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Campos JL, Pons G, Al-Sakkaf AM, Lusetti IL, Pires L, Vela FJ, Ramos E, Crisóstomo V, Sánchez-Margallo FM, Abellán E, Masiá J. Lymphatic Regeneration after Popliteal Lymph Node Excision and Implantation of Aligned Nanofibrillar Collagen Scaffolds: An Experimental Rabbit Model. J Funct Biomater 2024; 15:235. [PMID: 39194673 DOI: 10.3390/jfb15080235] [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] [Received: 07/07/2024] [Revised: 08/11/2024] [Accepted: 08/21/2024] [Indexed: 08/29/2024] Open
Abstract
Lymphedema presents significant challenges to patients' quality of life, prompting the exploration of innovative treatments, such as collagen scaffolds, aimed at treating and reducing the risk of lymphedema. We aimed to evaluate the preventive and therapeutic efficacy and the lymphangiogenic potential of implanted aligned nanofibrillar collagen scaffolds (BioBridgeTM) following the induction of secondary lymphedema in a rabbit model. Thirty rabbits were divided into treatment (G1), prevention (G2), and control (G3) groups. Secondary lymphedema was induced in all groups. BioBridgeTM implantation was performed in G2 and G1 on days 0 and 60, respectively. Follow-ups included hindlimb circumference measurements and indocyanine green lymphography at 0, 60, and 90 days. None of the study rabbits exhibited dermal backflow on day 0 before surgery. At 60 days, the incidence rates of dermal backflow in G1, G2, and G3 were 100%, 44.4%, and 90%, respectively. Furthermore, at 90 days, the incidence rates were 22.2%, 44.4%, and 90%, respectively. New linear lymphatic observation was seen in rabbits with resolved dermal backflow. The findings of this study demonstrated the capacity of BioBridgeTM scaffolds to induce new lymphatic vessel formation and reduce dermal backflow in secondary lymphedema in a rabbit model.
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Affiliation(s)
- José Luis Campos
- Department of Microsurgery, Jesús Usón Minimally Invasive Surgery Centre, 10071 Cáceres, Spain
| | - Gemma Pons
- Department of Plastic Surgery, Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain
| | - Ali M Al-Sakkaf
- Department of Plastic Surgery, Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain
| | - Irene Laura Lusetti
- Department of Plastic Surgery, Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain
| | - Laura Pires
- Department of Microsurgery, Jesús Usón Minimally Invasive Surgery Centre, 10071 Cáceres, Spain
| | - Francisco Javier Vela
- Department of Microsurgery, Jesús Usón Minimally Invasive Surgery Centre, 10071 Cáceres, Spain
| | - Elena Ramos
- Department of Microsurgery, Jesús Usón Minimally Invasive Surgery Centre, 10071 Cáceres, Spain
| | - Verónica Crisóstomo
- Jesús Usón Minimally Invasive Surgery Centre, 10071 Cáceres, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Francisco Miguel Sánchez-Margallo
- Jesús Usón Minimally Invasive Surgery Centre, 10071 Cáceres, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Elena Abellán
- Department of Microsurgery, Jesús Usón Minimally Invasive Surgery Centre, 10071 Cáceres, Spain
| | - Jaume Masiá
- Department of Plastic Surgery, Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain
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Tartaglione G. Advantages of the intradermal lymphoscintigraphy. World J Radiol 2024; 16:241-246. [PMID: 39086608 PMCID: PMC11287431 DOI: 10.4329/wjr.v16.i7.241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2024] [Revised: 05/30/2024] [Accepted: 07/01/2024] [Indexed: 07/24/2024] Open
Abstract
Lymphoscintigraphy is a nuclear medicine procedure that uses a small quantity of radioactive particles for visualizing the lymphatic system. Traditionally, the radiotracer was injected subcutaneously, but the quality of lymphatic path imaging was scarce due to high background. Intradermal radiotracer injection is considered the modern-day intralymphatic injection. We propose rest/stress intradermal lymphoscintigraphy for the diagnosis, staging and surgical planning of lymphedema. Major and minor findings were described in primary and secondary lymphedema. Based on the in-depth information of the lymphatic pathways, physiotherapists and microsurgeons can obtain important functional information in patients' selection to treat with physical treatments and/or undergo microsurgery.
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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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Noguchi M, Inokuchi M, Yokoi-Noguchi M, Morioka E, Haba Y, Takahashi T, Shioya A, Yamada S. Axillary Reverse Mapping in Clinically Node-Positive Breast Cancer Patients. Cancers (Basel) 2023; 15:5302. [PMID: 37958475 PMCID: PMC10650122 DOI: 10.3390/cancers15215302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 10/31/2023] [Accepted: 11/01/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND Axillary reverse mapping (ARM) nodes are involved in a significant proportion of clinically node-positive (cN+) breast cancer patients. However, neoadjuvant chemotherapy (NAC) is effective at decreasing the incidence of nodal metastases in cN+ patients. PATIENTS AND METHODS One hundred forty-five cN+ patients with confirmed nodal involvement on ultrasound-guided fine needle aspiration cytology were enrolled in this study: one group underwent axillary lymph node dissection (ALND) without NAC (upfront surgery group), and the other group underwent ALND following NAC (NAC group). The patients underwent 18F-FDG-positron emission tomography/computed tomography (18F-FDG-PET/CT) before surgery, as well as an ARM procedure during ALND. RESULTS the rates of involvement of ARM nodes in the NAC group were significantly lower than those of the upfront surgery group (36.6% vs. 62.2%, p < 0.01). Notably, involvement was significantly decreased after NAC in non-luminal-type tumors as compared to the luminal-type (18.4% vs. 48.5%: p < 0.01). Moreover, there was a significant difference in ARM node involvement after NAC between patients with or without axillary uptake of 18F-FDG (61.5% vs. 32.5%: p < 0.01). CONCLUSIONS NAC significantly decreased the risk of ARM node metastases in cN+ patients, but 18F-FDG-PET/CT was not suitable to detect residual metastatic disease of the axilla after NAC.
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Affiliation(s)
- Masakuni Noguchi
- Breast Center, Department of Breast and Endocrine Surgery, Kanazawa Medical University Hospital, Daigaku-1-1, Uchinada, Kahoku 920-0293, Ishikawa, Japan; (M.I.); (M.Y.-N.); (E.M.); (Y.H.)
| | - Masafumi Inokuchi
- Breast Center, Department of Breast and Endocrine Surgery, Kanazawa Medical University Hospital, Daigaku-1-1, Uchinada, Kahoku 920-0293, Ishikawa, Japan; (M.I.); (M.Y.-N.); (E.M.); (Y.H.)
| | - Miki Yokoi-Noguchi
- Breast Center, Department of Breast and Endocrine Surgery, Kanazawa Medical University Hospital, Daigaku-1-1, Uchinada, Kahoku 920-0293, Ishikawa, Japan; (M.I.); (M.Y.-N.); (E.M.); (Y.H.)
| | - Emi Morioka
- Breast Center, Department of Breast and Endocrine Surgery, Kanazawa Medical University Hospital, Daigaku-1-1, Uchinada, Kahoku 920-0293, Ishikawa, Japan; (M.I.); (M.Y.-N.); (E.M.); (Y.H.)
| | - Yusuke Haba
- Breast Center, Department of Breast and Endocrine Surgery, Kanazawa Medical University Hospital, Daigaku-1-1, Uchinada, Kahoku 920-0293, Ishikawa, Japan; (M.I.); (M.Y.-N.); (E.M.); (Y.H.)
| | - Tomoko Takahashi
- Department of Radiology, Kanazawa Medical University Hospital, Daigaku-1-1, Uchinada, Kahoku 920-0293, Ishikawa, Japan;
| | - Akihiro Shioya
- Department of Clinical Pathology, Kanazawa Medical University Hospital, Uchinada, Kahoku 920-0293, Ishikawa, Japan; (A.S.); (S.Y.)
| | - Sohsuke Yamada
- Department of Clinical Pathology, Kanazawa Medical University Hospital, Uchinada, Kahoku 920-0293, Ishikawa, Japan; (A.S.); (S.Y.)
