional volume calculation over the 27 months follow-up showed evidence of decompression of the lesion with patent bypass. There were no known immediate complications nor requirement of further interventions. The patient's subjective pain also decreased substantially. This report confirms long-term efficacy of LVA for retroperitoneal lymphangiectasia as an alternative to sclerotherapy and surgical excision in the setting of previously failed treatments.
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Affiliation(s)
| | - Grzegorz Kwiecien
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Eric J Wenzinger
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Irene Lee
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Cagri Cakmakoglu
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Graham S Schwarz
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
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Lampejo AO, Ghavimi SAA, Hägerling R, Agarwal S, Murfee WL. Lymphatic/blood vessel plasticity: motivation for a future research area based on present and past observations. Am J Physiol Heart Circ Physiol 2023; 324:H109-H121. [PMID: 36459445 PMCID: PMC9829479 DOI: 10.1152/ajpheart.00612.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 11/23/2022] [Accepted: 11/23/2022] [Indexed: 12/04/2022]
Abstract
The lymphatic system plays a significant role in homeostasis and drainage of excess fluid back into venous circulation. Lymphatics are also associated with a number of diseases including lymphedema, tumor metastasis, and various lymphatic malformations. Emerging evidence suggests that lymphatics might have a bigger connection to the blood vascular system than originally presumed. As these two systems are often studied in isolation, several knowledge gaps exist surrounding what constitutes lymphatic vascular plasticity, under what conditions it arises, and where structures characteristic of plasticity can form. The objective of this review is to overview current structural, cell lineage-based, and cell identity-based evidence for lymphatic plasticity. These examples of plasticity will then be considered in the context of potential clinical and surgical implications of this evolving research area. This review details our current understanding of lymphatic plasticity, highlights key unanswered questions in the field, and motivates future research aimed at clarifying the role and therapeutic potential of lymphatic plasticity in disease.
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Affiliation(s)
- Arinola O Lampejo
- J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, Florida
| | | | - René Hägerling
- Institute of Medical and Human Genetics, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Berlin Institute of Health Center for Regenerative Therapies, Berlin Institute of Health at Charité-Universitätsmedizin Berlin, Berlin, Germany
- Clinician Scientist Program, Berlin Institute of Health Academy, Berlin Institute of Health at Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Shailesh Agarwal
- Division of Plastic and Reconstructive Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Walter L Murfee
- J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, Florida
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Watanabe S, Kajita H, Suzuki Y, Urano M, Otaki M, Sakuma H, Imanishi N, Tsuji T, Jinzaki M, Kishi K. Photoacoustic lymphangiography is a possible alternative for lymphedema staging. J Vasc Surg Venous Lymphat Disord 2022; 10:1318-1324.e2. [PMID: 35995329 DOI: 10.1016/j.jvsv.2022.07.012] [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: 01/26/2022] [Revised: 07/08/2022] [Accepted: 07/18/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Photoacoustic imaging is a new technique that uses the photoacoustic effect. In photoacoustic lymphangiography (PAL), images of the lymphatic vessels can be visualized using light-absorbing contrast agents. In the present study, we investigated the efficacy of PAL for lymphedema staging. METHODS We performed PAL of the lower extremities and examined the clinical implications of using PAL for staging lymphedema by comparing the PAL images with those obtained using lymphoscintigraphy. Of 47 patients with lymphedema who had been outpatients or hospitalized at our institution between May 2018 and September 2020 and had undergone PAL, 15 with 18 limbs who had also undergone lymphoscintigraphy were included in the present study. The lymphoscintigraphy findings were classified using the Maegawa classification. We also investigated whether PAL could clearly visualize the lymphatic vessels and concisely reflect the disease state by counting the number of lymphatic vessels observed using PAL. RESULTS The PAL findings were categorized into three groups: collecting lymphatic vessels, dermal backflow (DBF), and no lymphatic vessels. The collecting lymphatic vessels group corresponded to types 2 and 3 in the Maegawa classification; DBF corresponded to types 3 and 4, and the no lymphatic vessels group corresponded to type 4. The number of lymphatic vessels visualized using PAL was similar to that with lymphoscintigraphy. As the disease progressed, the number of lymphatic vessels observed decreased, increased DBF was detected, and, eventually, the lymphatic vessels were not visible, corresponding to the general changes observed via lymphoscintigraphy with stage progression. CONCLUSIONS The findings from PAL and lymphoscintigraphy tended to correspond, suggesting that PAL could be useful for lymphedema staging.
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Affiliation(s)
- Shiho Watanabe
- Department of Plastic and Reconstructive Surgery, Keio University School of Medicine, Tokyo, Japan.
| | - Hiroki Kajita
- Department of Plastic and Reconstructive Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yushi Suzuki
- Department of Plastic and Reconstructive Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Moemi Urano
- Department of Anatomy, Keio University School of Medicine, Tokyo, Japan
| | - Marika Otaki
- Department of Plastic and Reconstructive Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Hisashi Sakuma
- Department of Plastic and Reconstructive Surgery, Tokyo Dental College Ichikawa General Hospital, Chiba, Japan
| | - Nobuaki Imanishi
- Department of Anatomy, Keio University School of Medicine, Tokyo, Japan
| | - Tetsuya Tsuji
- Department of Rehabilitation Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Masahiro Jinzaki
- Department of Radiology, Keio University School of Medicine, Tokyo, Japan
| | - Kazuo Kishi
- Department of Plastic and Reconstructive Surgery, Keio University School of Medicine, Tokyo, Japan
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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: 6] [Impact Index Per Article: 3.0] [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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Brown S, Mehrara BJ, Coriddi M, McGrath L, Cavalli M, Dayan JH. A Prospective Study on the Safety and Efficacy of Vascularized Lymph Node Transplant. Ann Surg 2022; 276:635-653. [PMID: 35837897 PMCID: PMC9463125 DOI: 10.1097/sla.0000000000005591] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE While vascularized lymph node transplant (VLNT) has gained popularity, there are a lack of prospective long-term studies and standardized outcomes. The purpose of this study was to evaluate the safety and efficacy of VLNT using all available outcome measures. METHODS This was a prospective study on all consecutive patients who underwent VLNT. Outcomes were assessed with 2 patient-reported outcome metrics, limb volume, bioimpedance, need for compression, and incidence of cellulitis. RESULTS There were 89 patients with the following donor sites: omentum (73%), axilla (13%), supraclavicular (7%), groin (3.5%). The mean follow-up was 23.7±12 months. There was a significant improvement at 2 years postoperatively across all outcome measures: 28.4% improvement in the Lymphedema Life Impact Scale, 20% average reduction in limb volume, 27.5% improvement in bioimpedance score, 93% reduction in cellulitis, and 34% of patients no longer required compression. Complications were transient and low without any donor site lymphedema. CONCLUSIONS VLNT is a safe and effective treatment for lymphedema with significant benefits fully manifesting at 2 years postoperatively. Omentum does not have any donor site lymphedema risk making it an attractive first choice.
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Affiliation(s)
- Stav Brown
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
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Nia ES, Patel MM, Chang EI, Legha RS, Kapoor MM. The Post-Operative Mammographic Appearance of Lymphovenous Bypass and Vascularized Lymph Node Transfer. Radiol Case Rep 2022; 17:3760-3762. [PMID: 35965918 PMCID: PMC9363951 DOI: 10.1016/j.radcr.2022.07.069] [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: 06/19/2022] [Accepted: 07/14/2022] [Indexed: 11/17/2022] Open
Abstract
The postoperative mammographic imaging appearance related to lymphovenous bypass and vascularized lymph node transfer has not been described. It is important for breast imagers to become familiar with the expected appearance of surgical changes that can be seen in the follow up imaging of breast cancer survivors in order to create accurate reports and adjust imaging protocols to improve imaging quality and lessen patient discomfort as needed.
