Surgical options for lymphedema after gynecological cancer treatment: current trends and advances.

Lower leg lymphedema is an important complication after gynecological treatment that can severely affect the quality of life of long-term survivors of these malignancies. As a chronic and progressive disease, affected patients will require life-long therapy centered on compression. Although conventional compressive treatments can be effective, they are extremely burdensome and time-consuming for most patients and adherence is challenging. With advances in the field of reconstructive microsurgery, new procedures have been developed in the past decades to help these patients in their continuous care and have been offered at many oncological centers around the world as a first line of treatment. We performed a PubMed search using the Mesh terms 'Lymphedema/surgery' and 'Lower extremity' yielding a total of 508 articles. Of these, 35 articles were included for analysis. Articles that failed to provide a comprehensive analysis of outcomes following surgical treatment, studies examining treatment for upper limb lymphedema, primary lymphedema, or lower extremity lymphedema resulting from non-gynecologic etiologies, and studies that failed to have a minimum of 6 months follow-up were excluded. A comprehensive review of these 35 articles including over 1200 patients demonstrated large variability on the outcomes reported; however, an overall benefit from these procedures was found. Surgical options including lymphovenous anastomosis, vascularized lymph node transfers, and excisional procedures can be performed in patients with lower leg lymphedema, depending on staging and findings in indocyanine green lymphography. Surgical treatment of lymphedema is an effective option that can improve symptoms and quality of life of patients suffering from lymphedema following gynecologic cancers.

Misdiagnosis of Uncomplicated Cellulitis: a Systematic Review and Meta-analysis.

BACKGROUND: Cellulitis is a clinical diagnosis with several mimics and no gold standard diagnostic criteria. Misdiagnosis is common. This review aims to quantify the proportion of cellulitis misdiagnosis in primary or unscheduled care settings based on a second clinical assessment and describe the proportion and types of alternative diagnoses. METHODS: Electronic searches of Medline, Embase and Cochrane library (including CENTRAL) using MeSH and other subject terms identified 887 randomised and non-randomised clinical trials, and cohort studies. Included articles assessed the proportion of cellulitis misdiagnosis in primary or unscheduled care settings through a second clinical assessment up to 14 days post initial diagnosis of uncomplicated cellulitis. Studies on infants and patients with (peri-)orbital, purulent and severe or complex cellulitis were excluded. Screening and data extraction was conducted independently in pairs. Risk of bias was assessed using a modified risk of bias tool from Hoy et al. Meta-analyses were undertaken where ≥ 3 studies reported the same outcome. RESULTS: Nine studies conducted in the USA, UK and Canada, including a total of 1600 participants, were eligible for inclusion. Six studies were conducted in the inpatient setting; three were in outpatient clinics. All nine included studies provided estimates of the proportion cellulitis misdiagnosis, with a range from 19 to 83%. The mean proportion misdiagnosed was 41% (95% CI 28 to 56% for random effects model). Heterogeneity between studies was very high both statistically (I2 96%, p-value for heterogeneity < 0.001) and clinically. Of the misdiagnoses, 54% were attributed to three conditions (stasis dermatitis, eczematous dermatitis and edema/lymphedema). DISCUSSION: The proportion of cellulitis misdiagnosis when reviewed within 14 days was substantial though highly variable, with the majority attributable to three diagnoses. This highlights the need for timely clinical reassessment and system initiatives to improve diagnostic accuracy of cellulitis and its most common mimics. TRIAL REGISTRATION: Open Science Framework ( https://osf.io/9zt72 ).

Primary Prevention of Cancer-Related Lymphedema Using Preventive Lymphatic Surgery: Systematic Review and Meta-analysis.

Background Several studies have proven prophylactic lymphovenous anastomosis (LVA) performed after lymphadenectomy can potentially reduce the risk of cancer-related lymphedema (CRL) without compromising the oncological treatment. We present a systematic review of the current evidence on the primary prevention of CRL using preventive lymphatic surgery (PLS). Patients and Methods A comprehensive search across PubMed, Cochrane-EBMR, Web of Science, Ovid Medline (R) and in-process, SCOPUS, and ScienceDirect was performed through December 2020. A meta-analysis with a random-effect method was accomplished. Results Twenty-four studies including 1547 patients fulfilled the inclusion criteria. Overall, 830 prophylactic LVA procedures were performed after oncological treatment, of which 61 developed lymphedema. The pooled cumulative rate of upper extremity lymphedema after axillary lymph node dissection (ALND) and PLS was 5.15% (95% CI, 2.9%-7.5%; p < 0.01). The pooled cumulative rate of lower extremity lymphedema after oncological surgical treatment and PLS was 6.66% (95% CI < 1-13.4%, p-value = 0.5). Pooled analysis showed that PLS reduced the incidence of upper and lower limb lymphedema after lymph node dissection by 18.7 per 100 patients treated (risk difference [RD] - 18.7%, 95% CI - 29.5% to - 7.9%; p < 0.001) and by 30.3 per 100 patients treated (RD - 30.3%, 95% CI - 46.5% to - 14%; p < 0.001), respectively, versus no prophylactic lymphatic reconstruction. Conclusions Low-quality studies and a high risk of bias halt the formulating of strong recommendations in favor of PLS, despite preliminary reports theoretically indicating that the inclusion of PLS may significantly decrease the incidence of CRL.

