A prospective study on combined lymphedema surgery: Gastroepiploic vascularized lymph nodes transfer and lymphaticovenous anastomosis followed by suction lipectomy.
Journal
Microsurgery
ISSN: 1098-2752
Titre abrégé: Microsurgery
Pays: United States
ID NLM: 8309230
Informations de publication
Date de publication:
Jan 2021
Jan 2021
Historique:
received:
09
02
2020
revised:
02
05
2020
accepted:
28
07
2020
pubmed:
28
8
2020
medline:
29
7
2021
entrez:
27
8
2020
Statut:
ppublish
Résumé
There is no consensus on the appropriate treatment of lymphedema. Proposed techniques include lymphaticovenous anastomosis (LVA), vascularized lymph nodes transfer (VLNT), and suction lipectomy (SL). The benefit of combined procedures has also been postulated. In this prospective study, a combined protocol is proposed as an alternative to single-procedure strategies. Between January 2016 and October 2018, we enrolled patients with secondary lymphedema of lower limbs, stage II-III according to the International Society of Lymphology, progressive swelling and skin tonicity >60. Thirty-seven consecutive patients were dichotomized into group I, undergoing VLNT, and group II undergoing VLNT and LVA. Gastroepiploic lymphnode flap was harvested through laparoscopy, and in the same operation, LVAs were performed in group II on the basis of indocyanine green lymphography and patent blue findings. Two weeks later, SL was performed in all the patients. Patients were prospectively evaluated through clinical examination, circumference measurement, and skin tonicity. The average follow-up was 2 ± 0.8 years. The first consecutive 21 patients were treated with VLNT followed by SL. The next 16 patients underwent combined VLNT and LVA, followed by SL. A mean of 2.4 LVAs were performed. A significant difference in the postoperative circumference measurements was found overall (p < .05): 52.6 ± 18.9 above the knee, 42.9 ± 25 below the knee, 36.2 ± 37 at foot. The postoperative tonicity dropped by 12.7 ± 6.3% (p < .05). The episodes of cellulitis significantly decreased to 0.1 ± 0.3 (p < .05). LVA, VLNT, and SL can be integrated together in a combined approach, in synergy to enhance the outcomes.
Sections du résumé
BACKGROUND
BACKGROUND
There is no consensus on the appropriate treatment of lymphedema. Proposed techniques include lymphaticovenous anastomosis (LVA), vascularized lymph nodes transfer (VLNT), and suction lipectomy (SL). The benefit of combined procedures has also been postulated. In this prospective study, a combined protocol is proposed as an alternative to single-procedure strategies.
METHODS
METHODS
Between January 2016 and October 2018, we enrolled patients with secondary lymphedema of lower limbs, stage II-III according to the International Society of Lymphology, progressive swelling and skin tonicity >60. Thirty-seven consecutive patients were dichotomized into group I, undergoing VLNT, and group II undergoing VLNT and LVA. Gastroepiploic lymphnode flap was harvested through laparoscopy, and in the same operation, LVAs were performed in group II on the basis of indocyanine green lymphography and patent blue findings. Two weeks later, SL was performed in all the patients. Patients were prospectively evaluated through clinical examination, circumference measurement, and skin tonicity.
RESULTS
RESULTS
The average follow-up was 2 ± 0.8 years. The first consecutive 21 patients were treated with VLNT followed by SL. The next 16 patients underwent combined VLNT and LVA, followed by SL. A mean of 2.4 LVAs were performed. A significant difference in the postoperative circumference measurements was found overall (p < .05): 52.6 ± 18.9 above the knee, 42.9 ± 25 below the knee, 36.2 ± 37 at foot. The postoperative tonicity dropped by 12.7 ± 6.3% (p < .05). The episodes of cellulitis significantly decreased to 0.1 ± 0.3 (p < .05).
CONCLUSIONS
CONCLUSIONS
LVA, VLNT, and SL can be integrated together in a combined approach, in synergy to enhance the outcomes.
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
34-43Informations de copyright
© 2020 Wiley Periodicals LLC.
