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.
The goal of this consensus conference, sponsored by the American Association of Plastic Surgeons, was to perform a systematic review and meta-analysis of controlled trials to examine both the ...benefits and risks of surgical treatment and surgical prevention of upper and lower extremity lymphedema.
The panel met in Boston for a 3-day, face-to-face meeting in July of 2017. After an exhaustive review of the existing literature, the authors created consensus recommendations using the Grading of Recommendations, Assessment, Development and Evaluation criteria. Important directions for future research were also identified.
There is evidence to support that lymphovenous anastomosis can be effective in reducing severity of lymphedema (grade 1C). There is evidence to support that vascular lymph node transplantation can be effective in reducing severity of lymphedema (grade 1B). Currently, there is no consensus on which procedure (lymphovenous bypass versus vascular lymph node transplantation) is more effective (grade 2C). A few studies show that prophylactic lymphovenous bypass in patients undergoing extremity lymphadenectomy may reduce the incidence of lymphedema (grade 1B). More studies with longer follow-up are required to confirm this benefit. Debulking procedures such as liposuction are effective in addressing a nonfluid component such as fat involving lymphedema (grade 1C). There is a role for liposuction combined with physiologic procedures although the timing of each procedure is currently unresolved (grade 1C).
Many studies seem to support some efficacy of lymphovenous bypass and vascular lymph node transplantation. Many studies show the important role of lymphedema therapy and other procedures such as liposuction and debulking. The management of lymphedema is a challenging field with many promising advances. However, many questions remain unanswered.
We report the outcomes of the European prospective study on prepectoral breast reconstruction using preshaped acellular dermal matrix for complete breast implant coverage. Seventy‐nine patients were ...enrolled between April 2014 and August 2015 all over Europe using a single protocol for patient selection and surgical procedure, according to the Association of Breast Surgery and British Association of Plastic Reconstructive and Aesthetic Surgeons joint guidelines for the use of acellular dermal matrix in breast surgery. The preshaped matrix completely wraps the breast implant, which is placed above the pectoralis major, without detaching the muscle. A total of 100 prepectoral breast reconstructions with complete implant coverage were performed. This series, with mean follow‐up of 17.9 months, had two cases of implant loss (2.0%) including one necrosis of the nipple and one wound breakdown (1.0% respectively). No implant rotations were observed. Good cosmetic outcomes were obtained with natural movement of the breasts and softness to the touch; none of the patients reported experiencing pain or reduction in the movements of the pectoralis major muscle postoperatively. The use of preshaped acellular dermal matrix for a complete breast implant coverage in selected patients is safe and gives satisfactory results, both from the aesthetic view point and the low postoperative complication rates. Further studies reporting long‐term outcomes are planned.
To perform temporal validation of a risk prediction model for breast cancer-related lymphoedema in the European population.
Temporal validation of a previously developed prediction model using a new ...retrospective cohort of women who had undergone axillary lymph node dissection between June 2018 and June 2020.
We reviewed clinical records to identify women who did and did not develop lymphoedema within 2 years of surgery and to gather data regarding the variables included in the prediction model. The model was calibrated by calculating Spearman's correlation between observed and expected cases. Its accuracy in discriminating between patients who did versus did not develop lymphoedema was assessed by calculating the area under the receiver operating characteristic curve (AUC).
The validation cohort comprised 154 women, 41 of whom developed lymphoedema within 2 years of surgery. The value of Spearman's coefficient indicated a strong correlation between observed and expected cases. Sensitivity of the model was higher than in the derivation cohort, as was the value of the AUC.
The model shows a good capacity to discriminate women at risk of lymphoedema and may therefore help in developing improved care pathways for individual patients.
Identifying risk factors for lymphoedema secondary to breast cancer treatment is vital given its impact on women's physical and emotional well-being.
What problem did the study address? Risk of BCRL. What were the main findings? The prediction model has a good capacity to discriminate women at risk of lymphoedema. Where and on whom will the research have an impact? In clinical practice with women at risk of BCRL.
STROBE checklist. WHAT DOES THIS PAPER CONTRIBUTE TO THE WIDER GLOBAL CLINICAL COMMUNITY?: It presents a validated risk prediction model for BCRL.
There was no patient or public contribution in the conduct of this study.
Background and Objectives
In the last years, prepectoral breast reconstruction has increased its popularity, becoming a standard reconstructive technique by preserving pectoralis major anatomy and ...functionality. Nevertheless, the lack of solid and extensive data negatively impacts on surgeons’ correct information about postoperative complication rates and proper patient selection. This study aims to collect the largest evidence on this procedure.