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Kim SA, Gelvosa MN, Cheon H, Jeon JY. The effects of postoperative treadmill exercise on rats with secondary lymphedema. PLoS One 2023; 18:e0285384. [PMID: 37220160 DOI: 10.1371/journal.pone.0285384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 04/20/2023] [Indexed: 05/25/2023] Open
Abstract
Cancer-related lymphedema (LE) is often caused by radiotherapy and surgery such as lymph node dissection (LND). Previous studies have reported that exercise is beneficial to relieve LE, but the changes in the lymphatic system following exercise are still unclear. This study aimed to examine the changes in lymphatic drainage pathways over the exercise period and beneficial effects of exercise in rats with LE. Twelve rats were randomly allocated into exercise and control groups (EG and CG; n = 6 each). To obtain LE, inguinal and popliteal LND followed by 20 Gy irradiation was performed. Treadmill exercise was 30 minutes/day, 5 days/week over the four-week period. Consecutive indocyanine green (ICG) lymphography images were collected and classified into five patterns: i) linear; ii) splash; iii) stardust; iv) diffuse, and v) none. Ankle thickness was measured weekly. Histopathological evaluation was performed to examine the skin thickness, collagen area fraction (%) and lymphatic vessel density in harvested tissue. ICG lymphography exhibited more linear and splash patterns in the EG at week 3. The difference of swelling between both groups was significantly different at week 4 (p = 0.016). Histopathologic data revealed a thinner epidermis (p = 0.041) and dermis (p = 0.002), lower collagen area fraction (%, p = 0.002), and higher lymph vessel density (p = 0.002) in the EG than the CG. In conclusion, we found that postoperative exercise can facilitate improvement in lymphatic fluid retention in the lymphedema rat model, resulting in improvement of pathological conditions in the lymphatic system.
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Affiliation(s)
- Sang Ah Kim
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Department of Biomedical Science, Graduate school of University of Ulsan College of Medicine, Seoul, Korea
| | - Ma Nessa Gelvosa
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hwayeong Cheon
- Biomedical Engineering Research Center, Asan Institute for Life Sciences, Asan Medical Center, Seoul, Korea
| | - Jae Yong Jeon
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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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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Manrique OJ, Bustos SS, Ciudad P, Adabi K, Chen WF, Forte AJ, Cheville AL, Jakub JW, McLaughlin SA, Chen HC. Overview of Lymphedema for Physicians and Other Clinicians: A Review of Fundamental Concepts. Mayo Clin Proc 2022; 97:1920-1935. [PMID: 32829905 DOI: 10.1016/j.mayocp.2020.01.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 10/17/2019] [Accepted: 01/06/2020] [Indexed: 12/16/2022]
Abstract
Lymphedema has historically been underrated in clinical practice, education, and scholarship to the detriment of many patients with this chronic, debilitating condition. The mechanical insufficiency of the lymphatic system causes the abnormal accumulation of protein-rich fluid in the interstitium, which triggers a cascade of adverse consequences such as fat deposition and fibrosis. As the condition progresses, patients present with extremity heaviness, itchiness, skin infections, and, in later stages, dermal fibrosis, skin papillomas, acanthosis, and other trophic skin changes. Correspondingly, lymphedema results in psychological morbidity, including anxiety, depression, social avoidance, and a decreased quality of life, encompassing emotional, functional, physical, and social domains. For this review, we conducted a literature search using PubMed and EMBASE and herein summarize the evidence related to the fundamental concepts of lymphedema. This article aims to raise awareness of this serious condition and outline and review the fundamental concepts of lymphedema.
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Affiliation(s)
- Oscar J Manrique
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, MN.
| | - Samyd S Bustos
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, MN
| | - Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Kian Adabi
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, MN
| | - Wei F Chen
- Division of Plastic and Reconstructive Surgery, University of Iowa, Iowa City
| | | | - Andrea L Cheville
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN
| | | | | | - Hung-Chi Chen
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
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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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Rodriguez JR, Yamamoto T. A Systematic Stepwise Method to Perform a Supermicrosurgical Lymphovenous Anastomosis. Ann Plast Surg 2022; 88:524-532. [PMID: 34670962 DOI: 10.1097/sap.0000000000003023] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Lymphovenous anastomosis (LVA) has become an increasingly common treatment for patients with extremity lymphedema. In this article, we present our current strategy for patient selection, preoperative planning, and a series of intraoperative clues that may help to perform a supermicrosurgical LVA. Technical considerations are presented using a systematic step-by-step method to make this procedure more reproducible and straightforward. PATIENTS AND METHODS We conducted a review of patients operated between January 2015 and June 2018 using the aforementioned approach. Data were collected prospectively, and all procedures were performed by the senior author. Preoperative assessment included lymphoscintigraphy, indocyanine green lymphography, noncontrast magnetic resonance lymphography and high-frequency ultrasonography. Lymphovenous anastomosis was decomposed into a sequential 6-step approach considering the main aspects that determine a successful anastomosis. RESULTS Lymphovenous anastomosis was performed in 229 patients, including 677 anastomoses. Median follow-up was 33 months (range, 13-51 months). A median of 3.1 (range, 1-7) LVA were performed on 2.7 (range, 1-6) incision sites per patient. Median time for dissection of lymphatic(s) and vein(s) was 8.7 minutes (1-18 minutes) with a median time of 27.2 minutes (range, 13-51 minutes) for a complete LVA. Lymphatic detection rate was 100% (677 of 677) and vein detection rate was 99.7% (675 of 677), with 31.0% (210 of 677) of reflux-free veins. For upper-extremity lymphedema (47 of 229; 20.6%), volume reduction was achieved in 100% (47 of 47) of the cases, with a median volume reduction rate of 67% (range, 7-93%). In lower-extremity lymphedema (182 of 229; 79.4%), volume reduction was achieved in 86.8% (158 of 182) of the cases, with a median volume reduction rate of 41% (range, 7-81%). Cellulitis episodes decreased from 2.1 to 0.2 episodes/year after LVA (P < 0.05). CONCLUSIONS Acceptable success rates were obtained using a sequential strategy for planning and execution of supermicrosurgical LVA for secondary extremity lymphedema. We believe including a stepwise approach may help to simplify this procedure, especially for surgeons in their early practice.
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Affiliation(s)
| | - Takumi Yamamoto
- From the Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
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Onoda S, Satake T, Kinoshita M. Relationship Between Lymphaticovenular Anastomosis Outcomes and The Number and Types of Anastomoses. J Surg Res 2021; 269:103-109. [PMID: 34547586 DOI: 10.1016/j.jss.2021.08.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 07/25/2021] [Accepted: 08/01/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Lymphaticovenular anastomosis (LVA) is the first-line treatment for lymphedema in many hospitals. However, many aspects of its effects remain unclear. This study aimed to analyze problems with regard to the relationship between lymphaticovenular anastomosis and outcomes of surgery for lymphedema in the upper and lower extremities. METHODS Eighteen articles were selected for review. The following information was extracted from these articles as factors associated with LVA for lymphedema in the upper and lower extremities: number of cases, average patient age, mean number of bypasses, lymphedema stage, duration and type of lymphedema, anastomotic technique, follow-up period, type of scale, and treatment outcomes. RESULTS Upper extremity lymphedema: The average age of patients was 54.2 (range: 41.3-60.1) years. The mean number of anastomoses was 3.91 (range: 1.0-7.2). Six of nine articles provided data for volume change, and the mean volume change was 29% (-5%-50%). Lower extremity lymphedema: The average age of patients was 50.3 (range: 34-64 years). The mean number of anastomoses was 4.6 (range: 2.1-9.3). Comparison was difficult as different methods were used for postoperative evaluation (lower extremity lymphedema index in three patients, limb circumference in one, volume change in two, and restaging in three). CONCLUSIONS We obtained useful information with regard to the effects of LVA in this review. An increased number of anastomoses between the lymphatic ducts and veins did not seem to improve the effectiveness of LVA. With regard to the stage of lymphedema, LVA may be useful for both early and advanced stages.