Lymphatic imaging and intervention in a pediatric population: Anesthetic considerations.

The recent adoption of an improved lymphatic access technique coupled with Dynamic Contrast-enhanced Magnetic Resonance Lymphangiography has introduced the ability to diagnose and treat severe lymphatic disorders unresponsive to other therapies. All pediatric patients presenting for lymphatic procedures require general anesthesia presenting challenges in managing highly morbid and comorbid conditions both from logistical as well as medical aspects. General anesthesia is used because of the procedural requirement for immobility to accurately place needles and catheters, treat pain secondary to contrast and glue injections, and to accommodate additional procedures. We reviewed a one-year cohort of all pediatric patients in a newly created Center for Lymphatic Imaging and Intervention at a tertiary care children's hospital presenting for lymphatic procedures. The patients ranged in age from 4 days to 17 years and weighed from 2.5 to 92 kg. There were 106 anesthetics for 68 patients. Patients were functionally impaired (98% ASA 3 or 4) and included significant comorbidities (79.4%). Concurrent with lymphatic imaging and intervention additional procedures were frequently performed (76%). They included cardiac catheterization, bronchoscopy, endoscopy, and drain placement (thoracic or abdominal). Paralysis and controlled ventilation was used for all interventions. Reversal of paralysis and tracheal extubation occurred in all patients not previously managed by invasive respiratory support. All patients having an intervention were admitted to intensive care for observation where escalation of care or complications (fever, hypotension, bleeding, or stroke) occurred in 25% in the first 24 hours.

Outcomes of vascularized versus non-vascularized lymph node transplant in animal models for lymphedema. Review of the literature.

Lymph node transfer has been performed to treat lymphedema for several years. The goal of this procedure is to provide a bridge between the lymphatic system distal and proximal to the lymph node dissection. There is a lack of consensus about the necessity of an additional vascular anastomosis for the transplanted lymph nodes. A systematic literature search in Cochrane Library database CENTRAL, MEDLINE, and EMBASE of animal studies using lymph node transplantation with and without additional vascularization was performed in March 2016. The strategy used for the search was: (("Models, Animal"[Mesh]) AND (("Lymphedema"[Mesh]) OR "Lymph Nodes"[Mesh]) OR "Lymph Node Excision"[Mesh])) AND ((vascularized lymph node transfer) OR ((non-vascularized lymph node transfer) OR lymph node graft)). The primary outcomes were: survival of transplanted lymph node and lymphatic vessel regeneration. Sixteen studies were included. Vascularization and the use of growth factors were significantly associated with lymph node survival. Lymphatic vessels regeneration was independent from vascularization. According to the results of the current study, additional vascular anastomosis might improve the transplanted lymph node survival. Further studies in both experimental and clinical setting are needed in order to support it. J. Surg. Oncol. 2017;115:32-36. © 2016 Wiley Periodicals, Inc.

Hypofractionation for Regional Nodal Irradiation in Breast Cancer: Best of Both the Worlds.

Locoregional radiotherapy play an important role in controlling the disease after surgery in patients with breast cancer. Radiotherapy schedules vary from conventional fraction to hypofractionation. The purpose of this review is to get an insight into the data on regional nodal irradiation (RNI) with hypofractionation in patients with breast cancer. This systematic review was constructed in accordance with Preferred Reporting Items for Systematic reviews and Meta-analysis (PRISMA) framework. Electronic databases such as PubMed, Cochrane and EMBASE were searched from January 1, 2023 to March 31, 2023 to identify studies published in English language on hypofractionated RNI in post mastectomy patients. The search was carried out with the National Library of Medicine's Medical Subject Heading (MeSH) terms like "regional nodal irradiation," "hypofractionated" and "hypofractionation in breast cancer" with different Boolean operators (and/or). A manual search of reference lists of included articles was also performed to make sure there were no additional cases unidentified from the primary search. Studies deemed potentially eligible were identified and assessed by same independent reviewers to confirm eligibility. RNI data are mainly from a randomized study from Beijing and pooled data from START trials. There are also data from retrospective and single institutional studies and a few phase II studies with limited number of patients using different dose fractionations and techniques of radiotherapy. Doses used in these trials ranged from 26-47.7 Gy in 5-19 fractions over 1-4 weeks. Grade ≥ 2 pulmonary fibrosis and lymphedema rate ranged from 2%-7.9% and 3%-19.8% respectively. Grade ≥ 2 shoulder dysfunction and brachial plexopathy ranged from 0.2%-28% and 0%-< 1%, respectively. Late effects with a dose range of 26-40 Gy delivered in 5 to 15 fractions over 1-3 weeks were less/similar to conventional fraction. Current data showed lower/similar rates of toxicity with hypofractionated RNI compared with conventional fractionation RNI. Doses of 26 Gy to 40 Gy delivered in 5 to 15 fractions over 1-3 weeks are safe for RNI. With limited data, ultra-hypofractionation 26 Gy/5 fractions/1 week also seems to be safe. However, long-term outcome is awaited and many trials are going on to address its efficacy and safety.