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Affiliation(s)
- Emily S. Nia
- Department of Breast Imaging, M.D. Anderson Cancer Center, Houston, TX, USA
- Corresponding author.
| | - Miral M. Patel
- Department of Breast Imaging, M.D. Anderson Cancer Center, Houston, TX, USA
| | - Edward I. Chang
- Department of Plastic Surgery, M.D. Anderson Cancer Center, Houston, TX, USA
| | - Ravinder S. Legha
- Department of Breast Imaging, M.D. Anderson Cancer Center, Houston, TX, USA
| | - Megha M. Kapoor
- Department of Breast Imaging, M.D. Anderson Cancer Center, Houston, TX, USA
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Knackstedt R, Chen WF. Current Concepts in Surgical Management of Lymphedema. Phys Med Rehabil Clin N Am 2022; 33:885-899. [DOI: 10.1016/j.pmr.2022.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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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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Imai H, Yoshida S, Mese T, Roh S, Fujita A, Sasaki A, Nagamatsu S, Koshima I. Correlation between Lymphatic Surgery Outcome and Lymphatic Image-Staging or Clinical Severity in Patients with Lymphedema. J Clin Med 2022; 11:jcm11174979. [PMID: 36078909 PMCID: PMC9456713 DOI: 10.3390/jcm11174979] [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: 07/21/2022] [Revised: 08/12/2022] [Accepted: 08/23/2022] [Indexed: 11/16/2022] Open
Abstract
Lymphoscintigraphy and indocyanine green (ICG) lymphography reveal the severity of extremity lymphedema. Lower extremity lymphedema (LEL) index and NECST classification are related to the clinical severity of lymphedema. We aimed to investigate the correlation between lymphatic surgery, lymphatic imaging, and clinical severity in patients with lymphedema. Thirty-five patients with lower-extremity lymphedema who underwent lymphatic venous anastomosis (LVA) were evaluated. Ten of the thirty-five patients underwent multi-surgery (additional vascularized lymphatic transfer and/or liposuction). We investigated the correlation between the LEL index, NECST classification, lymphoscintigraphy staging, ICG lymphography staging, and rate of improvement (RI: [preoperative LEL index − postoperative LEL index]/[preoperative LEL index] × 100). The LEL index in 35 patients after LVA and all procedures decreased significantly compared to that of preoperative (272.4 vs. 256.2 vs. 243.5, p < 0.05). RI after LVA and all procedures showed positive correlations with the preoperative LEL index; however, there was no correlation with any other lymphatic image or clinical severity. LVA can reduce lymphedema circumference at any stage. Additional surgery improved the circumference. Hence, LVA as the first line of treatment, and vascularized lymphatic transfer and liposuction as additional procedures, should be considered as the standard treatment for lymphedema.
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Affiliation(s)
- Hirofumi Imai
- International Center for Lymphedema, Hiroshima University Hospital, Hiroshima 734-8551, Japan
- Correspondence: ; Tel.: +81-82-257-5555
| | - Shuhei Yoshida
- International Center for Lymphedema, Hiroshima University Hospital, Hiroshima 734-8551, Japan
| | - Toshiro Mese
- International Center for Lymphedema, Hiroshima University Hospital, Hiroshima 734-8551, Japan
| | - Solji Roh
- International Center for Lymphedema, Hiroshima University Hospital, Hiroshima 734-8551, Japan
| | - Asuka Fujita
- Plastic and Reconstructive Surgery, Hiroshima University Hospital, Hiroshima 734-8551, Japan
| | - Ayano Sasaki
- Plastic and Reconstructive Surgery, Hiroshima University Hospital, Hiroshima 734-8551, Japan
| | - Shogo Nagamatsu
- Plastic and Reconstructive Surgery, Hiroshima University Hospital, Hiroshima 734-8551, Japan
| | - Isao Koshima
- International Center for Lymphedema, Hiroshima University Hospital, Hiroshima 734-8551, Japan
- Plastic and Reconstructive Surgery, Hiroshima University Hospital, Hiroshima 734-8551, Japan
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Lee S, Lee DG, Kim KT. Temporal Changes in Subcutaneous Fibrosis in Patients with Lower Extremity Lymphedema Following Surgery for Gynecologic Cancer: A Computed Tomography-Based Quantitative Analysis. Diagnostics (Basel) 2022; 12:diagnostics12081949. [PMID: 36010297 PMCID: PMC9406798 DOI: 10.3390/diagnostics12081949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 08/11/2022] [Accepted: 08/11/2022] [Indexed: 11/16/2022] Open
Abstract
Lymphedema causes inflammation, which provokes fibrosis within the epifascial tissue. Temporal change in fibrosis according to severity of the lymphedema has not been widely investigated. We aimed to study the quantitative changes in epifascial fibrosis during lymphedema treatment using computed tomography (CT). Forty-five patients (mean age: 57.75 ± 11.12 years) who developed lymphedema following gynecologic surgery were included in this retrospective study. Two weeks of complete decongestive therapy and continued self-bandaging or compression garments were prescribed under regular follow-up monitoring. Lower-extremity epifascial fibrosis was quantitatively analyzed on the initial and follow-up CT scans. Circumference, skin fibrosis, subcutaneous tissue, and fibrosis ratio were calculated in the axial scan. Based on the change in lymphedema severity, we divided subjects into ‘improved’ and ‘aggravated’ groups. The affected lower extremities showed higher circumference, more skin fibrosis and subcutaneous tissue, and higher fibrosis ratio than the unaffected sides on initial CT scan. At follow-up, compared to the aggravated group, the improved group showed significant decreases in fibrosis of skin and subcutaneous tissue and fibrosis ratio. Subcutaneous fibrosis was reversible with volume resolution of lymphedema. Therapeutic approaches should be established on the basis of the reversible nature of fibrotic changes in patients with lower extremity lymphedema.