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Affiliation(s)
- Satoshi Onoda
- Department of Plastic and Reconstructive Surgery, Kagawa Rosai Hospital, Kagawa, Japan.
| | - Toshihiko Satake
- Department of Plastic and Reconstructive Surgery, Toyama University Hospital, Toyama, Japan
| | - Masahito Kinoshita
- Department of Plastic and Reconstructive Surgery, Kagawa Rosai Hospital, Kagawa, Japan
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11
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Maldonado AA, Ramos E, García-Alonso P, Jover JJ, Holguín P, Fernández-Cañamaque JL, Cristóbal L. [Multidisciplinary approach in the lymphedema patient: From rehabilitation to microsurgery]. Rehabilitacion (Madr) 2021; 56:150-158. [PMID: 34538653 DOI: 10.1016/j.rh.2021.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 02/02/2021] [Accepted: 06/11/2021] [Indexed: 10/20/2022]
Abstract
Lymphedema is a chronic disease with a high incidence in our society. In this paper, we present a review with the latest advances in imaging techniques and surgical reconstructive treatment of lymphedema (lymphovenous anastomosis, vascularized lymph node transfer, and prophylactic lymphedema surgery). In addition, a protocol is established based on a multidisciplinary team (composed of physiatrists, plastic surgeons, radiologists and nuclear medicine radiologists) to optimize the treatment of these patients.
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Affiliation(s)
- A A Maldonado
- Departamento de Cirugía Plástica, Hospital Universitario Getafe, Getafe (Madrid), España; Department of Plastic, Hand and Reconstructive Surgery, BG Trauma Center Frankfurt am Main, Academic Hospital of the Goethe University Frankfurt am Main, Frankfurt am Main, Frankfurt, Alemania.
| | - E Ramos
- Departamento de Rehabilitación, Hospital Universitario Getafe, Getafe (Madrid), España
| | - P García-Alonso
- Departamento de Medicina Nuclear, Hospital Universitario Getafe, Getafe (Madrid), España
| | - J J Jover
- Departmento de Radiología, Hospital Universitario Getafe, Getafe (Madrid), España
| | - P Holguín
- Departamento de Cirugía Plástica, Hospital Universitario Getafe, Getafe (Madrid), España
| | | | - L Cristóbal
- Departamento de Cirugía Plástica, Hospital Universitario Getafe, Getafe (Madrid), España
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Pappalardo M, Starnoni M, Franceschini G, Baccarani A, De Santis G. Breast Cancer-Related Lymphedema: Recent Updates on Diagnosis, Severity and Available Treatments. J Pers Med 2021; 11:jpm11050402. [PMID: 34065795 PMCID: PMC8151072 DOI: 10.3390/jpm11050402] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 04/30/2021] [Accepted: 05/07/2021] [Indexed: 02/07/2023] Open
Abstract
Breast cancer-related lymphedema (BCRL) represents a global healthcare issue affecting the emotional and life quality of breast cancer survivors significantly. The clinical presentation is characterized by swelling of the affected upper limb, that may be accompanied by atrophic skin findings, pain and recurrent cellulitis. Cardinal principles of lymphedema management are the use of complex decongestive therapy and patient education. Recently, new microsurgery procedures have been reported with interesting results, bringing in a new opportunity to care postmastectomy lymphedema. However, many aspects of the disease are still debated in the medical community, including clinical examination, imaging techniques, patient selection and proper treatment. Here we will review these aspects and the current literature.
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Affiliation(s)
- Marco Pappalardo
- Division of Plastic and Reconstructive Surgery, Department of Medical and Surgical Sciences, Modena Policlinico Hospital, University of Modena and Reggio Emilia, 41124 Modena, Italy; (M.P.); (A.B.); (G.D.S.)
| | - Marta Starnoni
- Division of Plastic and Reconstructive Surgery, Department of Medical and Surgical Sciences, Modena Policlinico Hospital, University of Modena and Reggio Emilia, 41124 Modena, Italy; (M.P.); (A.B.); (G.D.S.)
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, 41124 Modena, Italy
- Correspondence:
| | - Gianluca Franceschini
- Multidisciplinary Breast Center, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8-00168 Rome, Italy;
| | - Alessio Baccarani
- Division of Plastic and Reconstructive Surgery, Department of Medical and Surgical Sciences, Modena Policlinico Hospital, University of Modena and Reggio Emilia, 41124 Modena, Italy; (M.P.); (A.B.); (G.D.S.)
| | - Giorgio De Santis
- Division of Plastic and Reconstructive Surgery, Department of Medical and Surgical Sciences, Modena Policlinico Hospital, University of Modena and Reggio Emilia, 41124 Modena, Italy; (M.P.); (A.B.); (G.D.S.)
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Changing the Paradigm: Lymphovenous Anastomosis in Advanced Stage Lower Extremity Lymphedema. Plast Reconstr Surg 2021; 147:199-207. [PMID: 33009330 DOI: 10.1097/prs.0000000000007507] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Traditionally, lymphovenous anastomosis is not routinely performed in patients with advanced stage lymphedema because of difficulty with identifying functioning lymphatics. This study presents the use of duplex ultrasound and magnetic resonance lymphangiography to identify functional lymphatics and reports the clinical outcome of lymphovenous anastomosis in advanced stage lower extremity lymphedema patients. METHODS This was a retrospective study of 42 patients (50 lower limbs) with advanced lymphedema (late stage 2 or 3) that underwent functional lymphovenous anastomoses. Functional lymphatic vessels were identified preoperatively using magnetic resonance lymphangiography and duplex ultrasound. RESULTS An average of 4.64 lymphovenous anastomoses were performed per limb using the lymphatics located in the deep fat underneath the superficial fascia. The average diameter of lymphatic vessels was 0.61 mm (range, 0.35 to 1 mm). The average limb volume was reduced 14.0 percent postoperatively, followed by 15.2 percent after 3 months, and 15.5 percent after 6 months and 1 year (p < 0.001). For patients with unilateral lymphedema, 32.4 percent had less than 10 percent volume excess compared to the contralateral side postoperatively, whereas 20.5 percent had more than 20 percent volume excess. The incidence of cellulitis decreased from 0.84 per year to 0.07 per year after surgery (p < 0.001). CONCLUSION This study shows that functioning lymphatic vessels can be identified preoperatively using ultrasound and magnetic resonance lymphangiography; thus, lymphovenous anastomoses can effectively reduce the volume of the limb and improve subjective symptoms in patients with advanced stage lymphedema of the lower extremity. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Evaluation and selection of lower limb lymphedema patients for lymphaticovenular anastomosis: A prospective study. Injury 2020; 51 Suppl 4:S108-S113. [PMID: 32209243 DOI: 10.1016/j.injury.2020.02.110] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 02/20/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Lymphaticovenular anastomosis (LVA) with supramicrosurgical technique has recently gained popularity as a treatment method for patients with lymphedema. The aim of this study was to prospectively evaluate objective changes in leg volume in patients operated with LVA for lymphedema in the lower extremity, and to find positive predictors for the treatment method to facilitate the location of the venules and lymphatic vessels. PATIENTS & METHODS 31 consecutive patients with lymphedema in the lower extremity and positive pitting test were examined with lymphoscintigraphy and indocyanine green (ICG) lymphography. The causes of the lymphedema were either cancer or unknown cause/primary lymphedema. Fourteen of the patients with pathological lymphangiographic patterns were chosen for surgery and 12 of them were operated with one to four LVAs each. The lymphedema volume in the lower extremity was measured preoperatively, 6- and 12 months after surgery according to the truncated cone formula with the patient´s contralateral leg used as control. Ten patients had unilateral lymphedema and two patients had bilateral lymphedema. RESULTS Five of 12 patients showed between 1-8% edema reductions in the lower extremity after 12 months. With examination considering edema duration, number of anastomoses, radiotherapy and lymph node dissection we found a 6,2% difference in edema reduction between patients who had undergone lymph node dissection and those who had not (p = 0.03). CONCLUSIONS The current study indicates that supramicrosurgery with LVA may reduce edema volumes, where the most distinctive positive predictor for edema reduction with LVAs was previous lymph node dissection.