Complex physical therapy employing self-adjusting garment (ReadyWrap®) in breast cancer-related lymphedema cases in Brazilian women: a protocol for a randomized controlled trial.

BACKGROUND: Lymphedema is a common complication following breast cancer treatment. The aim of this study is to evaluate the effectiveness of a self-adjusting compression garment (ReadyWrap®) in reducing (phase 1) and maintaining (phase 2) upper limb volume in women presenting breast cancer-related lymphedema. METHODS: This study will comprise a randomized, controlled, single-blind clinical trial concerning women with breast cancer-related lymphedema undergoing treatment at a public cancer treatment reference hospital in the city of Rio de Janeiro, Brazil. The intervention will be carried out by adapting self-dressing versus the standard treatment of compressive bandaging (phase 1) and compressive mesh (phase 2). Both groups will be assessed at the beginning and end of intensive treatment and followed up for up to 12 months to evaluate immediate and late outcomes. Assessments will be carried out by physical upper limb examination (inspection, palpation, volume, dynamometry, and thermography) and questionnaires application to assess patient's quality of life pertaining to the health, functionality, and symptoms of the affected upper limb, as well adverse effects and adherence to treatment. Data will be analyzed descriptively and analytically through univariate and multiple linear regressions. P values < 0.05 will be considered statistically significant. DISCUSSION: This study will evaluate the effectiveness of a self-adjustable garment (ReadyWrap®) in the treatment of lymphedema secondary to breast cancer in Brazilian women compared to the gold standard treatment for limb volume reduction (phase 1) and maintenance (phase 2) phases comprising, respectively, a compressive bandaging and a compressive mesh. The outcome results will provide data based on both quantitative responses and self-reported participant outcomes. The study will also assess the cost-effectiveness of the ReadyWrap® treatment versus standard care. Finally, we expect to reaffirm one more product/therapy as a treatment for this extremely complex and impactful condition following the data analysis. TRIAL REGISTRATION: NCT04934098 [Clinical trials phase 1]. Registered on June 22, 2021. NCT04881604 [Clinical trials phase 2]. Registered on May 11, 2021.

Secondary Lymphedema: Clinical Interdisciplinary Tricks to Overcome an Intriguing Disease.

Secondary lymphedema is a complex pathology which is very impairing to the patient, consisting of fluid accumulation in the tissue, accompanied by alteration of the interstitial fibrous tissue matrix, deposition of cellular debris and local inflammation. It develops mostly in limbs and/or external genitals because of demolishing oncological surgery with excision of local lymph nodes, or it may depend upon inflammatory or infective diseases, trauma, or congenital vascular malformation. Its treatment foresees various approaches, from simple postural attitude to physical therapy, to minimally invasive lymphatic microsurgery. This review focuses on the different types of evolving peripheral lymphedema and describes potential solutions to single objective symptoms. Particular attention is paid to the newest lymphatic microsurgical approaches, such as lymphatic grafting and lympho-venous shunt application, to successfully heal, in the long term, serious cases of secondary lymphedema of limbs or external genitals. The presented data also emphasize the potential role of minimally invasive microsurgery in enhancing the development of newly formed lymphatic meshes, focusing on the need for further accurate research in the development of microsurgical approaches to the lymphatic vascular system.

Interdisciplinary aspects of abdominal and plastic surgery - what does the (abdominal) surgeon need to know?