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Affiliation(s)
- Soyoung Lee
- Department of Rehabilitation Medicine, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu 42601, Korea
| | - Dong Gyu Lee
- Department of Physical Medicine and Rehabilitation, Yeungnam University College of Medicine, Daegu 42415, Korea
| | - Kyoung Tae Kim
- Department of Rehabilitation Medicine, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu 42601, Korea
- Correspondence: ; Tel.: +82-53-258-7692
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Yang CY, Tinhofer IE, Nguyen D, Cheng MH. Enhancing lymphangiogenesis and lymphatic drainage to vascularized lymph nodes with nanofibrillar collagen scaffolds. J Surg Oncol 2022; 126:1169-1175. [PMID: 35950942 DOI: 10.1002/jso.27058] [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: 05/17/2022] [Revised: 07/12/2022] [Accepted: 08/01/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND This study investigated the effect of nanofibrillar collagen scaffold (BioBridge) implantation from the affected limb to the unaffected contralateral femoral vein or lymph node in a rat model. METHODS Hind limb lymphedema in Lewis rats was created with lymphadenectomy and inguinal circumcision without radiation. The volumetric difference (greater than 5%) using computed tomography and indocyanine green fluorescence evaluated the progress of lymphedema at 4 weeks. The lymphedema rats have separated into Group I: Controls; Group II: implanted BioBridge to the contralateral femoral vein; and Group III: implanted BioBridge to the contralateral inguinal lymph node. RESULTS A total of 14 of 30 (46.7%) rats developed hind limb lymphedema with a mean volume difference of 5.83 ± 0.99% and showed diffuse dermal backflow at 4 weeks postlymphadenectomy. Four weeks postimplantation of BioBridge, the mean volumetric difference was 5.62 ± 2.11%, 4.97 ± 0.59%, and -2.47 ± 2.37% in Group I, II, and III, respectively (p < 0.05). The dermal backflow on the affected limb increased in Groups I and II but decreased in Group III. CONCLUSIONS Implantation of BioBridge from the affected limb to the contralateral inguinal lymph node significantly reduced the hind limb lymphedema at 4 weeks.
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Affiliation(s)
- Chin-Yu Yang
- Center for Tissue Engineering, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Ines E Tinhofer
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Hospital of Divine Savior, Vienna, Austria
| | - Dung Nguyen
- Division of Plastic and Reconstructive Surgery, Stanford University, Palo Alto, California, USA
| | - Ming-Huei Cheng
- Center for Tissue Engineering, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University and Medical College, Taoyuan, Taiwan.,Section of Plastic Surgery, Department of Surgery, The University of Michigan, Ann Arbor, Michigan, USA
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Zhang YD, Zhang X, Wang XY, Han DM, Du JS. Visual analysis of global research output of lymphedema based on bibliometrics. Front Oncol 2022; 12:926237. [PMID: 35992843 PMCID: PMC9389543 DOI: 10.3389/fonc.2022.926237] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 06/29/2022] [Indexed: 11/13/2022] Open
Abstract
Background Globally, several generations of doctors in the field of lymphedema have created numerous publications. To date, no bibliometric analysis has been performed specifically on these publications. For the further promotion of research on lymphedema and to align with the international research frontiers, it is essential to understand the current state of Lymphedema research output. Objective This study aims to statistically and visually analyze the characteristics of publications output, distribution of contributions and development process of lymphedema, enriching the knowledge base of Lymphedema, and then seek potential research topics and collaborators. Methods Based on the Web of Science core collection database, we firstly analyzed the quantity and quality of publications in the field of lymphedema, secondly profiled the publishing groups in terms of country, institution, author's publication and cooperation network, and finally sorted out and summarized the hot topics of research. Results A total of 8569 papers were retrieved from 1900-2021. The top4 journals with the most publications were LYMPHOLOGY, LYMPHATIC RESEARCH AND BIOLOGY, PLASTIC AND RECONSTRUCTIVE SURGERY and ANNALS OF SURGICAL ONCOLOGY. The top 4 countries with the most publications were USA, Japan, UK, and China. The United States dominates the total number of publications and the international cooperation network. The most productive research institution is Harvard University, and the research institution with the most collaborating institutions is Memorial Sloan Kettering Cancer Center. Mortimer, Peter S contributes the most research in this field. The research achievements of Japanese scholars in this field are of great significance. The top 5 ranked keywords are "Breast Cancer", "Health-Related Quality Of Life", "Lymphscintigraphy", "Lymphovenous Anastomosis", and "Lymphangiogenesis". Conclusion More and more scholars are devoted to the research of cancer-related Lymphedema. It is foreseeable that breast cancer-related lymphedema and lymphangiogenesis will remain a focus of future research. Advances in Lymphatic vessel imaging and the development of lymphatic microsurgery will further play a role in the clinical workup of lymphedema. Meanwhile, This study can help researchers identify potential collaborators and partner institutions and contribute to further research.
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Affiliation(s)
- Yun-dong Zhang
- Department of the Lymphatic and Vascular Surgery, China-Japan Union Hospital of Jilin University, Changchun, China
- Key Laboratory of Lymphatic Surgery Jilin Province, Engineering Laboratory of Lymphatic Surgery, Changchun, China
| | - Xue Zhang
- Chengdu Library and Information Center, Chinese Academy of Sciences, Chengdu, China
- Department of Library, Information and Archives Management, School of Economics and Management, University of Chinese Academy of Sciences, Beijing, China
| | - Xin-yu Wang
- Department of the Lymphatic and Vascular Surgery, China-Japan Union Hospital of Jilin University, Changchun, China
- Key Laboratory of Lymphatic Surgery Jilin Province, Engineering Laboratory of Lymphatic Surgery, Changchun, China
| | - Dong-mei Han
- Department of the Lymphatic and Vascular Surgery, China-Japan Union Hospital of Jilin University, Changchun, China
- Key Laboratory of Lymphatic Surgery Jilin Province, Engineering Laboratory of Lymphatic Surgery, Changchun, China
| | - Jian-shi Du
- Department of the Lymphatic and Vascular Surgery, China-Japan Union Hospital of Jilin University, Changchun, China
- Key Laboratory of Lymphatic Surgery Jilin Province, Engineering Laboratory of Lymphatic Surgery, Changchun, China
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Surgical Treatment and Rehabilitation Strategies for Upper and Lower Extremity Lymphedema: A Comprehensive Review. Medicina (B Aires) 2022; 58:medicina58070954. [PMID: 35888673 PMCID: PMC9324426 DOI: 10.3390/medicina58070954] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 07/10/2022] [Accepted: 07/15/2022] [Indexed: 02/07/2023] Open
Abstract
Lymphedema is a chronic disabling condition affecting a growing number of patients worldwide. Although lymphedema is not life-threatening, several reports underlined detrimental consequences in terms of distress, pain, functional impairment, and infections with a relevant decrease in quality of life. Currently, there is no cure, and the therapeutic management of this condition aims at slowing down the disease progression and preventing secondary complications. Early diagnosis is paramount to enhance the effects of rehabilitation or surgical treatments. On the other hand, a multidisciplinary treatment should be truly integrated, the combination of microsurgical and reductive procedures should be considered a valid strategy to manage extremity lymphedema, and rehabilitation should be considered the cornerstone of the multidisciplinary treatment not only for patients not suitable for surgical interventions but also before and after surgical procedures. Therefore, a specialized management of Plastic Reconstructive Surgeons and Physical and Rehabilitative Medicine physicians should be mandatory to address patients’ needs and optimize the treatment of this disabling and detrimental condition. Therefore, the aim of this review was to characterize the comprehensive management of lymphedema, providing a broad overview of the potential therapy available in the current literature to optimize the comprehensive management of lymphedema and minimize complications.