Références
Agko, M., Ciudad, P., & Chen, H.-C. (2018). Staged surgical treatment of extremity lymphedema with dual gastroepiploic vascularized lymph node transfers followed by suction-assisted lipectomy-A prospective study. Journal of Surgical Oncology, 117(6), 1148-1156. https://doi.org/10.1002/jso.24969
Allen, R. J., & Cheng, M.-H. (2016). Lymphedema surgery: Patient selection and an overview of surgical techniques. Journal of Surgical Oncology, 113(8), 923-931. https://doi.org/10.1002/jso.24170
Avraham, T., Yan, A., Zampell, J. C., Daluvoy, S. V., Haimovitz-Friedman, A., Cordeiro, A. P., & Mehrara, B. J. (2010). Radiation therapy causes loss of dermal lymphatic vessels and interferes with lymphatic function by TGF-beta1-mediated tissue fibrosis. American Journal of Physiology. Cell Physiology, 299(3), C589-C605. https://doi.org/10.1152/ajpcell.00535.2009
Ayestaray, B., Bekara, F., & Andreoletti, J.-B. (2013). Patent blue-enhanced lymphaticovenular anastomosis. Journal of Plastic, Reconstructive & Aesthetic Surgery, 66(3), 382-389. https://doi.org/10.1016/j.bjps.2012.10.019
Becker, C., Assouad, J., Riquet, M., & Hidden, G. (2006). Postmastectomy lymphedema: Long-term results following microsurgical lymph node transplantation. Annals of Surgery, 243(3), 313-315. https://doi.org/10.1097/01.sla.0000201258.10304.16
Bolletta, A., Di Taranto, G., Chen, S. H., Elia, R., Amorosi, V., Chan, J. C., & Chen, H. C. (2020). Surgical treatment of Milroy disease. Journal of Surgical Oncology, 121(1), 175-181. https://doi.org/10.1002/jso.25583
Brorson, H. (2004). Adipose tissue in lymphedema: The ignorance of adipose tissue in lymphedema. Lymphology, 37(4), 175-177.
Brorson, H. (2016). Liposuction in lymphedema treatment. Journal of Reconstructive Microsurgery, 32(1), 56-65. https://doi.org/10.1055/s-0035-1549158
Casella, D., Di Taranto, G., Marcasciano, M., Sordi, S., Kothari, A., Kovacs, T., … Ribuffo, D. (2019). Evaluation of Prepectoral implant placement and complete coverage with TiLoop bra mesh for breast reconstruction: A prospective study on long-term and patient-reported BREAST-Q outcomes. Plastic and Reconstructive Surgery, 143(1), 1e-9e. https://doi.org/10.1097/PRS.0000000000005078
Chang, D. W., Masia, J., Garza, R., Skoracki, R., & Neligan, P. C. (2016). Lymphedema: Surgical and medical therapy. Plastic and Reconstructive Surgery, 138(3 Suppl), 209S-218S. https://doi.org/10.1097/PRS.0000000000002683
Chang, E. I., Ibrahim, A., Liu, J., Robe, C., Suami, H., Hanasono, M. M., & Nguyen, A. T. (2020). Optimizing quality of life for patients with breast cancer related lymphedema: A prospective study combining DIEP flap breast reconstruction and lymphedema surgery. Plastic and Reconstructive Surgery, 145, 676e-685e. https://doi.org/10.1097/PRS.0000000000006634
Chen, H. C., O'Brien, B. M., Pribaz, J. J., & Roberts, A. H. (1988). The use of tonometry in the assessment of upper extremity lymphoedema. British Journal of Plastic Surgery, 41(4), 399-402. https://doi.org/10.1016/0007-1226(88)90081-1
Cheng, M.-H., Chang, D. W., Masia, J., & Koshima, I. (2020). Introduction of the 8th world symposium for lymphedema surgery. Journal of Surgical Oncology, 121(1), 7. https://doi.org/10.1002/jso.25620
Cheng, M.-H., Huang, J.-J., Nguyen, D. H., Saint-Cyr, M., Zenn, M. R., Tan, B. K., & Lee, C. L. (2012). A novel approach to the treatment of lower extremity lymphedema by transferring a vascularized submental lymph node flap to the ankle. Gynecologic Oncology, 126(1), 93-98. https://doi.org/10.1016/j.ygyno.2012.04.017
Cheng, M.-H., Huang, J.-J., Wu, C.-W., Yang, C. Y., Lin, C. Y., Henry, S. L., & Kolios, L. (2014). The mechanism of vascularized lymph node transfer for lymphedema: Natural lymphaticovenous drainage. Plastic and Reconstructive Surgery, 133(2), 192e-198e. https://doi.org/10.1097/01.prs.0000437257.78327.5b
Cheng, M.-H., Loh, C. Y. Y., & Lin, C.-Y. (2018). Outcomes of vascularized lymph node transfer and Lymphovenous anastomosis for treatment of primary lymphedema. Plastic and Reconstructive Surgery. Global Open, 6(12), e2056. https://doi.org/10.1097/GOX.0000000000002056