Introduction: The aim was to reflect the established interdisciplinary aspects of general/abdominal and plastic surgery by means of a narrative review. Methods: (i) With specific references out of the medical literature and (ii) own clinical and perioperative as well as operating technical and tactical management experiences obtained in surgical daily practice, we present a choice of options for interdisciplinary cooperation that could be food of thought for other surgeons. Content: - Decubital ulcers require pressure relieve, debridement and plastic surgery coverage, e.g., by a rotation flap plasty, V-Y flap or "tensor-fascia-lata" (TFL) flap depending on localization (sacral/gluteal defects, ischiadic tuber). - Coverage of soft tissue defects, e.g., after lymph node dissection, tumor lesions or disturbance of wound healing can be managed with fasciocutaneous or muscle flaps. - Bariatric surgery: Surgical interventions such as butt lift, tummy tuck should be explained and demonstrated in advance and performed commonly after reduction of the body weight. - Abdominoperineal rectum extirpation (APE): Holm's procedure with greater circumferential extent of resection at the mesorectum and the insertion site of the levator muscle at the anal sphicter muscle resulting in a substantial defect is covered by myocutaneous flap plasty. - Hernia surgery: Complicated/recurrent hernias or abdominal wall defect can be covered by flap plasty to achieve functional reconstruction, e.g., using innervated muscle. Thus, abdominal wall can respond better onto changes of pressure and tension. - Necrotising fasciitis: Even in case of suspicious fasciitis, an immediate radical debridement must be performed, followed by intensive care with calculated antibiotic treatment; after appropriate stabilization tissue defects can be covered by mesh graft of flap plasty. - Soft tissue tumor lesions cannot be resected with primary closure to achieve appropriate as intended R0 resection status by means of local radical resection all the time - plastic surgery expertise has to be included into interdisciplinary tumor concepts. - Liposuction/-filling: Liposuction can be used with aesthetic intention after bariatric surgery or for lipedema. Lipofilling is possible for reconstruction and for aesthetic purpose. - Reconstruction of lymphatic vessels: Lymphedema after tumor operations interrupting or blocking lymphatic drainage can be treated with microsurgical reconstructions (such as lympho-venous anastomoses, lympho-lymphatic anastomoses or free microvascular lymph node transfer). - Microsurgery: It is substantial part of modern reconstructive plastic surgery, i.e., surgery of peripheral nerves belongs to this field. For visceral surgery, it can become important for reconstruction of the recurrent laryngeal nerve. - Sternum osteomyelitis: Radical debridement (eventually, complete sternal resection) with conditioning of the wound by vacuum-assisted closure followed by plastic surgery coverage can prevent chronification, threatening mediastinitis, persisting infectious risk, long-term suffering or limited quality of life. Summary: The presented selection of single topics can only be an excerpt of all the options for surgical cooperation in daily clinical and surgical practice. Outlook: An interdisciplinary approach of abdominal and plastic surgery is characterized by a highly developed cooperation in common surgical interventions including various techniques and tactics highlighting the specifics of the two fields.

Panniculus morbidus resection complicated by multiple gastrointestinal hernias: A case report.

Introduction: Prevalence of obesity and obesity-related complications are steadily rising in the United States. Panniculus morbidus is a rare end stage complication of abdominal obesity characterized by excess abdominal skin and subcutaneous tissue induced by severe lymphedema. The resulting pannus can limit a patient's mobility, impair activities of daily living including hygiene maintenance and subject the skin and soft tissue to intertrigo, cellulitis and chronic skin ulcerations. Case presentation: We present the case of a 39-year-old female with a BMI of 57 kg/m2 who presented for evaluation of primary umbilical and ventral hernias, as well as a large pannus causing significant abdominal and back pain. A massive panniculectomy with hernia repair was performed to correct the gastrointestinal herniation and panniculus. Clinical discussion: Panniculus morbidus is a debilitating complication of longstanding obesity. Massive panniculectomy is one of the only treatments available to restore functional status and facilitate future weight loss. Ventral and umbilical hernias commonly accompany panniculus morbidus and can pose a challenge to repair. Conclusion: This case demonstrates that both panniculus morbidus and multiple primary gastrointestinal hernias can be effectively managed with a panniculectomy and concomitant hernia repair with onlay mesh, all together safely improving patient ambulation, weight loss and quality of life.

What does a (general and abdominal) surgeon need to know on plastic surgery?

