Effects of diet-induced obesity in the development of lymphedema in the animal model: A literature review.

BACKGROUND: Obesity poses deleterious consequences on every organ system, especially the lymphatic network. However, the underlying cellular mechanisms through which obesity causes lymphatic dysfunction remains unclear. We aimed to summarize experimental studies that evaluated the effect of obesity on the lymphatic system on animal models. METHODS: We used the following terms to search the Ovid EMBASE, Ovid MEDLINE(R), Cochrane, and Scopus databases: "lymphedema", "lymphatic diseases", "lymphatic system/complications* ", "lymphatic system/injuries* ", "lymphatic system/abnormalities* ", AND "obesity/complications* ", "diet/high-fat", "adipogenesis" and "lipid metabolism disorder". From a total of 166 articles identified in the initial search, 13 met our eligibility criteria. RESULTS: Long-term exposure to high-fat diet in mice demonstrated significant amount of adipose tissue deposition which sets off an inflammatory cascade resulting in disruption of the chemokine gradient, inhibition of lymphangiogenesis, and changes in gene expression of lymphatic endothelial cells, that alter vessel permeability and induce cell death. Reduced contractile properties of lymphatic collectors, dilated capillaries, increased tissue pressure, and reduced hydraulic conductivity collectively contribute to reduced impaired lymphatic drainage. Aerobic exercise has shown reversal of lymphatic dysfunction in the obese and pharmacological interventions targeting T-cells, iNOS and VEGFR-3 signaling have the potential to combat acquired lymphedema. CONCLUSION: Scientists should focus their future experiments on developing therapies that regulate expression of T-cell derived cytokines and VEGFR-3 expression whereas clinicians are urged to counsel their patients to reduce weight through aerobic exercise.

Surgical techniques of phalloplasty in transgender patients: a systematic review.

Gender confirmation surgery has a crucial role among transgender individuals. Phalloplasty is a procedure that uses flaps for phallic shaft creation. Flaps can be classified in free flaps or pedicle flaps and can be obtained from different donor sites such as forearm, thigh, abdomen, groin, and leg, and upper back. We conducted a systematic review about surgical flaps for phallic shaft creation in transgender patients. A systematic review was conducted on PubMed/MEDLINE, Cochrane Clinical Answers, and Cochrane Central Register of Controlled Trials databases without timeframe limitations. Exclusion criteria included articles that reported phalloplasty on patients other than transgender, as well as other surgical techniques such as urethroplasty, vaginectomy, hysterectomy and studies focused on psychosocial outcomes. Two hundred twenty-eight potential articles were identified in the initial search. Forty-one studies fulfilled the inclusion and exclusion criteria. Surgical flaps for phallic shaft creation in transgender patients were reported on 1,391 cases. Microsurgical flaps were the most common (24 of 33). The flap technique most frequently described was radial forearm flap (15 of 33) followed by Anterolateral thigh flap (7 of 33), Latissimus dorsi flap (5 of 33), abdominal flap (4 of 33), fibular flap (3 of 33), and groin flaps (3 of 33). The literature on surgical flaps for phallic shaft creation in transgender patients reflected how challenging the reconstruction of the phallus is. In summary, there is no universal choice of flap that could be applied to every patient. Therefore, the surgical approach must be chosen considering surgeon experience, physical examination, and patient desire. We hope this review supports future studies on surgical flaps for phallic shaft creation in transgender patients.

Single versus two-stage phalloplasty for transgender female-to-male patients: a systematic review of the literature.

Phalloplasty is the main treatment for gender dysphoria disorder. It is difficult to ascertain if staging of phalloplasty influences the rate of complications. We aim to describe and compare the rates of complication between single versus two-stage phalloplasty for transgender female-to-male patients. PubMed, Ovid Medline, EMBASE and SCOPUS databases were queried for studies reporting complications of female-to-male transgender patients who underwent phalloplasty. The keywords "phalloplasty", "female to male", "outcome", "complication" and synonyms in different combinations were used for the search. Only studies that could identify whether phallic shaft creation was performed in a single or two-stage procedure were included. From a total of 336 articles, 20 met the inclusion criteria. Sixteen studies reported complications associated with a single-stage phalloplasty and seven studies identified complications after a two-stage procedure. The most common complications found for both groups of staging were fistula, stricture and total/partial flap necrosis. Patients who underwent two-stage phalloplasty had higher complication rates (partial or total flap necrosis and fistulas), compared with the single-stage procedure (P<0.05). In conclusion, this systematic review identified the impact of staging in the rate of complications related to phalloplasty for transgender female-to-male patients; a two-stage phalloplasty has a higher rate of complications.

Umbilical Reconstruction Techniques: A Literature Review.

BACKGROUND: There are many instances in which sacrificing the umbilicus is unavoidable. Umbilical reconstruction (umbiliconeoplasty) is an important surgical procedure to complete the abdomen's reconstruction and to give again a pleasant cosmetic appearance. OBJECTIVES: To provide a complete overview of all surgical techniques for umbiliconeoplasty described in the literature. METHODS: PubMed database was queried using 'umbilical and reconstruction', 'umbilicus and reconstruction', 'navel and reconstruction', 'umbiliconeoplasty', 'neo-omphaloplasty' or 'umbilicaneoplasty' to select the papers dealing with the reconstruction of the umbilicus. RESULTS: Sixty different techniques for the reconstruction of the missing umbilicus were described in 77 papers. Local skin flaps and the purse-string suture technique were the most frequently described techniques. The Three flaps technique, the Four flaps technique and the 2 Lateral rectangular pedicle lateral flaps technique were the most popular local flap techniques. