Clinical progress of microsurgical management for lymphedema
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Objective To review the clinical progress of microsurgical management for lymphedema. Methods The literature on microsurgical treatment for lymphedema at home and abroad in recent years was reviewed and analyzed. Results At present, conservative treatment is the main treatment for lymphedema, which has limited effectiveness only for early stages of lymphedema; and it is not curative and demands patient compliance. In contrast, microsurgical approaches can solve the problems in the prevention or management of lymphedema and showed promising results, such as lymphatic-venous anastomosis (LVA), vascularized lymph node transfer (VLNT), and other lymphatic reconstructions. Conclusion Microsurgical approaches like LVA and VLNT have been broadly used in recent years, the effectiveness and safety have been proved. But the evidence of long-term randomized controlled studies is still required to establish standard treatment practices.Keywords:
Conservative Management
Abstract Objectives: To report the wide clinical experience and the research studies in the microsurgical treatment of peripheral lymphedema. Methods: More than 1800 patients with peripheral lymphedema have been treated with microsurgical techniques. Derivative lymphatic microvascular procedures recognize today its most exemplary application in multiple lymphatic‐venous anastomoses (LVA). In case of associated venous disease reconstructive lymphatic microsurgery techniques have been developed. Objective assessment was undertaken by water volumetry and lymphoscintigraphy. Results: Subjective improvement was noted in 87% of patients. Objectively, volume changes showed a significant improvement in 83%, with an average reduction of 67% of the excess volume. Of those patients followed‐up, 85% have been able to discontinue the use of conservative measures, with an average follow‐up of more than 10 years and average reduction in excess volume of 69%. There was a 87% reduction in the incidence of cellulitis after microsurgery. Conclusions: Microsurgical LVA have a place in the treatment of peripheral lymphedema, and should be the therapy of choice in patients who are not sufficiently responsive to nonsurgical treatment. © 2010 Wiley‐Liss, Inc. Microsurgery, 2010.
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Secondary lymphedema
Animal model
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Background: Conservative nonsurgical treatment has traditionally been applied to lymphedema. Early surgical procedures were invasive and disfiguring and their long-term success was often limited. In contrast, contemporary surgical techniques are much less invasive and have been shown to be effective in reducing excess limb volume, the risk of cellulitis, and the need for compression garments. Microsurgical procedures such as lymphovenous anastomosis and vascularized lymph node transfer can treat the excess fluid component of lymphedema and are gaining in popularity. In this study, we first evaluate the possibility of generating lymphedema in the hind limb of a rabbit and then describe its treatment with microsurgical lymph node transfer without lymph vessel transfer. Methods and Results: In experimental rabbit models, animals first underwent surgery in which the popliteal lymph node was removed to create lymphedema in the hind limb. After 15 days, another operation was performed to excise the contralateral popliteal lymph node and transfer it to the limb with lymphedema. Our model showed that lymph node transfer was able to reduce lymphedema in the rabbit's hind limb; intervened hind limb: basal volume (51.94 ± 11.23), volume day transfer (73.40 ± 26.47), and final volume (50.13 ± 12). Conclusion: We have developed a feasible model to microsurgically induce and treat lymphedema by lymph node transfer that shows promising results.
Hindlimb
Groin
Lymphangiogenesis
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Lymphedema is a chronic, morbid condition in which the upper or lower extremity experiences swelling and fibrosis due to impaired lymphatic clearance. Among breast cancer patients, this condition is primarily attributed to axillary lymph node dissection (ALND) performed for oncologic management. While nonoperative and operative approaches to lymphedema management may be implemented to “manage” this condition, they are typically not curative. Therefore, lymphedema prevention in patients who have undergone ALND is of critical importance. Here, we briefly describe lymphedema and available management strategies, and focus on prevention in patients undergoing ALND using the Lymphatic Microsurgical Preventive Healing Approach (LYMPHA). Currently available clinical and experimental evidence suggests that LYMPHA may provide protection against the development of lymphedema in carefully selected patients. This procedure can serve as an adjunct surgical option for patients at the time of ALND.
Secondary lymphedema
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Lymphangitis
Surgical oncology
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Secondary lymphedema
DIEP flap
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Abstract Lymphedema is a chronic, debilitating condition that causes physical and psychological morbidity, affecting up to 250 million people worldwide. In the United States and other developed countries, cancer and its treatments are the most common causes of lymphedema. Lymphedema can evolve into progressive swelling, fibrosis, functional deficits, and chronic infections, thus adversely affecting quality of life and health care costs. Unfortunately, no definitive treatment for lymphedema currently exists. The advents of microsurgery, and more recently supermicrosurgery, have had a major impact on the evolution of these physiologic procedures, which have gained popularity to help reduce the severity of lymphedema. Lymphatic Bypass LVB are typically performed through incisions 2-3 cm in length and the number of bypasses can vary depending on a patient as well as a surgeon. In our prospective study in 100 consecutive patients, we have found that LVB can be effective in reducing lymphedema severity, particularly in patients with early-stage, upper-extremity lymphedema with reasonable amount of intact functioning lymphatic vessels and minimal tissue fibrosis. One recent technological advance in lymphovenous bypass procedures is the use of indocyanine green (ICG) fluorescence lymphangiography to map lymphatic vessels. ICG fluorescence lymphangiography enables surgeons to locate and make incisions precisely over functional lymphatic vessels for the lymphovenous bypass, substantially reducing operating time and may significantly improve the outcomes of LVB surgeries. Vascularized Lymph Node Transfer This procedure aims to bring vascularized tissue and healthy lymph nodes into sites affected by lymphedema. A flap containing lymph nodes can then be harvested typically from either the cervical region, axillary region or from the inguinal region. One proposed theory for mechanism is that lymphangiogenesis occur via growth factors produced by the transplanted lymph nodes and thereby bridging lymphatic pathways. A second proposed theory of mechanism is that vascularized lymph node transfer act as a lymphatic pump. Recently, simultaneous breast reconstruction using the transverse lower abdominal flap harvested with inguinal lymph nodes have gained popularity as a convenient option for lymphedematous women who desire reconstruction after mastectomy. Conclusions Currently there is no cure for lymphedema. Worldwide interest in using microsurgical procedures to treat lymphedema is gaining momentum. However, there is no consensus on the indications for which procedure to perform, when to intervene, or how to comparatively grade outcomes. We need further research and better understanding of lymphatic anatomy and lymphedema pathophysiology. In addition, more prospective and controlled studies are needed to objectively evaluate the outcomes of various treatment methods. Citation Format: Chang D. Microsurgical treatment of lymphedema [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr ES11-3.
Indocyanine Green
Lymphatic vessel
Secondary lymphedema
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There has been a paradigm shift in the management of lymphedema with a better understanding of the functioning of lymphatics with the introduction of “lymphosome concept” and with the recent advances in super-microsurgical techniques. The most frequently used intraoperative imaging modality now is indo cyanine green lymphangiography. In endemic countries, any patient with lymphedema without prior history of trauma or, oncosurgical or radiotherapy interventions must undergo Alere filariasis test strip. Patients in early stages of disease can benefit from complex decongestive therapy and physiologic surgical procedures such as lymphovenous anastomosis or vascularized lymph node transfers. However, in advanced disease, excisions or debulking through radical reduction with preservation of perforators will be required. The localized adipose tissue deposits in lymphedema can be removed by liposuction. At present, there is still no cure for lymphedema, but emerging research in tissue engineering, lymphangiogenic growth factors, and immunomodulatory therapy may provide better management options for lymphedema in future.
Liposuction
Debulking
Lymphangiogenesis
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