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Kim Y, Kim HB, Pak CJ, Suh HP, Hong JP. Using Lymphovenous Anastomosis and Lymph Node to Vein Anastomosis for Treatment of Posttraumatic Chylothorax with Increased Thoracic Duct Pressure in 3-Year-Old Child. Arch Plast Surg 2022; 49:549-553. [PMID: 35919557 PMCID: PMC9340176 DOI: 10.1055/s-0042-1751026] [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] [Indexed: 11/07/2022] Open
Abstract
Chylothorax is a rare disease and massive lymph fluid loss can cause life-threatening condition such as severe malnutrition, weight loss, and impaired immune system. If untreated, mortality rate of chylothorax can be up to 50%. This is a case report of a 3-year-old child with iatrogenic chylothorax. Despite conservative treatment and procedures, like perm catheter insertion, the patient failed to improve the respiratory symptoms over 3 months of period. As an alternative to surgical option, such as pleurodesis and thoracic duct ligation which has high complication rate, the patient underwent lymphovenous anastomosis (LVA) and lymph node to vein anastomosis (LNVA). Follow-up at fourth month showed clear lungs without breathing difficulty despite perm catheter removal. This is the first report to show the effectiveness of LVA and LNVA against iatrogenic chylothorax.
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Affiliation(s)
- Yeongsong Kim
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Korea
| | - Hyung B Kim
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Korea
| | - Changsik J Pak
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Korea
| | - Hyunsuk P Suh
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Korea
| | - Joon P Hong
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Korea
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Cook JA, Sinha M, Lester M, Fisher CS, Sen CK, Hassanein AH. Immediate Lymphatic Reconstruction to Prevent Breast Cancer-Related Lymphedema: A Systematic Review. Adv Wound Care (New Rochelle) 2022; 11:382-391. [PMID: 34714158 DOI: 10.1089/wound.2021.0056] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Significance: Lymphedema is chronic limb swelling from lymphatic dysfunction. The condition affects up to 250 million people worldwide. In breast cancer patients, lymphedema occurs in 30% who undergo axillary lymph node dissection (ALND). Recent Advances: Immediate lymphatic reconstruction (ILR), also termed Lymphatic Microsurgical Preventing Healing Approach (LyMPHA), is a method to decrease the risk of lymphedema by performing prophylactic lymphovenous anastomoses at the time of ALND. The objective of this study is to assess the risk reduction of ILR in preventing lymphedema. Critical Issues: Lymphedema has significant effects on the quality of life and morbidity of patients. Several techniques have been described to manage lymphedema after development, but prophylactic treatment of lymphedema with ILR may decrease risk of development to 6.6%. Future Directions: Long-term studies that demonstrate efficacy of ILR may allow for prophylactic management of lymphedema in the patient undergoing lymph node dissection.