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Yildirim MEC, Chen SH, Weng HC, Mousavi SA, Chen HC. Treatment of toes as an integrated part of infection control for advanced lower limb lymphedema. J Plast Reconstr Aesthet Surg 2020; 74:168-173. [PMID: 32900654 DOI: 10.1016/j.bjps.2020.08.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 04/02/2020] [Accepted: 08/01/2020] [Indexed: 11/17/2022]
Abstract
The aim of this study was to compare the incidence of infection and verrucous hyperkeratosis in patients who underwent surgery for advanced lymphedema according to the algorithm designed by the senior author, and were treated concurrently with/without toe treatment. A case series (Between 2004-2015) of 46 patients with unilateral advanced lower limb lymphedema was reviewed. Lymphoscintigraphy was used for evaluation of lymphedema severity. The ICG lymphography was used for staging. Fibrosis and skin induration were reflected by the tonicity. They were divided into two groups: (1) patients who underwent further treatment of toes according to the algorithm, and (2) patients who did not have toe-related treatment. Infection episodes and verrucous hyperkeratosis were recorded. There were 21 and 25 patients in Groups 1 and 2, respectively. All lymphoscintigrams showed severe dermal backflow with severe stagnation by 2.5 h after injection of Tc-99 colloid. All patients were stage IV or V. Tonicity values of skin were <60. Group 1 was reduced to an average of 0.6 episodes per year in the past year of follow-up, and Group 2 was reduced to an average of 1.5 episodes per year in the past year of follow-up (p <0.001). The average frequency of preoperative cellulitis was 3.6 episodes per year. The occurrence of verrucous hyperkeratosis was observed in 14.3% and 32% of Groups 1 and 2, respectively. The incidences of cellulitis and verrucous hyperkeratosis were significantly lower in Group 1 than in Group 2 (p <0.001). To achieve successful control of infection, they should be treated carefully according to the strategy described above.
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Affiliation(s)
| | - Shih-Heng Chen
- Department of Plastic Surgery, Chang Gung Memorial Hospital, Taipei, Taiwan.
| | - Hui-Ching Weng
- Institute of Gerontology, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | | | - Hung Chi Chen
- Department of Plastic Surgery, China Medical University Hospital, Taichung, Taiwan.
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Qiu SS, Pruimboom T, Cornelissen AJM, Schols RM, van Kuijk SMJ, van der Hulst RRWJ. Outcomes following lymphaticovenous anastomosis (LVA) for 100 cases of lymphedema: results over 24-months follow-up. Breast Cancer Res Treat 2020; 184:173-183. [PMID: 32767202 PMCID: PMC7568701 DOI: 10.1007/s10549-020-05839-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 07/25/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE Lymphedema is a debilitating condition that significantly affects patient's quality of life (QoL). The aim of this study was to assess the long-term outcomes after lymphaticovenous anastomosis (LVA) for extremity lymphedema. METHODS A single-center prospective study on upper and lower extremity lymphedema patients was performed. All LVA procedures were preceded by outpatient Indocyanine Green (ICG) lymphography. Quality of life measured by the Lymph-ICF was the primary outcome. Limb circumference, use of compression garments, and frequency of cellulitis episodes and manual lymphatic drainage (MLD) sessions were secondary outcomes. RESULTS One hundred consecutive patients, predominantly experiencing upper extremity lymphedema following breast cancer (n = 85), underwent a total of 132 LVAs. During a mean follow-up of 25 months, mean Lymph-ICF score significantly decreased from 43.9 preoperative to 30.6 postoperative, representing significant QoL improvement. Decrease in upper and lower limb circumference was observed in 52% of patients with a mean decrease of 6%. Overall mean circumference was not significantly different. Percentage of patients that could reduce compression garments in the upper and lower extremity group was 65% and 40%, respectively. Number of cellulitis episodes per year and MLD sessions per week showed a mean decrease of respectively 0.6 and 0.8 in the upper extremity and 0.4 and 1.0 in the lower extremity group. CONCLUSIONS LVA resulted in significant QoL improvement in upper and lower extremity lymphedema patients. Limb circumference did not significantly improve but good results concerning compression garments, cellulitis episodes, and MLD sessions were obtained. Additionally, a simple and patient-friendly method for outpatient ICG lymphography is presented.
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Affiliation(s)
- Shan S Qiu
- Department of Plastic and Reconstructive Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands.
| | - Tim Pruimboom
- Department of Plastic and Reconstructive Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - Anouk J M Cornelissen
- Department of Plastic and Reconstructive Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - Rutger M Schols
- Department of Plastic and Reconstructive Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - Sander M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - René R W J van der Hulst
- Department of Plastic and Reconstructive Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
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Surgical Approaches to the Prevention and Management of Breast Cancer–Related Lymphedema. CURRENT BREAST CANCER REPORTS 2020. [DOI: 10.1007/s12609-020-00372-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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18
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Biermann N, Ruewe M, Zeman F, Geis S, Schiltz D, Prantl L, Taeger CD. The Influence of Pulsed Electromagnetic Field Therapy on Lymphatic Flow During Supermicrosurgery. Lymphat Res Biol 2020; 18:549-554. [PMID: 32250722 DOI: 10.1089/lrb.2019.0094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: The influence of pulsed electromagnetic field therapy (PEMFT) on medium-sized vessels as well as capillary microcirculation is well known. Effects on lymphatic vessels, however, are difficult to visualize and have not been investigated to date. One of the operative treatment options in primary and secondary lymphedemas is lymphovenous anastomoses using supermicrosurgery. To prove patency of the anastomosis, the lymphatic flow is visualized by fluorescence using indocyanine green. The aim of this study was to investigate the influence of PEMFT on the lymphatic microcirculation, and compare it with conventional manual lymphatic drainage (MLD) during supermicrosurgery. Methods and Results: Ten patients with lymphedema were included. Indocyanine green was injected before the operation for intraoperative visualization of the lymphatic vessels using a microscope equipped with an integrated near-infrared illumination system (Zeiss). The PEMFT system (Bio-Electro-Magnetic-Energy Regulation [BEMER]) was used as our standard device during a single 2-minute application period (AP) followed by MLD or vice versa. The mean light intensity in the calibration period (CP) was 46.53 ± 24.3 and 33.41 ± 12.92 for PEMFT and MLD, respectively. During the AP, the mean light intensity changed to 45.61 ± 24.40 for PEMFT and 57.05 ± 18.80 during MLD. This change between CP and AP did not differ significantly for the PEMFT application (p = 0.26), but showed an increase in light intensity during MLD (p < 0.001). Conclusion: We found a light intensity enhancement equivalent to a flow increase during MLD of 78.7% ± 45.7% (range 20%-144%) and no significant difference during the PEMFT application. A single period application of PEMFT did not affect the lymphatic flow.
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Affiliation(s)
- Niklas Biermann
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Marc Ruewe
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Florian Zeman
- Center for Clinical Studies, University Hospital Regensburg, Regensburg, Germany
| | - Sebastian Geis
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Daniel Schiltz
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Lukas Prantl
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Christian D Taeger
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
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Forte AJ, Sisti A, Huayllani MT, Boczar D, Cinotto G, Ciudad P, Manrique OJ, Lu X, McLaughlin S. Lymphaticovenular anastomosis for breast cancer-related upper extremity lymphedema: a literature review. Gland Surg 2020; 9:539-544. [PMID: 32420289 DOI: 10.21037/gs.2020.03.41] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Breast cancer-related lymphedema is a long-term condition that affects almost half of breast cancer survivors. Clinical studies have looked at the benefits of lymphaticovenular anastomosis (LVA) for the treatment of upper extremities lymphedema after breast cancer, however, there is still controversy if it improves lymphedema. This study aimed to analyze the studies and outcomes related to LVA for breast cancer-related lymphedema. A PubMed/Medline search was performed using "lymphovenous bypass", "upper extremity lymphedema", "arm lymphedema after breast cancer treatment", and "lymphaticovenular anastomosis" as key words. Only English articles reporting outcomes after LVA were included. We found 22 articles that met the inclusion criteria. Positive outcomes were found in 21 studies with an objective volume reduction and subjective symptoms relief after LVA. This literature review concluded that LVA has demonstrated a significant decrease in upper extremity volumes and an improvement in subjectively reporting symptoms in breast cancer-related lymphedema patients.