Ciudad, P., Agko, M., Huang, T. C. T., Manrique, O. J., Chang, W. L., Nicoli, F., … Chen, H. C. (2019). Comprehensive multimodal surgical treatment of end-stage lower extremity lymphedema with toe management: The combined Charles', Homan's, and vascularized lymph node transfer (CHAHOVA) procedures. Journal of Surgical Oncology, 119(4), 430-438. https://doi.org/10.1002/jso.25356
Ciudad, P., Agko, M., Perez Coca, J. J., Manrique, O. J., Chang, W. L., Nicoli, F., … Chen, H. C. (2017). Comparison of long-term clinical outcomes among different vascularized lymph node transfers: 6-year experience of a single center's approach to the treatment of lymphedema. Journal of Surgical Oncology, 116(6), 671-682. https://doi.org/10.1002/jso.24730
Ciudad, P., Manrique, O. J., Bustos, S. S., Coca, J. J. P., Chang, C. C., Shih, P. K., … Chen, H. C. (2020). Comparisons in long-term clinical outcomes among patients with upper or lower extremity lymphedema treated with diverse vascularized lymph node transfer. Microsurgery, 40(2), 130-136. https://doi.org/10.1002/micr.30508
Ciudad, P., Manrique, O. J., Date, S., Agko, M., Perez Coca, J. J., Chang, W. L., … Chen, H. C. (2017). Double gastroepiploic vascularized lymph node tranfers to middle and distal limb for the treatment of lymphedema. Microsurgery, 37(7), 771-779. https://doi.org/10.1002/micr.30168
Cuzzone, D. A., Weitman, E. S., Albano, N. J., Ghanta, S., Savetsky, I. L., Gardenier, J. C., … Mehrara, B. J. (2014). IL-6 regulates adipose deposition and homeostasis in lymphedema. American Journal of Physiology. Heart and Circulatory Physiology, 306(10), H1426-H1434. https://doi.org/10.1152/ajpheart.01019.2013
de Sire, A., Losco, L., Cigna, E., Lippi, L., Gimigliano, F., Gennari, A., … Invernizzi, M. (2020). Three-dimensional laser scanning as a reliable and reproducible diagnostic tool in breast cancer related lymphedema rehabilitation: A proof-of-principle study. European Review for Medical and Pharmacological Sciences, 24(8), 4476-4485. https://doi.org/10.26355/eurrev_202004_21030
Di Taranto, G., Chen, S.-H., Elia, R., Bolletta, A., Amorosi, V., Sitpahul, N., …Chen, H. C. (2020). Free gastroepiploic lymph nodes and omentum flap for treatment of lower limb ulcers in severe lymphedema: Killing two birds with one stone. Journal of Surgical Oncology, 121(1), 168-174. https://doi.org/10.1002/jso.25581
Di Taranto, G., Chen, S.-H., Elia, R., Sitpahul, N., Chan, J. C. Y., Losco, L., … Chen, H. C. (2019). Outcomes following head neck free flap reconstruction requiring interposition vein graft or vascular bridge flap. Head & Neck, 41(9), 2914-2920. https://doi.org/10.1002/hed.25767
Di Taranto, G., Elia, R., Amorosi, V., Alamouti, R., Sitpahul, N., Chan, J., … Chen, H. C. (2018). The difference in the caliber of efferent lymphatic vessels among various lymph node flaps. Journal of Surgical Oncology, 118(7), 1212-1213. https://doi.org/10.1002/jso.25257
Fernández Peñuela, R., Casaní Arazo, L., & Masiá Ayala, J. (2019). Outcomes in vascularized lymph node transplantation in rabbits: A reliable model for improving the surgical approach to lymphedema. Lymphatic Research and Biology, 17, 413-417. https://doi.org/10.1089/lrb.2018.0038
Fino, P., Di Taranto, G., Toscani, M., & Scuderi, N. (2016). Surgical therapy of breast hypertrophy: A comparison of complications and satisfaction rate in large and small superior pedicle custom-made reduction mammaplasty. European Review for Medical and Pharmacological Sciences, 20(21), 4411-4415.
Hayashi, A., Hayashi, N., Yoshimatsu, H., & Yamamoto, T. (2018). Effective and efficient lymphaticovenular anastomosis using preoperative ultrasound detection technique of lymphatic vessels in lower extremity lymphedema. Journal of Surgical Oncology, 117(2), 290-298. https://doi.org/10.1002/jso.24812
Inserra, I., Martelli, C., Cipollina, M., Cicione, C., Iavarone, F., di Taranto, G., … Lattanzi, W. (2016). Lipoaspirate fluid proteome: A preliminary investigation by LC-MS top-down/bottom-up integrated platform of a high potential biofluid in regenerative medicine. Electrophoresis, 37(7-8), 1015-1026. https://doi.org/10.1002/elps.201500504
International Society of Lymphology. (2013). The diagnosis and treatment of peripheral lymphedema: 2013 consensus document of the International Society of Lymphology. Lymphology, 46(1), 1-11.