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Affiliation(s)
- Julia A. Cook
- Division of Plastic Surgery; Indianapolis, Indiana, USA
| | - Mithun Sinha
- Division of Plastic Surgery; Indianapolis, Indiana, USA
- Indiana Center for Regenerative Medicine, Department of Surgery; Indianapolis, Indiana, USA
| | - Mary Lester
- Division of Plastic Surgery; Indianapolis, Indiana, USA
| | - Carla S. Fisher
- Division of Surgical Oncology; Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Chandan K. Sen
- Division of Plastic Surgery; Indianapolis, Indiana, USA
- Indiana Center for Regenerative Medicine, Department of Surgery; Indianapolis, Indiana, USA
| | - Aladdin H. Hassanein
- Division of Plastic Surgery; Indianapolis, Indiana, USA
- Indiana Center for Regenerative Medicine, Department of Surgery; Indianapolis, Indiana, USA
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A meta-analysis of 37 studies on the effectiveness of microsurgical techniques for lymphedema. Ann Vasc Surg 2022; 86:440-451.e6. [PMID: 35589027 DOI: 10.1016/j.avsg.2022.04.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 03/03/2022] [Accepted: 04/24/2022] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Microsurgery is a new technique for lymphedema treatment. Its advantages and disadvantages remain controversial. This study sought to collect clinical data from patients who underwent lymphovenous bypass and vascularized lymph node transplantation to explore whether surgical procedures can effectively treat lymphedema. METHODS We performed a meta-analysis of the effectiveness of lymphatic microsurgery. We searched the databases of literature for articles in Chinese and English. These articles were graded for quality. Report details and outcomes were recorded. Data extraction, systematic review, and meta-analysis were performed. RESULTS Thirty-seven studies were included. Patients who underwent microsurgery had a significantly better chance of achieving an excellent result than patients who received conservative treatment (odds ratio=7.07). The affected limb circumference was reduced by approximately 44.68% after the microsurgery. After the microsurgery, 63% of the patients did not need physiotherapy, and 96% were free from painful skin infections. Lymphography showed that lymphatic transport capacity was enhanced. Moreover, 12% of the patients reported that edema reappeared in the long-term, 26% required reoperation for unsatisfactory results, and 32% experienced lymphatic leakage. CONCLUSIONS A vast majority of patients derive more benefit from lymphatic microsurgery than from conventional treatment. The advantages of lymphatic microsurgery outweigh the disadvantages for patients in the early and middle stages of chronic secondary lymphedema and patients in whom conventional treatment failed.
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Winters H, Tielemans H, Hummelink S, Slater N, Ulrich D. DIEP flap breast reconstruction combined with vascularized lymph node transfer for patients with breast cancer-related lymphedema. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2022; 48:1718-1722. [DOI: 10.1016/j.ejso.2022.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Revised: 05/06/2022] [Accepted: 05/09/2022] [Indexed: 11/29/2022]
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Treatment of Early-Stage Gynecological Cancer-Related Lower Limb Lymphedema by Lymphaticovenular Anastomosis-The Triple Incision Approach. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58050631. [PMID: 35630048 PMCID: PMC9143574 DOI: 10.3390/medicina58050631] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 04/23/2022] [Accepted: 04/26/2022] [Indexed: 11/17/2022]
Abstract
Background and Objectives: Lower extremity lymphedema (LEL) is one of the most relevant chronic and disabling sequelae after gynecological cancer therapy involving pelvic lymphadenectomy (PL). Supermicrosurgical lymphaticovenular anastomosis (LVA) is a safe and effective procedure to treat LEL, particularly indicated in early-stage cases when conservative therapies are insufficient to control the swelling. Usually, preoperative assessment of these patients shows patent and peristaltic lymphatic vessels that can be mapped throughout the limb to plan the sites of skin incision to perform LVA. The aim of this study is to report the efficacy of our approach based on planning LVA in three areas of the lower limb in improving early-stage gynecological cancer-related lymphedema (GCRL) secondary to PL. Materials and Methods: We retrospectively reviewed the data of patients who underwent LVA for the treatment of early-stage GCRL following PL. Patients who had undergone groin dissection were excluded. Our preoperative study based on indocyanine green lymphography (ICG-L) and color doppler ultrasound (CDU) planned three incision sites located in the groin, in the medial surface of the distal third of the thigh, and in the upper half of the leg, to perform LVA. The primary outcome measure was the variation of the mean circumference of the limb after surgery. The changes between preoperative and postoperative limbs’ measures were analyzed by Student’s t-test. p values < 0.05 were considered significant. Results: Thirty-three patients were included. In every patient, three incision sites were employed to perform LVA. A total of 119 LVA were established, with an average of 3.6 for each patient. The mean circumference of the operated limb showed a significant reduction after surgery, decreasing from 37 cm ± 4.1 cm to 36.1 cm ± 4.4 (p < 0.01). Conclusions: Our results suggest that in patients affected by early-stage GCRL secondary to PL, the placement of incision sites in all the anatomical subunits of the lower limb is one of the key factors in achieving good results after LVA.
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