BACKGROUND: Plastic surgery was first introduced as a sub-specialty of general surgery in Germany in 1978. Since then, this surgical subspecialty/discipline has evolved enormous potential, e.g. in collaboration with other disciplines such as general andabdominal surgery. AIM: To highlight and summarize the basic potential, technical options and novel aspects of plastic surgery, which are relevant for the common interdisciplinary surgical strategies of plastic and general as well as abdominal surgery in clinical practice. METHOD: Short and compact narrative review based on 1) a selection of relevant references from the medical scientific literature and 2) surgical experiences obtained in daily practice. R esults (selected corner points): 1) Biological protection procedures in vascular surgery by flap coverage after meticulous debridement with or without autogenic vascular reconstruction are used to overcome infection of a vascular prosthesis, a serious problem, associated with the risk of anastomotic rupture and bleeding by transfer of immunological competence due to tissue coverage and finally to induce healing in the area of an infected vascular prosthesis. 2) Fistula treatment for aorto-tracheal or aorto-duodenal fistulas, a big challenge for the referring general surgeon, can be treated by flap coverage, i.e. interposition of the pectoralis-major flap and the omentum-majus flap, respectively. 3) With regard to nerve surgery, encouraging results have been reported after early microsurgical recurrent laryngeal nerve repair, i.e. improved subjective voice quality or reconstitution of respiratory capacity in diaphragmatic. 4) Lymphatic surgery for lymphedema occurring either primarily due to an absence or lack of lymphatic vessels or secondarily due to infection, trauma, radiation therapy or surgery can be indicated in specialized microsurgical centers, e.g. for surgical repair of the lymphatic pathway: I) the interrupted lymphatic system can be reconstructed by an interposition, or II) the lymphatic fluid can be drained extraanatomically (e.g. by a lymphatic-venous anastomosis). Further techniques are the following: free lymph node transplantation included in a free vascularized groin flap or autologous lymphatic vessel transfer or vein graft interposition (used for lymphatic vessel interposition). 5) Mass reduction such as dermolipectomy with subsequent split-thickness is a valuable option, which provides excellent volume reduction. 6) Defect coverage: A. Split- or full-thickness skin grafts are a common method of defect coverage (in cases of clean and well-vascularized wound bed and lacking donor skin, or if the graft bed is of questionable quality) using various allogenic or xenogenic skin substitute materials. B. Further methods offer a wide-range armamentarium of local and free fasciocutaneous and musculocutaneous flaps, e.g. after abdomino-perineal rectum extirpation using the vertical rectus-abdominis myocutaneous flap (VRAM) or propeller flaps according to the "angiosome". 7) Abdominal wall hernia closure with instable skin coverage, flap closure, either alone or in combination with mesh is superior to mesh closure only. 8) Free flaps: If there is no option for a local or pedicled flap available, free flaps can be well used for abdominal wall defect closure (complication rate in experienced hands is low). CONCLUSION: Plastic surgery is an indispensable partner for specific surgical problems and clinical situations of general and abdominal surgery, which indicates that each general and abdominal surgeon should be well notified on great options and surgical techniques offered by modern plastic surgery to achieve best outcomes and quality of life for patients and should combine the expertise of these two surgical disciplines.

Quality of Life Questionnaires in Breast Cancer-Related Lymphedema Patients: Review of the Literature.

PURPOSE: Lymphedema of the arm is one of the most common and underestimated side effects of breast cancer treatment. It is known to negatively affect the quality of life (QoL) in breast cancer survivors. However, there are multiple questionnaires used to measure QoL in lymphedema patients. The current study aimed to determine the most complete and accurate questionnaire. METHODS: A systematic literature search in Cochrane Library database CENTRAL, MEDLINE, and EMBASE was conducted in August 2016 by two independent researchers. The strategy used for the search was: (("Lymphedema"[Mesh]) AND ("Quality of life"[Mesh])). All QoL questionnaires for patients with breast cancer-related lymphedema (BCRL) were included. An overview of the assessed QoL domains and arm symptom-specific questions was made, to assess the most complete and accurate questionnaire. RESULTS: A total of 142 studies were identified, of which 49 met the inclusion criteria and 15 different questionnaires were extracted. The Lymphedema Quality of Life Inventory (LyQLI), assesses all QoL domains, except for the possibility of wearing the clothes of choice, and assess all specific arm symptoms. The Lymphedema Functioning, Disability, and Health (Lymph-ICF) Questionnaire assesses all QoL domains, except for sexual functioning, and does assess all specific arm symptoms. CONCLUSION: According to the results obtained, the LyQLI and Lymph-ICF questionnaires were the two most complete and accurate questionnaires to assess QoL in patients with BCRL, because these questionnaires assess the largest number of QoL domains and specific arm symptoms.

Fluorescence microlymphography: diagnostic potential in lymphedema and basis for the measurement of lymphatic pressure and flow velocity.