Ito, R., Zelken, J., Yang, C.-Y., Lin, C.-Y., & Cheng, M.-H. (2016). Proposed pathway and mechanism of vascularized lymph node flaps. Gynecologic Oncology, 141(1), 182-188. https://doi.org/10.1016/j.ygyno.2016.01.007
Kaciulyte, J., Losco, L., Maruccia, M., Delia, G., Lo Torto, F., di Taranto, G., … Cigna, E. (2019). Postsurgical antithrombotic therapy in microsurgery: Our protocol and literature review. European Review for Medical and Pharmacological Sciences, 23(10), 4448-4457. https://doi.org/10.26355/eurrev_201905_17955
Lin, C.-H., Ali, R., Chen, S.-C., Wallace, C., Chang, Y. C., Chen, H. C., & Cheng, M. H. (2009). Vascularized groin lymph node transfer using the wrist as a recipient site for management of postmastectomy upper extremity lymphedema. Plastic and Reconstructive Surgery, 123(4), 1265-1275. https://doi.org/10.1097/PRS.0b013e31819e6529
Lo Torto, F., Parisi, P., Casella, D., Di Taranto, G., Cigna, E., & Ribuffo, D. (2018). Impact of evolving radiation therapy techniques on implant-based breast reconstruction. Plastic and Reconstructive Surgery, 141(1), 182e-183e. https://doi.org/10.1097/PRS.0000000000003972
Loh, C. Y. Y., Wu, J. C.-W., Nguyen, A., Dayan, J., Smith, M., Masia, J., … Cheng, M. H. (2017). The 5th world symposium for lymphedema surgery-recent updates in lymphedema surgery and setting up of a global knowledge exchange platform. Journal of Surgical Oncology, 115(1), 6-12. https://doi.org/10.1002/jso.24341
Losco, L., Roxo, A. C., Roxo, C. W., Lo Torto, F., Bolletta, A., de Sire, A., … Roxo, C. P. (2020). Lower body lift after bariatric surgery: 323 consecutive cases over 10-year experience. Aesthetic Plastic Surgery, 44(2), 421-432. https://doi.org/10.1007/s00266-019-01543-x
Maeda, T., Yamamoto, Y., Iwasaki, D., Hayashi, T., Funayama, E., Oyama, A., … Furukawa, H. (2018). Lymphatic reconnection and restoration of lymphatic flow by nonvascularized lymph node transplantation: Real-time fluorescence imaging using Indocyanine green and fluorescein Isothiocyanate-dextran. Lymphatic Research and Biology, 16(2), 165-173. https://doi.org/10.1089/lrb.2016.0070
Maruccia, M., Pezzolla, A., Nacchiero, E., Dicillo, P., Macchia, L., Fiore, P., … Elia, R. (2019). Efficacy and early results after combining laparoscopic harvest of double gastroepiploic lymph node flap and active physiotherapy for lower extremity lymphedema. Microsurgery, 39(8), 679-687. https://doi.org/10.1002/micr.30511
Masià, J., Pons, G., & Rodríguez-Bauzà, E. (2016). Barcelona lymphedema algorithm for surgical treatment in breast cancer-related lymphedema. Journal of Reconstructive Microsurgery, 32(5), 329-335. https://doi.org/10.1055/s-0036-1578814
Mihara, M., Hara, H., Hayashi, Y., Narushima, M., Yamamoto, T., Todokoro, T., … Koshima, I. (2012). Pathological steps of cancer-related lymphedema: Histological changes in the collecting lymphatic vessels after lymphadenectomy. PLoS One, 7(7), e41126. https://doi.org/10.1371/journal.pone.0041126
Patel, K. M., Lin, C.-Y., & Cheng, M.-H. (2015). A prospective evaluation of lymphedema-specific quality-of-life outcomes following vascularized lymph node transfer. Annals of Surgical Oncology, 22(7), 2424-2430. https://doi.org/10.1245/s10434-014-4276-3
Phillips, G. S. A., Gore, S., Ramsden, A., & Furniss, D. (2019). Lymphaticovenular anastomosis improves quality of life and limb volume in patients with secondary lymphedema after breast cancer treatment. The Breast Journal, 25(5), 859-864. https://doi.org/10.1111/tbj.13348
