Secondary lymphedema of the upper and lower extremities related to prior oncologic therapies, including cancer surgeries, radiation therapy, and chemotherapy, is a major cause of long-term morbidity ...in cancer patients. For the upper extremities, it is most commonly associated with prior oncologic therapies for breast cancer, while for the lower extremities, it is most commonly associated with oncologic therapies for gynecologic cancers, urologic cancers, melanoma, and lymphoma. Both non-surgical and surgical management strategies have been developed and utilized, with the primary goal of all management strategies being volume reduction of the affected extremity, improvement in patient symptomology, and the reduction/elimination of resultant extremity-related morbidities, including recurrent infections. Surgical management strategies include: (i) ablative surgical methods (i.e., Charles procedure, suction-assisted lipectomy/liposuction) and (ii) physiologic surgical methods (i.e., lymphaticolymphatic bypass, lymphaticovenular anastomosis, vascularized lymph node transfer, vascularized omental flap transfer). While these surgical management strategies can result in dramatic improvement in extremity-related symptomology and improve quality of life for these cancer patients, many formidable challenges remain for successful management of secondary lymphedema. It is hopeful that ongoing clinical research efforts will ultimately lead to more complete and sustainable treatment strategies and perhaps a cure for secondary lymphedema and its devastating resultant morbidities.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Lymphedema: Surgical and Medical Therapy Chang, David W; Masia, Jaume; Garza, Ramon ...
Plastic and reconstructive surgery (1963),
2016-September, Letnik:
138, Številka:
3S Current Concepts in Wound Healing: Update 2016
Journal Article
Recenzirano
BACKGROUND:Secondary lymphedema is a dreaded complication that sometimes occurs after treatment of malignancies. Management of lymphedema has historically focused on conservative measures, including ...physical therapy and compression garments. More recently, surgery has been used for the treatment of secondary lymphedema.
METHODS:This article represents the experience and treatment approaches of 5 surgeons experienced in lymphatic surgery and includes a literature review in support of the techniques and algorithms presented.
RESULTS:This review provides the reader with current thoughts and practices by experienced clinicians who routinely treat lymphedema patients.
CONCLUSION:The medical and surgical treatments of lymphedema are safe and effective techniques to improve symptoms and improve quality of life in properly selected patients.
Breast reconstruction is an option that should be considered for any patient facing a mastectomy. Autologous breast reconstruction provides the benefits of excellent longterm results, natural ...appearance, natural feel, and the best opportunity for sensory restoration. These factors lead many patients to choose autologous tissue over implant-based reconstruction. With improved anatomic and technical knowledge, the donor site morbidity previously associated with abdominally based autologous reconstruction has been significantly reduced. Today, the DIEP flap is the preferred autologous method allowing restoration of a "natural," aesthetic breast with potential for sensation while simultaneously minimizing abdominal donor site morbidity. Alternative flaps and adjunctive procedures provide options when dealing with patients who present with challenging clinical scenarios because of an inadequate abdominal donor site. This paper reviews current methods employed by a high volume breast reconstruction practice to achieve these goals.
This study aimed to determine benefits of the Enhanced Recovery After Surgery (ERAS) pathway implementation in free flap breast reconstruction related to postoperative narcotic use and health care ...resource utilization.
A retrospective analysis of consecutive patients undergoing deep inferior epigastric perforator flap breast reconstruction from November of 2015 to April of 2018 was performed before and after implementation of the ERAS protocol.
Four hundred nine patients met inclusion criteria. The pre-ERAS group comprised 205 patients, and 204 patients were managed through the ERAS pathway. Mean age, laterality, timing of reconstruction, and number of previous abdominal surgical procedures were similar (p > 0.05) between groups. Mean operative time between both groups (450.1 ± 92.7 minutes versus 440.7 ± 93.5 minutes) and complications were similar (p > 0.05). Mean intraoperative (58.9 ± 32.5 versus 31.7 ± 23.4) and postoperative (129.5 ± 80.1 versus 90 ± 93.9) morphine milligram equivalents used were significantly (p < 0.001) higher in the pre-ERAS group. Mean length of stay was significantly (p < 0.001) longer in the pre-ERAS group (4.5 ± 0.8 days versus 3.2 ± 0.6 days). Bivariate linear regression analysis demonstrated that operative time was positively associated with total narcotic requirements (p < 0.001) and length of stay (p < 0.001).
ERAS pathways in microsurgical breast reconstruction promote reduction in intraoperative and postoperative narcotic utilization with concomitant decrease in hospital length of stay. In this study, patients managed through ERAS pathways required 46 percent less intraoperative and 31 percent less postoperative narcotics and had a 29 percent reduction in hospital length of stay.