Fluorescence microlymphography (FML) is an almost atraumatic technique used to visualize the superficial skin network of initial lymphatics through the intact skin of man. Visualization was performed with an incident light fluorescence microscope following subepidermal injection of minute amounts of FITC-dextran 150,000 using microneedles. Emanating from the bright dye depot, the surrounding network of microvessels is filled, documentation performed by photography or video film. In congenital Milroy lymphedema, a lack of microlymphatics (aplasia) is typical while in other primary lymphedemas and in secondary lymphedema after mastectomy or irradiation of proximal lymph nodes, the network remains intact but the depicted area is enlarged. Lymphatic microangiopathy characterized by obliterations of capillary meshes or mesh segments develops in phleboedema with trophic skin changes, progressive systemic sclerosis and Fabry's disease. In lipedema, lymphatic microaneurysms are stained. Microlymphatic pressure may also be measured using FML. For this purpose, glass micropipettes are inserted into the capillaries by means of a micromanipulator and pressure is determined by the servo-nulling technique. Normal subjects produced significantly lower pressure (7.9 +/- 3.4 mmHg) compared to patients with primary lymphedema (15.0 +/- 5.1 mmHg, p<0.001). This characteristic lymphatic hypertension may be improved by complex physiotherapy or local application of prostaglandins. Additionally, a modification of the FML procedure can be used to measure lymphatic capillary flow velocity in controls and patients. FML is suited to confirm the clinical diagnosis of lymphedema, contributes to distinguish among various forms of edema, and is useful in clinical research. In addition, FML has also become a tool for experimental animal studies including the depiction of gastric microlymphatics, the measurement of flow velocity in the naked mouse tail, and in evaluation of lymphangiogenesis in a model of Milroy disease.

Terapia descongestiva como complemento a la cirugía de anastomosis linfáticovenosas y transferencia de linfonodos vascularizados: Una revisión de la literatura / Decongestive therapy as an adjunct to lymphatic-venous anastomosis surgery and vascularized lymph node transfer: A review of the literature

Resumen Introducción: El linfedema es una enfermedad inflamatoria crónica que afecta cerca de 250 millones de personas en el mundo. El tratamiento tradicional es la terapia descongestiva. Últimamente, existe la opción de complementar el tratamiento tradicional con procedimientos quirúrgicos fisiológicos como anastomosis linfáticovenosas y transferencia de linfonodos vascularizados. Sin embargo, la evidencia del uso de la terapia descongestiva en los cuidados pre y posoperatorios en estas cirugías es limitada. Objetivo: Evaluar el uso de terapia descongestiva como complemento a la cirugía de linfedema mediante anastomosis linfáticovenosas y transferencia de linfonodos vascularizados. Materiales y Método: Se realizó una revisión de la literatura en las siguientes bases de datos: Cochrane, Pubmed y Google académico, utilizando los siguientes términos mesh: "anastomosis, surgical", "lymphedema", "perioperative care", "microsurgery", "rehabilitation", "therapy", "lymph nodes", "bypass", "lymphedema and microsurgery". Se incluyó aquellos artículos que describían el uso de la terapia descongestiva en los cuidados pre- y posoperatorios. Resultados: Se identificó un total de 201 artículos y 12 fueron incluidos en el análisis. La evidencia reporta que las terapias más usadas en el cuidado pre- y posoperatorio son compresión, drenaje linfático manual y tratamientos personalizados. Sin embargo, la mayoría de los autores hace una descripción vaga de las terapias mencionadas. Discusión y Conclusión: La evidencia respecto al uso de terapia descongestiva como tratamiento complementario es débil. Los expertos recomiendan su uso, sin embargo, se necesitan futuras investigaciones que describan el uso de cada uno de sus componentes como complemento de procedimientos quirúrgicos fisiológicos para el manejo del linfedema.

Background: Lymphedema is a disease that affects about 250 million people around the world. The traditional treatment is decongestive therapy. In the past years, there is the option to complementing the traditional treatment with physiological surgical procedures such as lymphatic-venous anastomosis (LVA) and vascularized lymph node transfer (VLNT). However, the evidence for the use of decongestive therapy in pre- and post-operative care in these surgeries is limited. Aim: To evaluate the use of decongestive therapy as a complement to lymphedema surgery such a lymphatic-venous anastomosis and transfer of vascularized lymph nodes. Materials and Method: A literature review was carried out in the following databases: Cochrane, Pubmed and Academic Google, using the following mesh terms: "anastomosis, surgical", "lymphedema", "perioperative care", "microsurgery", "rehabilitation", "therapy", "lymph nodes","bypass", "lymphedema and microsurgery". "Those articles that described the use of decongestive therapy in pre- and post-operative care were included. Results: 201 articles were identified and 12 were included in the analysis. The evidence reports that the most used therapies in pre- and post-operative care are compression, manual lymphatic drainage and personalized treatments. However, most of the authors give a vague description of the mentioned therapies. Discussion and Conclusion: The evidence regarding the use of decongestive therapy as a complementary treatment is weak. Experts recommend its use; however, future research is needed to describe the use of each of its components as a complement to physiological surgical procedures for the management of lymphedema.

Surgical management of selected patients with lymphedema of the extremities.