Pons, G., Clavero, J. A., Alomar, X., Rodríguez-Bauza, E., Tom, L. K., & Masia, J. (2019). Preoperative planning of lymphaticovenous anastomosis: The use of magnetic resonance lymphangiography as a complement to indocyanine green lymphography. Journal of Plastic, Reconstructive & Aesthetic Surgery, 72(6), 884-891. https://doi.org/10.1016/j.bjps.2019.02.024
Qiu, S. S., Chen, H.-Y., & Cheng, M.-H. (2014). Vascularized lymph node flap transfer and lymphovenous anastomosis for klippel-trenaunay syndrome with congenital lymphedema. Plastic and Reconstructive Surgery. Global Open, 2(6), e167. https://doi.org/10.1097/GOX.0000000000000099
Rockson, S. G., & Rivera, K. K. (2008). Estimating the population burden of lymphedema. Annals of the New York Academy of Sciences, 1131, 147-154. https://doi.org/10.1196/annals.1413.014
Saaristo, A. M., Niemi, T. S., Viitanen, T. P., Tervala, T. V., Hartiala, P., & Suominen, E. A. (2012). Microvascular breast reconstruction and lymph node transfer for postmastectomy lymphedema patients. Annals of Surgery, 255(3), 468-473. https://doi.org/10.1097/SLA.0b013e3182426757
Seki, Y., Kajikawa, A., Yamamoto, T., Takeuchi, T., Terashima, T., & Kurogi, N. (2019). The dynamic-lymphaticovenular anastomosis method for breast cancer treatment-related lymphedema: Creation of functional lymphaticovenular anastomoses with use of preoperative dynamic ultrasonography. Journal of Plastic, Reconstructive & Aesthetic Surgery, 72(1), 62-70. https://doi.org/10.1016/j.bjps.2018.09.005
Tarallo, M., Fino, P., Ribuffo, D., Casella, D., Toscani, M., Spalvieri, C., … di Taranto, G. (2018). Liposuction aspirate fluid adipose-derived stem cell injection and secondary healing in fingertip injury: A pilot study. Plastic and Reconstructive Surgery, 142(1), 136-147. https://doi.org/10.1097/PRS.0000000000004506
Viitanen, T. P., Mäki, M. T., Seppänen, M. P., Suominen, E. A., & Saaristo, A. M. (2012). Donor-site lymphatic function after microvascular lymph node transfer. Plastic and Reconstructive Surgery, 130(6), 1246-1253. https://doi.org/10.1097/PRS.0b013e31826d1682
Yamamoto, T., & Koshima, I. (2015). Supermicrosurgical anastomosis of superficial lymphatic vessel to deep lymphatic vessel for a patient with cellulitis-induced chronic localized leg lymphedema. Microsurgery, 35(1), 68-71. https://doi.org/10.1002/micr.22327
Yamamoto, T., Yamamoto, N., Fuse, Y., Narushima, M., & Koshima, I. (2018). Optimal sites for Supermicrosurgical Lymphaticovenular anastomosis: An analysis of lymphatic vessel detection rates on 840 surgical fields in lower extremity lymphedema patients. Plastic and Reconstructive Surgery, 142(6), 924e-930e. https://doi.org/10.1097/PRS.0000000000005042
Yamamoto, T., Yamamoto, N., Yamashita, M., Furuya, M., Hayashi, A., & Koshima, I. (2016). Efferent lymphatic vessel anastomosis: Supermicrosurgical efferent lymphatic vessel-to-venous anastomosis for the prophylactic treatment of subclinical lymphedema. Annals of Plastic Surgery, 76(4), 424-427. https://doi.org/10.1097/SAP.0000000000000381
Yamamoto, T., Yoshimatsu, H., & Yamamoto, N. (2016). Complete lymph flow reconstruction: A free vascularized lymph node true perforator flap transfer with efferent lymphaticolymphatic anastomosis. Journal of Plastic, Reconstructive & Aesthetic Surgery, 69(9), 1227-1233. https://doi.org/10.1016/j.bjps.2016.06.028
Yap, Y. L., Lim, J., Shim, T. W. H., Naidu, S., Ong, W. C., & Lim, T. C. (2009). Patent blue dye in lymphaticovenular anastomosis. Annals of the Academy of Medicine, Singapore, 38(8), 704-706.
Zampell, J. C., Yan, A., Elhadad, S., Avraham, T., Weitman, E., & Mehrara, B. J. (2012). CD4(+) cells regulate fibrosis and lymphangiogenesis in response to lymphatic fluid stasis. PLoS One, 7(11), e49940. https://doi.org/10.1371/journal.pone.0049940