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Affiliation(s)
- Antonio J Forte
- Division of Plastic Surgery Mayo Clinic, Jacksonville, FL, USA
| | - Andrea Sisti
- Division of Plastic Surgery Mayo Clinic, Jacksonville, FL, USA
| | | | - Daniel Boczar
- Division of Plastic Surgery Mayo Clinic, Jacksonville, FL, USA
| | | | - Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Oscar J Manrique
- Division of Plastic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Xiaona Lu
- Division of Plastic and Reconstructive Surgery, Yale School of Medicine, New Haven, Connecticut, USA
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20
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Onoda S, Kinoshita M. Lymphaticovenular anastomosis in elderly patients. J Plast Reconstr Aesthet Surg 2020; 73:1174-1205. [PMID: 32113958 DOI: 10.1016/j.bjps.2020.02.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 10/12/2019] [Accepted: 02/09/2020] [Indexed: 10/25/2022]
Affiliation(s)
- Satoshi Onoda
- Department of Plastic and Reconstructive Surgery, Kagawa Rosai Hospital, Kagawa 763-8502, Japan.
| | - Masahito Kinoshita
- Department of Plastic and Reconstructive Surgery, Kagawa Rosai Hospital, Kagawa 763-8502, Japan
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Sakuma H, Watanabe S, Kono H. A Novel Surgical Approach for Refractory Secondary Lymphedema of the Lower Extremity Accompanying Micro-Arteriovenous Fistula. Ann Vasc Surg 2019; 65:284.e13-284.e18. [PMID: 31705986 DOI: 10.1016/j.avsg.2019.10.098] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 07/17/2019] [Accepted: 10/30/2019] [Indexed: 10/25/2022]
Abstract
Lymphaticovenous anastomosis (LVA) for lymphedema of the lower extremity has been established as a minimally invasive and effective surgical treatment to return static lymph fluid to the vein. However, we often experience cases in which the effect of LVA cannot be obtained sufficiently, or the anastomotic site becomes obstructed and the edema deteriorates over a long term. One of the causes is the combination of local venous hypertension (VT) by micro-arteriovenous fistula (mAVF). We report two cases of refractory lymphedema at the lower extremity caused by mAVF and incompetent perforating vein (IPV). In these cases, surgical ligation and separation of the mAVF and IPV is effective in reducing edema.
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Affiliation(s)
- Hisashi Sakuma
- Department of Plastic and Reconstructive Surgery, Yokohama Citizens' Municipal Hospital, Kanagawa, Japan.
| | - Shiho Watanabe
- Department of Plastic and Reconstructive Surgery, Yokohama Citizens' Municipal Hospital, Kanagawa, Japan
| | - Hikaru Kono
- Department of Plastic and Reconstructive Surgery, Yokohama Citizens' Municipal Hospital, Kanagawa, Japan
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Rodriguez JR, Hsieh F, Huang CT, Tsai TJ, Chen C, Cheng MH. Clinical features, microbiological epidemiology and recommendations for management of cellulitis in extremity lymphedema. J Surg Oncol 2019; 121:25-36. [PMID: 31264724 DOI: 10.1002/jso.25525] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 05/14/2019] [Accepted: 05/14/2019] [Indexed: 11/11/2022]
Abstract
BACKGROUND This high volume, single center study investigated the prevalence, bacterial epidemiology, and responsiveness to antibiotic therapy of cellulitis in extremity lymphedema. METHODS From 2003 to 2018, cellulitis events from a cohort of 420 patients with extremity lymphedema were reviewed. Demographics, lymphedema grading, symptoms, inflammatory markers, cultures and antibiotic therapy regimens were compiled from cellulitis episodes data. Univariate and multivariate analyses were performed for detailed analysis. RESULTS A total of 131 separate episodes of cellulitis were recorded from 43 (81.1%) lower limb and 10 (19.9%) upper limb lymphedema patients. The prevalence and recurrence rates for cellulitis in lymphedema patients were 12.6% (53 of 420) and 56.6% (30 of 53), respectively. The most common findings were increased limb circumference (127 of 131; 96.9%) and abnormal C-reactive protein (CRP) level (86 of 113; 76.1%). Blood cultures were obtained in 79 (60.3%) incidents, with 9 (11.4%) returning positive. Streptococcus agalactiae was the most isolated bacterium (5 of 9; 55.5%). CONCLUSIONS The cellulitis prevalence and recurrence rate in extremity lymphedema were 12.6%, and 56.6%, respectively. Strongest indicators of cellulitis were increased affected limb circumference and elevated CRP level. Empiric antibiotic therapy began with coverage for Steptococcus species before broadening to anti-Methicillin-resistant Staphylococcus aureus and anti-Gram negatives if needed for effective treatment of extremity lymphedema cellulitis.
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Affiliation(s)
- Jose R Rodriguez
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Frank Hsieh
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Ching-Tai Huang
- Department of Infectious Diseases, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Tai-Jung Tsai
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Courtney Chen
- Medical Doctor Candidate, UC San Diego School of Medicine, San Diego, California
| | - Ming-Huei Cheng
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
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23
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Experimental Drainage Device to Reduce Lymphoedema in a Rat Model. Eur J Vasc Endovasc Surg 2019; 57:859-867. [DOI: 10.1016/j.ejvs.2018.04.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 04/22/2018] [Indexed: 12/11/2022]
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Anatomical Basis of the Gastroepiploic Vascularized Lymph Node Transfer: A Radiographic Evaluation Using Computed Tomographic Angiography. Plast Reconstr Surg 2019; 142:1046-1052. [PMID: 30020230 DOI: 10.1097/prs.0000000000004772] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND The omentum, nourished by the gastroepiploic vessels, has gained popularity as an option for vascularized lymph node transfer. The anatomy of the gastroepiploic vessels, omentum, and lymph nodes has not been investigated. The purpose of this article is to describe the right gastroepiploic artery and related structures by using computed tomographic angiography. METHODS A retrospective analysis was conducted on 34 patients who underwent computed tomographic angiography. Statistical models were applied to identify right gastroepiploic artery and lymph node anatomical characteristics. RESULTS The right gastroepiploic artery was identified in 33 of 34 patients. It was found to have a diameter of 2.49 ± 0.66 mm at its origin. The gastroduodenal artery length before right gastroepiploic artery takeoff was 3.09 ± 1.31 cm. Twenty-five patients had lymph nodes in the right gastroepiploic artery lymphosome. There were 2.7 ± 2.12 lymph nodes identified per patient. The distance from the right gastroepiploic artery origin to the most proximal lymph node was 3.99 ± 2.21 cm. The distance from the gastroepiploic artery origin to the third lymph node was 9.12 ± 5.06 cm. Each lymph node was within 7.00 ± 6.2 mm of the right gastroepiploic artery. CONCLUSIONS When using the right gastroepiploic artery donor site for vascularized lymph node transfer, the plastic surgeon should anticipate using a pedicle length of 4 cm, a total flap length of 9 cm, and 3 cm of surrounding tissue to obtain at least three lymph nodes for transfer. Computed tomographic angiography is an effective imaging modality that can be used for patient-specific surgical navigation before vascularized lymph node transfer.