In the management of moderately severe lymphedema of the extremities, two types of "physiological" surgery have been employed with acceptable results. The methods involve (1) subcutaneous drainage of lymph by a synthetic suture network or loops of #2 prolene and (2) lymphatic-venous anastomosis of lymphatic channels into adjacent superficial veins. In 126 patients treated by the first method, there was an average reduction of edema of approximately 60%. In 77 patients the second method (306 anastomoses) resulted in an average reduction of edema of 75% in follow-up rangeing up to 11 years. These procedures are contraindicated in patients with limb paralysis or frequent recurrent skin infection.

Evolución distinta de linfedema primario etapa II de miembros inferiores / Different evolution of stage 2 primary lymphedema of the lower limbs

Resumen Introducción. Un linfedema es el aumento de fluido rico en proteínas y macromoléculas en el espacio intersticial de un segmento corporal con incremento de volumen en el miembro afectado, el cual causa cambios fibroescleróticos progresivos en los tejidos. Objetivo. Informar sobre la evolución clínica y el análisis de la progresión de un paciente de 52 años con linfedema bilateral primario estadio II. Presentación del caso. Paciente masculino de 52 años quien había sufrido por más de 20 años edema linfostático; el sujeto había recibido diversas opiniones y tratamientos inefectivos los últimos 5 años, hasta que llegó a la Clínica Godoy en Sao Jose de Rio Preto, Brasil, en el año 2016, en donde fue sometido a proceso de terapia intensiva según el modelo de tratamiento propuesto por Godoy & Godoy. Conclusión. Se obtuvieron resultados favorables en un periodo muy corto de tiempo; durante el proceso se observaron distintas evoluciones clínicas en cada pierna, aun recibiendo ambas el mismo tratamiento.

Abstract Introduction: Lymphedema is the accumulation of protein-rich fluid and macromolecules in the interstitial space of a body segment with increased volume in the affected limb, causing progressive fibrosclerotic changes in tissues. Objective: To describe the clinical course and progression analysis of a 52-year-old patient with stage 2 primary bilateral lymphedema. Case presentation: This is the case of a 52-year-old male patient who had suffered from lymphedema for more than 20 years. He had received several opinions and ineffective treatments in the last 5 years, until he was treated at the Clínica Godoy in Sao Jose de Rio Preto, Brazil, in 2016. There, he underwent intensive therapy according to the treatment model proposed by Godoy & Godoy. Conclusion: Favorable outcomes were obtained in a very short period of time; during the process, different clinical evolutions were observed in both legs, even though both received the same treatment.

Uso da terapia por ondas de choque para o tratamento do linfedema associado ao câncer de mama: uma revisão sistemática / Use of shockwave therapy for the treatment of lymphedema associated to breast cancer: a systematic review

O linfedema associado ao câncer de mama é causa de prejuízo significativo da qualidade de vida deste grupo de pacientes e constitui complicação frequente das intervenções necessárias nesse tipo de câncer. Sabe-se que o tratamento utilizado no linfedema associado ao câncer de mama envolve a Terapia Física Complexa (TFC), cuja eficácia é limitada e não atua diretamente na patogênese dessa comorbidade. Conforme já demonstrado em alguns estudos, o uso da Terapia por Ondas de Choque (TOC) demonstra-se potencialmente benéfico para reduzir o linfedema pela indução de neoangiogênese e linfangiogênese. Objetivo: Avaliar o impacto da TOC no tratamento do linfedema associado ao câncer de mama comparado ao uso da TFC. Métodos: Foram utilizadas as seguintes bases de dados: PubMed/MedLine; BIREME; LILACS; The Cochrane Library e EMBASE, e através de busca manual de artigos. Adotou-se o método de pesquisa PICO e os descritores MeSH ajustados conforme a respectiva base de dados. Resultados: Foram encontrados um total de 262 artigos e selecionados por leitura do título ou resumo um total de 17 estudos. Seis foram excluídos por serem duplicatas, totalizando 11 artigos eleitos para verificação dos critérios de inclusão. Destes, nenhum artigo atendeu ao delineamento da metodologia proposta para esta revisão. Três deles se destacaram por se aproximarem mais da temática proposta e foram discutidos. Conclusão: É necessária a realização de estudos com qualidade metodológica adequada para avaliar o potencial benefício do uso da TOC, visando contribuir para a composição de um tratamento mais eficaz, seguro e que atue na patogênese da doença.