Therapeutic, III.
BACKGROUND:Breast reconstruction plays a significant role in breast cancer treatment recovery. Introduction of the BREAST-Q questionnaire has facilitated quantifying patient-reported quality-of-life ...measures, promoting improved evidence-based clinical practice. Information regarding the effects of body mass index on patient-reported outcomes and health-related quality of life is significantly lacking.
METHODS:Consecutive deep inferior epigastric perforator (DIEP) flap breast reconstruction patients prospectively completed BREAST-Q questionnaires preoperatively and at two points postoperatively. The first (postoperative time point A) and second (postoperative time point B) postoperative questionnaires were completed 1 month postoperatively and following breast revision, respectively. Postoperative flap and donor-site complications were recorded prospectively. BREAST-Q scores were compared at all time points and stratified by body mass index group (≤25, >25 to 29.9, 30 to 34.9, and ≥35 kg/m).
RESULTS:Between July of 2012 and August of 2016, 73 patients underwent 130 DIEP flap breast reconstructions. Breast satisfaction and psychosocial and sexual well-being scores increased significantly postoperatively. Chest and abdominal physical well-being scores returned to baseline levels by postoperative point B. Preoperatively, stratified by body mass index, breast satisfaction and psychosocial well-being scores were significantly lower among patients with body mass index of 35 or higher and of more than 30, respectively. After reconstruction, not only were breast satisfaction, psychosocial, and sexual well-being scores significantly improved in all body mass index groups versus baseline, but also between–body mass index group differences were no longer present. Outcome satisfaction, flap, and donor-site morbidity were similar irrespective of body mass index.
CONCLUSIONS:Patient-reported outcomes demonstrate significant improvements in breast satisfaction and psychosocial and sexual well-being among patients following DIEP flap reconstruction. Preoperative differences in quality-of-life scores were improved in patients with obesity (body mass index ≥30 kg/m).
CLINICAL QUESTION/LEVEL OF EVIDENCE:Risk, II.
Without reconstruction, mastectomy alone can produce significant detrimental effects on health-related quality of life. The magnitude of quality-of-life benefits following breast reconstruction may ...be unique based on timing of reconstruction. Facilitated by the BREAST-Q questionnaire, characterization of how reconstruction timing differentially affects patient-reported quality of life is essential for improved evidence-based clinical practice.
Consecutive DIEP flap breast reconstruction patients prospectively completed BREAST-Q questionnaires preoperatively and at two different time intervals postoperatively. The first (postoperative time point A) and second (postoperative time point B) postoperative questionnaires were completed 1 month postoperatively and following breast revision/symmetry procedures, respectively. Postoperative flap and donor-site complications were recorded prospectively. Stratified by timing (immediate versus delayed) of reconstruction, preoperative clinical data, operative morbidity, and BREAST-Q scores were compared at all time points.
Between July of 2012 and August of 2016, 73 patients underwent 130 DIEP flap breast reconstructions. Collectively, breast satisfaction, psychosocial well-being, and sexual well-being scores significantly (p < 0.001) increased postoperatively versus baseline. Chest and abdominal physical well-being scores returned to baseline levels by postoperative time point B. Preoperatively, patients undergoing delayed breast reconstruction reported significantly (p < 0.05) lower breast satisfaction, psychosocial well-being, and sexual well-being scores compared to immediate reconstruction patients. Postoperatively, delayed and immediate reconstruction patients reported similar quality-of-life scores. Outcome satisfaction and flap and donor-site morbidity were similar between groups irrespective of timing of reconstruction.
In this prospective study, patient-reported outcomes demonstrate significant improvements in breast satisfaction, psychosocial well-being, and sexual well-being among patients following DIEP flap reconstruction. Moreover, preoperative differences in quality-of-life scores among delayed/immediate reconstruction patients were eliminated postoperatively.
Therapeutic, II.
Operative morbidity is a common yet modifiable feature of complex surgical procedures. With increasing case volume, improvement in morbidity has been reported through designated procedural processes ...and greater repetition. Defined as a volume-outcome association, improvement in breast reconstruction morbidity with increasing free flap volume requires further characterization.
A retrospective analysis was conducted among consecutive free flap patients using a two-microsurgeon model between January of 2002 and December of 2017. Patient demographics and operative characteristics were obtained from medical records. Complications including unplanned surgical intervention (take-back) and flap loss were obtained from prospectively kept databases. Individual surgeon operative volume was estimated by considering overall practice volume and correcting for the number of surgeons at any given time.