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Garza RM, Chang DW. Lymphovenous bypass for the treatment of lymphedema. J Surg Oncol 2018; 118:743-749. [DOI: 10.1002/jso.25166] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 06/28/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Rebecca M. Garza
- Section of Plastic and Reconstructive Surgery, Department of SurgeryThe University of Chicago Medicine & Biological SciencesChicago Illinois
| | - David W. Chang
- Section of Plastic and Reconstructive Surgery, Department of SurgeryThe University of Chicago Medicine & Biological SciencesChicago Illinois
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Gillespie TC, Sayegh HE, Brunelle CL, Daniell KM, Taghian AG. Breast cancer-related lymphedema: risk factors, precautionary measures, and treatments. Gland Surg 2018; 7:379-403. [PMID: 30175055 DOI: 10.21037/gs.2017.11.04] [Citation(s) in RCA: 172] [Impact Index Per Article: 28.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Breast cancer-related lymphedema (BCRL) is a negative sequela of breast cancer treatment, and well-established risk factors include axillary lymph node dissection (ALND) and regional lymph node radiation (RLNR). BCRL affects approximately 1 in 5 patients treated for breast cancer, and it has a significant negative impact on patients' quality of life after breast cancer treatment, serving as a reminder of previous illness. This paper is a comprehensive review of the current evidence regarding BCRL risk factors, precautionary guidelines, prospective screening, early intervention, and surgical and non-surgical treatment techniques. Through establishing evidence-based BCRL risk factors, researchers and clinicians are better able to prevent, anticipate, and provide early intervention for BCRL. Clinicians can identify patients at high risk and utilize prospective screening programs, which incorporate objective measurements, patient reported outcome measures (PROM), and clinical examination, thereby creating opportunities for early intervention and, accordingly, improving BCRL prognosis. Innovative surgical techniques that minimize and/or prophylactically correct lymphatic disruption, such as axillary reverse mapping (ARM) and lymphatic-venous anastomoses (LVAs), are promising avenues for reducing BCRL incidence. Nonetheless, for those patients with BCRL who remain unresponsive to conservative methods like complete decongestive therapy (CDT), surgical treatment options aiming to reduce limb volume or restore lymphatic flow may prove to be palliative or corrective. It is only through a strong team-based approach that such a continuum of care can exist, and a multidisciplinary approach to BCRL screening, intervention, and research is therefore strongly encouraged.
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Affiliation(s)
- Tessa C Gillespie
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Hoda E Sayegh
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Cheryl L Brunelle
- Department of Physical Therapy, Massachusetts General Hospital, Boston, MA, USA
| | - Kayla M Daniell
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Alphonse G Taghian
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
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Lymphedema surgery: the current state of the art. Clin Exp Metastasis 2018; 35:553-558. [DOI: 10.1007/s10585-018-9897-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 05/09/2018] [Indexed: 11/26/2022]
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28
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Stewart C, Munnoch D. Liposuction as an effective treatment for lower extremity lymphoedema: A single surgeon's experience over nine years. J Plast Reconstr Aesthet Surg 2018; 71:239-245. [DOI: 10.1016/j.bjps.2017.11.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 10/08/2017] [Accepted: 11/07/2017] [Indexed: 01/21/2023]
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Lee KT, Park JW, Mun GH. Serial two-year follow-up after lymphaticovenular anastomosis for the treatment of lymphedema. Microsurgery 2017; 37:763-770. [DOI: 10.1002/micr.30200] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 06/11/2017] [Accepted: 06/23/2017] [Indexed: 11/06/2022]
Affiliation(s)
- Kyeong-Tae Lee
- Department of Plastic Surgery; Samsung Medical Center, Sungkyunkwan University School of Medicine; Irwon-ro 81, Gangnam-gu, Seoul 06351 South Korea
| | - Jin-Woo Park
- Department of Plastic Surgery; Samsung Medical Center, Sungkyunkwan University School of Medicine; Irwon-ro 81, Gangnam-gu, Seoul 06351 South Korea
| | - Goo-Hyun Mun
- Department of Plastic Surgery; Samsung Medical Center, Sungkyunkwan University School of Medicine; Irwon-ro 81, Gangnam-gu, Seoul 06351 South Korea
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Eretta C, Ferrarese A, Moggia E, Francone E, Sagnelli C, Martino MD, de Franciscis S, Amato B, Grande R, Butrico L, Amato M, Serra R, Martino V, Berti S. Surgical treatment of recidivist lymphedema. Open Med (Wars) 2017; 11:121-124. [PMID: 28352779 PMCID: PMC5329810 DOI: 10.1515/med-2016-0023] [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: 05/05/2013] [Accepted: 05/05/2014] [Indexed: 11/15/2022] Open
Abstract
Lymphedema is a chronic disease with a progressively ingravescent evolvement and an appearance of recurrent complications of acute lymphangitic type; in nature it is mostly erysipeloid and responsible for a further rapid increase in the volume and consistency of edema. The purpose of this work is to present our experience in the minimally invasive treatment for recurrence of lymphedema; adapting techniques performed in the past which included large fasciotomy with devastating results cosmetically; but these techniques have been proposed again by the use of endoscopic equipment borrowed from the advanced laparoscopy surgery, which allows a monoskin access of about one cm.
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Affiliation(s)
| | - Alessia Ferrarese
- Department of Oncology, University of Turin, Section of General Surgery, San Luigi Gonzaga Teaching Hospital, Regione Gonzole 10, 10043 Orbassano - Turin ( Italy ), Tel. +39 0119026224, Fax +39 0119026523
| | | | - Elisa Francone
- Department of Surgery, S. Andrea Hospital, La Spezia, Italy
| | - Carlo Sagnelli
- Department of Surgery, S. Andrea Hospital, La Spezia, Italy
| | | | - Stefano de Franciscis
- Interuniversity Center of Phlebolymphology (CIFL). International Research and Educational Program in Clinical and Experimental Biotechnology. Headquarters: University Magna Græcia of Catanzaro, Viale Europa 88100 Catanzaro, Italy
| | - Bruno Amato
- Interuniversity Center of Phlebolymphology (CIFL). International Research and Educational Program in Clinical and Experimental Biotechnology. Headquarters: University Magna Græcia of Catanzaro, Viale Europa 88100 Catanzaro, Italy
| | - Raffaele Grande
- Department of Medical and Surgical Sciences, University of Catanzaro, 88100, Italy
| | - Lucia Butrico
- Department of Medical and Surgical Sciences, University of Catanzaro, 88100, Italy
| | - Maurizio Amato
- Department of General, Geriatric, Oncologic Surgery and Advanced Technologies, University of Naples "Federico II". 80100 Naples, Italy
| | - Raffaele Serra
- Department of Medical and Surgical Sciences, University of Catanzaro, 88100, Italy
| | - Valter Martino
- Department of Oncology, University of Turin, Section of General Surgery, San Luigi Gonzaga Teaching Hospital, Regione Gonzole 10, 10043 Orbassano - Turin ( Italy ), Tel. +39 0119026224, Fax +39 0119026523
| | - Stefano Berti
- Department of Surgery, S. Andrea Hospital, La Spezia, Italy
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Boccardo F, Valenzano M, Costantini S, Casabona F, Morotti M, Sala P, De Cian F, Molinari L, Spinaci S, Dessalvi S, Campisi CC, Villa G, Campisi C. LYMPHA Technique to Prevent Secondary Lower Limb Lymphedema. Ann Surg Oncol 2016; 23:3558-3563. [DOI: 10.1245/s10434-016-5282-4] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Multisite Lymphaticovenular Bypass Using Supermicrosurgery Technique for Lymphedema Management in Lower Lymphedema Cases. Plast Reconstr Surg 2016; 138:262-272. [DOI: 10.1097/prs.0000000000002254] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Vignes S. [Lymphedema: A diagnosis not easy but indispensable]. ACTA ACUST UNITED AC 2016; 41:235-7. [PMID: 27317269 DOI: 10.1016/j.jmv.2016.05.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 04/30/2016] [Indexed: 01/05/2023]
Affiliation(s)
- S Vignes
- Unité de lymphologie, centre de référence des maladies vasculaires rares (lymphœdèmes primaires), hôpital Cognacq-Jay, 15, rue Eugène-Millon, 75015 Paris, France.