Lymphedema associated with breast cancer is a cause of significant impairment of the quality of life and is a frequent complication of the necessary interventions in this type of cancer. It is known that the treatment used in lymphedema associated with breast cancer involves Complex Physical Therapy (CPT), whose efficacy is limited and does not act directly in the pathogenesis of this comorbidity. As demonstrated in some studies, the use of Shock Wave Therapy (TSWT) is potentially beneficial in reducing lymphedema by inducing neoangiogenesis and lymphangiogenesis. Objective: To evaluate the impact of TSWT on the treatment of lymphedema associated with breast cancer compared to the use of CPT. Methods: The following databases were used: PubMed / MedLine; BIREME; LILACS; The Cochrane Library and EMBASE, and through manual article search. We adopted the PICO search method and the Mesh descriptors were adjusted according to the respective database. Results: A total of 262 articles were found and selected by reading the title or abstract a total of 17 studies. Six were excluded because they were duplicates, totaling 11 articles elected to verify the inclusion criteria. Of these, no article met the outline of the methodology proposed. Three of them were closer to the proposed theme and were discussed. Conclusion: It is necessary to carry out studies with adequate methodological quality to evaluate the potential benefit of the use of TSWT, in order to contribute to the composition of a more effective and safe treatment, that acts in the pathogenesis of the disease.

Massive paraumbilical hernia: not all is as it seems.

We discuss the management of an otherwise healthy obese patient who presented with a massive paraumbilical hernia extending into a large lymphoedematous abdominal apron. After anaesthetic assessment and abdominal computed tomography (CT), the patient underwent an elective operation. The hernia was dissected free of the heavy lymphoedematous apron with the aid of orthopaedic pins and a motorised patient lifter. Despite the size of the hernia, the primary defect was found to be relatively small and easy to reduce. The defect was repaired with a sublay Proceed(®) mesh and skin closure was achieved primarily. The patient had an uneventful post-operative course and gained significant improvement in her mobility.

Squamous cell carcinoma arising from chronic lymphedema: case report and review of the literature.

CONTEXT: Squamous cell carcinoma arising from chronic lymphedema has only been reported in the literature 11 times (12 cases). Some aspects of its pathogenesis remain unclear and, for the first time, attention has been drawn to epidemiological data. CASE REPORT: A 90-year-old white female with chronic unilateral lower-limb lymphedema, secondary to trauma 20 years earlier, presented with a three-month history of a vegetating cutaneous lesion. There had not been any previous local ulceration. The tumor was completely excised and the histopathological analysis showed that it was an infiltrating squamous cell carcinoma. A literature review in the Medline (Medical Literature Analysis and Retrieval System Online) and Lilacs (Literatura Latino-Americana e do Caribe em Ciências da Saúde) databases using the MeSH (Medical Subject Heading) terms "Carcinoma, Squamous Cell" AND "Lymphedema" identified 112 references and found 12 similar case reports.

Limb sparing surgical resection of groin sarcoma. Surgical approach and reconstructive options.

PURPOSE: The aim of this study is to evaluate limb sparing surgical resection and reconstructive options in a group of patients having soft tissue sarcoma of the groin and nearly most of them were previously subjected elsewhere to some sort of mismanagement. PATIENTS AND METHODS: Between 2001 and 2006, 14 patients having soft tissue sarcoma of the groin presented to National Cancer Institute with some sort of mismanagement elsewhere. Preoperative reevaluation included CT chest, MRI or MRA, Doppler US and angiography in some selected patients. According to the Enneking staging system, 9 patients had stage II, 4 had stage IIA and 1 patient had stage III. Limb sparing resection was done including wide resection of the tumor enbloc with the pubic bone or its rami and involved femoral vessels and nerve. Abdominal wall defect was reconstructed by mesh, skin defect was reconstructed by local myocutaneous flaps and vascular replacement was done by vascular prosthesis. RESULTS: The mean follow-up period was 31 months (range 25-53 months). Surgical margins were negative in 13 patients and microscopically positive in one patient. Femoral nerve was resected in 3 cases. Pubic bone resection was done in all patients. Vascular resection and prothetic replacement were done in 2 cases. Ten cases required myocutaneous flap reconstruction of skin defect, 2 cases required muscle flap only. All mobilized flaps showed no failure. Complications included seroma in all cases, superficial stitch gaping in 3 cases, wound breakdown and deep infection occurred in one case and chronic lymphedema in 5 cases. Limb sparing function according to MSTS functional score ranged from 92 % to 97 %. The 2 year local control rate was 92.8 % and the 2 years survival rate was 85.7 %. CONCLUSION: Patients having groin sarcoma with some sort of improper management may still have a chance of successful limb sparing surgical resection with a curative intent and achievement of good functional results. This requires proper preoperative reevaluation of the extension of the tumor and vascular involvement, wide retroperitoneal exposure to maximize tumor resection, vascular replacement if ileofemoral vessels are involved and local myocutaneous flap transfer to minimize the problems of wound healing and subsequent infection. KEY WORDS: Groin sarcoma - Limb salvage - Groin defect reconstruction.