During the study period, 3949 patients met inclusion criteria. A total of 6607 breasts underwent reconstruction with 6675 free flaps. Mean patient age was 50 ± 9.4 years and mean body mass index was 28.8 ± 5.0 kg/m2. Bilateral reconstruction was performed on 2633 patients (66.5 percent), with 4626 breasts (70.5 percent) reconstructed in the immediate setting. Overall, breast and donor-site complications were reported in 507 breasts (7.7 percent) and 607 cases (15.4 percent), respectively. Take-back was required in 375 cases (9.5 percent), with complete flap loss occurring in 57 cases (0.9 percent). Based on annual flaps per surgeon, the incidence of complications decreased with increasing volume (slope = -0.12; p = 0.056).
Through procedural efficiency and execution of defined clinical processes using a two-microsurgeon model, increases in microsurgical breast reconstruction case volume result in decreased morbidity.
Therapeutic, IV.
The standard of care for treatment of lymphedema is manual lymphatic drainage and compression therapy, which is time intensive and requires a life-long commitment. Autologous lymph node transfer is a ...microsurgical treatment in which a vascularized lymph node flap is harvested with its blood supply and transferred to the lymphedematous region to assist with lymph fluid clearance. An ideal donor lymph node site minimizes the risk of iatrogenic lymphedema and other donor site morbidity. To address this, we have used jejunal mesentery lymph nodes and omental flaps and hypothesize that the mesoappendix, as a “spare part,” may be an ideal autologous lymph node transfer donor site.
In this Institutional Review Board–approved study, 25 mesoappendix pathology specimens resected for benign disease underwent gross pathologic examination for the presence of lymph nodes and measurement of the appendicular artery and vein caliber and length.
A single lymph node was present in two of 25 specimens (8%). Mean arterial and vein calibers at the point of ligation were 0.87 ± 0.44 mm and 0.86 ± 0.48 mm (range 0.30-2.2 mm and 0.25-2.2 mm), respectively. Mean arterial and vein length was 1.70 ± 1.06 cm and 1.84 ± 1.09 cm (range 0.8-4.5 cm for each), respectively.
The mesoappendix rarely contains a lymph node. The artery and vein calibers of 46% of the specimens were greater than 0.8 mm, the minimum caliber preferred for microsurgical anastomosis. If transplantation of a vascularized lymph node for the treatment of lymphedema is desired, the mesoappendix is inconsistent in providing adequate lymph nodes.
Breast implant surgery is one of the most commonly performed procedures in the field of plastic surgery. While silicone implants are now routinely used in breast surgery, they have previously been ...the subject of controversy. This was particularly true in the U.S., where there was a moratorium on their use from 1992 to 2006. Following subsequent scientific validation of their safety, silicone implants have re-gained widespread acceptance for clinical use. Modern implant design has aimed to optimize aesthetic outcomes while minimizing implant-related complications, such as capsular contracture and device rupture. One of the most significant advances has been the use of highly cohesive silicone which, through extensive cross-linking, maintains its shape within the body in the presence of physiologic forces. Overall, silicone breast implants are associated with a high degree of patient satisfaction and low rates of complications. Further independent research is necessary to better establish long-term outcomes.
Introduction
Breast cancer‐related extremity lymphedema is a potentially devastating condition. Vascularized lymph node transfer (VLNT) has shown benefit in lymphedema treatment. Due to concerns over ...potential iatrogenic complications, various donor sites have been described. The current study aims at defining the deep inferior epigastric lymph node basin as a novel donor site for VLNT.
Methods
A retrospective study was performed on patients undergoing routine abdominal‐based breast reconstruction. Resection of all perivascular adipose and lymphatic tissue surrounding the proximal deep inferior epigastric pedicle was performed at the time of pedicle dissection and submitted for Pathologic evaluation. Patient demographics and pertinent medical/surgical history was obtained from medical records.
Results
Specimens were obtained from 10 consecutive patients. Seven patients underwent bilateral reconstruction for a total of 17 specimens obtained. Mean patient age and BMI were 48 years ± 9.4 and 27 ± 4.2, respectively. Fourteen out of 17 (82%) specimens contained viable lymph nodes displaying a thin fibrous connective tissue capsule overlying an unremarkable subcapsular sinus with a cortex and paracortex containing germinal centers composed of B lymphocytes, tangible body macrophages, and T‐cells. The medullary sinus space displayed a fatty unremarkable hilum. The mean number and size of lymph nodes were 2.6 ±1.2 nodes/specimen and 3.67 mm ± 2.3, respectively. All patients experienced an uneventful postoperative course without evidence any of compromised flap viability.
Conclusion
Lacking previous description, the deep inferior epigastric lymph node basin is a readily accessible donor site with significant anatomic advantages for potential VLNT during autologous breast reconstruction.
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