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Use of Indocyanine Green-SPY Angiography for Tracking Lymphatic Recovery After Lymphaticovenous Anastomosis. Ann Plast Surg 2016; 76 Suppl 3:S232-7. [DOI: 10.1097/sap.0000000000000766] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Chowdhry M, Rozen WM, Griffiths M. Lymphatic mapping and preoperative imaging in the management of post-mastectomy lymphoedema. Gland Surg 2016; 5:187-96. [PMID: 27047786 DOI: 10.3978/j.issn.2227-684x.2015.11.06] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Early detection and diagnosis of upper extremity lymphoedema in patients after mastectomy and axillary lymph node clearance is important in order to treat disease before it is too advanced to achieve favourable outcomes. Patients with disease refractory to conservative management can be efficiently assessed for diagnosis and surgical intervention using advanced lymphatic imaging techniques. The current paper highlights the more readily available of these: lymphoscintigraphy, indocyanine green (ICG) lymphangiography and immunofluorescence, magnetic resonance lymphangiography (MRL) and computed tomographic lymphangiography in combination or individually. With such techniques, both diagnosis and treatment of lymphoedema has become more readily achieved, with lymphatico-venous and lymphatico-lymphatic anastomosis, and lymph node transfer now increasingly common undertakings.
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Affiliation(s)
- Muhammed Chowdhry
- 1 St. Andrew's Centre for Plastic Surgery and Burns, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, Chelmsford, Essex CM1 7ET, UK ; 2 Department of Surgery, School of Clinical Science at Monash Health, Faculty of Medicine, Monash University, Monash Medical Centre, Clayton 3168, Victoria, Australia ; 3 Department of Surgery, Monash University, Level 5, E Block, Monash Medical Centre, Clayton 3168, Victoria, Australia
| | - Warren Matthew Rozen
- 1 St. Andrew's Centre for Plastic Surgery and Burns, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, Chelmsford, Essex CM1 7ET, UK ; 2 Department of Surgery, School of Clinical Science at Monash Health, Faculty of Medicine, Monash University, Monash Medical Centre, Clayton 3168, Victoria, Australia ; 3 Department of Surgery, Monash University, Level 5, E Block, Monash Medical Centre, Clayton 3168, Victoria, Australia
| | - Matthew Griffiths
- 1 St. Andrew's Centre for Plastic Surgery and Burns, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, Chelmsford, Essex CM1 7ET, UK ; 2 Department of Surgery, School of Clinical Science at Monash Health, Faculty of Medicine, Monash University, Monash Medical Centre, Clayton 3168, Victoria, Australia ; 3 Department of Surgery, Monash University, Level 5, E Block, Monash Medical Centre, Clayton 3168, Victoria, Australia
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37
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A randomized control study of treating secondary stage II breast cancer-related lymphoedema with free lymph node transfer. Breast Cancer Res Treat 2016; 156:73-9. [DOI: 10.1007/s10549-016-3716-0] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 02/08/2016] [Indexed: 11/25/2022]
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38
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The Superior-Edge-of-the-Knee Incision Method in Lymphaticovenular Anastomosis for Lower Extremity Lymphedema. Plast Reconstr Surg 2015; 136:665e-675e. [DOI: 10.1097/prs.0000000000001715] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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A Propensity-Matched Analysis of the Influence of Breast Reconstruction on Subsequent Development of Lymphedema. Plast Reconstr Surg 2015. [PMID: 26218386 DOI: 10.1097/prs.0000000000001417] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Recent literature demonstrates a lower incidence of lymphedema with breast reconstruction. This study compared the incidence of lymphedema after axillary dissection in a propensity-matched cohort of patients with and without immediate breast reconstruction. METHODS A review of patients undergoing axillary lymphadenectomy with or without immediate breast reconstruction from January 1, 2000, to July 1, 2013, was conducted. Comorbidities, cancer treatment, operative characteristics, and pathologic findings were reviewed. The primary outcome was postoperative lymphedema. Univariate analysis identified baseline differences between the patient groups. Cohorts were propensity-matched by age, body mass index greater than 30 kg/m, adjuvant radiation therapy, cardiovascular disease, and hypertension. Subsequent multivariate regression was performed to identify independent predictors of lymphedema among matched patients. RESULTS A total of 4647 patients underwent breast cancer resection, with 1955 having axillary lymphadenectomy (no reconstruction, n = 1200; autologous, n = 563; implant-based, n = 192). Matching yielded a cohort of 239 reconstruction and 239 no-reconstruction patients demonstrating no differences in age, body mass index, hypertension, adjuvant radiation therapy, or axillary dissection extent. With 55.9 months' follow-up, postoperative lymphedema was diagnosed in 94 patients (19.7 percent). Reconstruction patients developed lymphedema in 19.2 percent of cases versus 20.1 percent for no- reconstruction patients (p = 0.82). Regression identified two independent predictors of lymphedema: postoperative radiation therapy (OR, 2.90; p < 0.001) and obesity (OR, 2.36; p < 0.001). CONCLUSIONS This study demonstrates a 19.7 percent incidence of lymphedema following axillary lymphadenectomy. Reconstruction does not appear to alter lymphedema risk, whereas postoperative radiation therapy, obesity, and extensive axillary dissection greatly increase risk. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Estimating Lymphodynamic Conditions and Lymphovenous Anastomosis Efficacy Using (99m)Tc-phytate Lymphoscintigraphy with SPECT-CT in Patients with Lower-limb Lymphedema. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2015; 3:e404. [PMID: 26090294 PMCID: PMC4457267 DOI: 10.1097/gox.0000000000000375] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Accepted: 04/01/2015] [Indexed: 11/27/2022]
Abstract
Background: Diagnostic and therapeutic strategies for lower-limb lymphedema have not yet been established. The purpose of this study was to estimate the lymphodynamic condition and therapeutic efficacy of lymphovenous anastomosis (LVA) in lower-limb lymphedema patients using 2-phase 99mTc-phytate lymphoscintigraphy with single-photon emission computed tomography-computed tomography (SPECT-CT). Methods: In this study, consecutive patients with lower-limb lymphedema who underwent 2-phase lymphoscintigraphy using 99mTc-phytate were enrolled between June 2013 and June 2014. SPECT-CT was also performed to clarify the relationships between functional and morphological information. In both the early and delayed images, inguinal lymph node accumulation, dermal backflow, and their sequential alternations were evaluated, and liver-to-blood ratio and inguinal lymph node-to-blood ratio were calculated. All participants were classified into 6 types of lymphodynamic conditions based on the image findings. Patients with both dermal backflow and associated normal lymphatic vessel accumulation proceeded to LVA and underwent a second lymphoscintigraphy after the operation. Results: Of all 30 participants, the largest population was categorized as type 4, which had consistent inguinal lymph node accumulation defect with dermal backflow. In 12 operated cases, dermal backflow was degraded in 10 cases by LVA. Liver-to-blood ratio in both early and delayed images and inguinal lymph node-to-blood ratio in delayed image significantly increased after LVA. Conclusions: Lymphoscintigraphy with SPECT-CT can provide both functional and morphological information simultaneously in patients with lower-limb lymphedema. Using these procedures, a type categorization for the patients was devised, which reflects their lymphodynamic conditions. The therapeutic efficacy of LVA could also be estimated quantitatively by the derived findings.