Methods
A multicentre retrospective audit, promoted by the Barcelona Hospital, collected the experience of 30 centers on prepectoral breast reconstruction with Braxon ADM. The study had the scientific support of INPECS and IIB societies which provided the online database Clinapsis.
Results
A total of 1450 procedures were retrospectively collected in a 6‐year period. Mean age 52.4 years, BMI 23.9, follow‐up 22.7 months. Reconstruction was carried out after a tumor in 77.1% of the cases, 20.1% had prophylactic surgery, 2.8% had revisions. Diabetes, smoke, and immunosuppression had an influence on complications occurrence, as well as implant weight. Capsular contracture was associated with postoperative radiotherapy, but the overall rate was low (2.1%). Complications led to implant loss in 6.5% of the cases.
Conclusions
The international Braxon Audit Group multicentre data collection represents a milestone in the field of breast reconstruction, extensively improving the knowledge on this procedure.
Lymphaticovenous anastomosis is widely used in lymphedema management. Although its effectiveness in reducing edema in patients can be clinically observed, evaluating the long-term outcomes of this ...technique can be complex. This study established an animal model to assess the outcomes of lymphaticovenous anastomosis technique at 15 and 30-days post-surgery using indocyanine green lymphography, Patent Blue V dye injection, and histopathological examination.
An experimental model was established in the hindlimbs of 10 rabbits using the popliteal vein and afferent lymphatic vessels in the popliteal area. The subjects were divided into two groups: the first group (n = 5) underwent patency assessment at 0 and 15 days, and the second group (n = 5) at 0 and 30-days, resulting in 20 anastomoses. Patency was verified at 0, 15, and 30-days using indocyanine green lymphography and Patent Blue V injection. Histopathological examinations were performed on the collected anastomosis samples.
The patency rate was 90% (19/20) initially, 60% (6/10) at 15 days post-surgery, and 80% (8/10) at 30-days. The average diameter of lymphatic vessels and veins was 1.0 mm and 0.8 mm, respectively. The median number of collateral veins was 3; the median surgical time was 65.8 min. Histopathology revealed minimal endothelial damage and inflammatory responses due to the surgical sutures, with vascular inflammation and thrombosis in a single case. Local vascular neoformations were observed.
This study highlights the reliability and reproducibility of using rabbits as experimental models for training in lymphaticovenous anastomosis technique owing to the accessibility of the surgical site and dimensions of their popliteal vasculature.
Surgical management of sarcoma has evolved from amputation to limb salvage. Nevertheless, subsequent resections in previously irradiated feet are still challenging to reconstruct. First foot ray ...functional reconstruction is relevant due to its function in weight‐bearing and gait. The reconstruction should include a thin, pliable and non‐shearing skin paddle with vascularized long cortical bone to mimic the first metatarsal. A clinical case of a 37‐year‐old patient with a second sarcoma recurrence of the first metatarsal is presented. The patient was irradiated before this new recurrence and had a previous reconstruction with fibula allograft, but subsequently developed a first metatarsal pseudoarthrosis. A wide resection was performed (3.5 cm bone defect) and immediate soft tissue and bone reconstruction with a chimeric SCIP flap with a 17 × 8 cm skin paddle and 3.5 × 1.5 cm iliac bone (cSCIP‐IB). At 7 months post‐operatively, the patient was able to resumed full weight‐bearing. Three years later, remains without disease progression. CSCIP‐IB is a good option for foot first ray reconstruction in irradiated beds. This flap has low donor site morbidity and a higher ossification success rate compared to bone allografts.
Perioperative transfusions are associated with complications of free flaps. The purpose of the present study was to find out whether there is a significant relationship between the risk of developing ...complications in vascular anastomoses and the history of transfusions.
We studied 372 patients retrospectively with microsurgical reconstruction between 2009 and 2017 with regards to the number of red blood cell concentrates transfused. Complications were analyzed relative to flap loss and complications in microvascular anastomoses.
130 patients (34.9%) received blood transfusions. Some 55% of them were transfused between the day of the intervention and the first postoperative day. Ninety-six patients were reoperated on (25.7%). Of those, thirty-six patients (37.5%) corresponded to anastomosis failure. The percentage of patients transfused among those who required reoperation was 55.2%. The percentage of patients transfused among those who were reoperated on within the first 72 h due to an alteration in the anastomosis was 60.6%, while it was 25.6% (Chi square P = 0.0001) for the rest of the patients.
Although there is a strong association between transfusion and vascular anastomosis failure, it is not possible to establish the causation between the two.
PDF