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41
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Torrisi JS, Joseph WJ, Ghanta S, Cuzzone DA, Albano NJ, Savetsky IL, Gardenier JC, Skoracki R, Chang D, Mehrara BJ. Lymphaticovenous bypass decreases pathologic skin changes in upper extremity breast cancer-related lymphedema. Lymphat Res Biol 2014; 13:46-53. [PMID: 25521197 DOI: 10.1089/lrb.2014.0022] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Recent advances in microsurgery such as lymphaticovenous bypass (LVB) have been shown to decrease limb volumes and improve subjective symptoms in patients with lymphedema. However, to date, it remains unknown if these procedures can reverse the pathological tissue changes associated with lymphedema. Therefore, the purpose of this study was to analyze skin tissue changes in patients before and after LVB. METHODS AND RESULTS Matched skin biopsy samples were collected from normal and lymphedematous limbs of 6 patients with unilateral breast cancer-related upper extremity lymphedema before and 6 months after LVB. Biopsy specimens were fixed and analyzed for inflammation, fibrosis, hyperkeratosis, and lymphangiogenesis. Six months following LVB, 83% of patients had symptomatic improvement in their lymphedema. Histological analysis at this time demonstrated a significant decrease in tissue CD4(+) cell inflammation in lymphedematous limb (but not normal limb) biopsies (p<0.01). These changes were associated with significantly decreased tissue fibrosis as demonstrated by decreased collagen type I deposition and TGF-β1 expression (all p<0.01). In addition, we found a significant decrease in epidermal thickness, decreased numbers of proliferating basal keratinocytes, and decreased number of LYVE-1(+) lymphatic vessels in lymphedematous limbs after LVB. CONCLUSIONS We have shown, for the first time, that microsurgical LVB not only improves symptomatology of lymphedema but also helps to improve pathologic changes in the skin. These findings suggest that the some of the pathologic changes of lymphedema are reversible and may be related to lymphatic fluid stasis.
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Affiliation(s)
- Jeremy S Torrisi
- 1 Department of Surgery, Division of Plastic and Reconstructive Surgery, Memorial Sloan-Kettering Cancer Center , New York, New York
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Mihara M, Hara H, Furniss D, Narushima M, Iida T, Kikuchi K, Ohtsu H, Gennaro P, Gabriele G, Murai N. Lymphaticovenular anastomosis to prevent cellulitis associated with lymphoedema. Br J Surg 2014; 101:1391-6. [PMID: 25116167 DOI: 10.1002/bjs.9588] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Revised: 03/29/2014] [Accepted: 05/09/2014] [Indexed: 11/06/2022]
Abstract
BACKGROUND One of the complications of lymphoedema is recurrent cellulitis. The aim was to determine whether lymphaticovenous anastomosis (LVA) was effective at reducing cellulitis in patients with lymphoedema. METHODS This was a retrospective review of patients with arm/leg lymphoedema who underwent LVA. The frequency of cellulitis was compared before and after surgery. The diagnostic criteria for cellulitis were a fever of 38·5°C or higher, and warmth/redness in the affected limb(s). RESULTS A total of 95 patients were included. The mean number of episodes of cellulitis in the year preceding surgery was 1·46, compared with 0·18 in the year after surgery (P < 0·001). CONCLUSION LVA reduced the rate of cellulitis in these patients with lymphoedema.
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Affiliation(s)
- M Mihara
- Department of Vascular Surgery, Saiseikai Kawaguchi General Hospital, Saitama, Japan
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Abstract
Lymphedema is the chronic, progressive swelling of tissue due to inadequate lymphatic function. Over time, protein-rich fluid accumulates in the tissue, causing it to enlarge. Lymphedema is a specific disease and should not be used as a generic term for an enlarged extremity. The diagnosis is made by evaluating the history and physical examination, and can be confirmed with lymphoscintigraphy. Intervention includes patient education, compression, and, rarely, surgery. Patients are advised to exercise, maintain a normal body mass index, and moisturize/protect the diseased limb from incidental trauma. Conservative management consists of compression regimens. Operative interventions either attempt to address the underlying lymphatic anomaly or the excess tissue. Lymphatic-venous anastomosis and lymph node transfer attempt to create new lymphatic connections to correct the defect. Suction-assisted lipectomy and staged cutaneous/subcutaneous excision reduce the size of the area by removing extra tissues.
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Affiliation(s)
- Reid A Maclellan
- Department of Plastic and Oral Surgery, Lymphedema Program, Boston Children׳s Hospital, Harvard Medical School, 300 Longwood Ave, Boston, Massachusetts 02115
| | - Arin K Greene
- Department of Plastic and Oral Surgery, Lymphedema Program, Boston Children׳s Hospital, Harvard Medical School, 300 Longwood Ave, Boston, Massachusetts 02115.
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Granzow JW, Soderberg JM, Kaji AH, Dauphine C. Review of Current Surgical Treatments for Lymphedema. Ann Surg Oncol 2014; 21:1195-201. [DOI: 10.1245/s10434-014-3518-8] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Indexed: 11/18/2022]
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Granzow JW, Soderberg JM, Kaji AH, Dauphine C. An Effective System of Surgical Treatment of Lymphedema. Ann Surg Oncol 2014; 21:1189-94. [DOI: 10.1245/s10434-014-3515-y] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Indexed: 11/18/2022]
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Onoda S, Todokoro T, Hara H, Azuma S, Goto A. Minimally invasive multiple lymphaticovenular anastomosis at the ankle for the prevention of lower leg lymphedema. Microsurgery 2013; 34:372-6. [DOI: 10.1002/micr.22204] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2013] [Revised: 10/16/2013] [Accepted: 10/21/2013] [Indexed: 11/09/2022]
Affiliation(s)
- Satoshi Onoda
- Department of Plastic and Reconstructive Surgery; Graduate School of Medicine, University of Tokyo; Bunkyo-ku Tokyo Japan
| | - Takeshi Todokoro
- Department of Plastic and Reconstructive Surgery; Graduate School of Medicine, University of Tokyo; Bunkyo-ku Tokyo Japan
| | - Hisako Hara
- Department of Plastic and Reconstructive Surgery; Graduate School of Medicine, University of Tokyo; Bunkyo-ku Tokyo Japan
| | - Shuchi Azuma
- Department of Plastic and Reconstructive Surgery; Graduate School of Medicine, University of Tokyo; Bunkyo-ku Tokyo Japan
| | - Aya Goto
- Department of Plastic and Reconstructive Surgery; Graduate School of Medicine, University of Tokyo; Bunkyo-ku Tokyo Japan
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External Valvuloplasty for Subcutaneous Small Veins to Prevent Venous Reflux in Lymphaticovenular Anastomosis for Lower Extremity Lymphedema. Plast Reconstr Surg 2013; 132:1008-1014. [DOI: 10.1097/prs.0b013e31829fe12f] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Vascularized groin lymph node flap transfer for postmastectomy upper limb lymphedema: flap anatomy, recipient sites, and outcomes. Plast Reconstr Surg 2013; 131:1286-1298. [PMID: 23714790 DOI: 10.1097/prs.0b013e31828bd3b3] [Citation(s) in RCA: 212] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Vascularized groin lymph node flap transfer is an emerging approach to the treatment of postmastectomy upper limb lymphedema. The authors describe the pertinent flap anatomy, surgical technique including different recipient sites, and outcome of this technique. METHODS Ten cadaveric dissections were performed to clarify the vascular supply of the superficial groin lymph nodes. Ten patients underwent vascularized groin lymph node flap transfer for postmastectomy upper limb lymphedema using the wrist (n=8) or elbow (n=2) as a recipient site. Ten patients who chose to undergo physical therapy were used as controls. Intraoperatively, indocyanine green was injected subcutaneously on the flap margin to observe the lymph drainage. Outcomes were assessed using improvement of circumferential differentiation, reduction rate, and decreased number of episodes of cellulitis. RESULTS A mean 6.2±1.3 groin lymph nodes with consistent pedicles were identified in the cadaveric dissections. After indocyanine injection, the fluorescence was drained from the flap edge into the donor vein, followed by the recipient vein. At a mean follow-up of 39.1±15.7 months, the mean improvement of circumferential differentiation was 7.3±2.7 percent and the reduction rate was 40.4±16.1 percent in the vascularized groin lymph node group, which were statistically greater than those of the physical therapy group (1.7±4.6 percent and 8.3±34.7 percent, respectively; p<0.01 and p=0.02, respectively). CONCLUSIONS The superficial groin lymph nodes were confirmed as vascularized with reliable arterial perfusion. Vascularized groin lymph node flap transfer using the wrist or elbow as a recipient site is an efficacious approach to treating postmastectomy upper limb lymphedema. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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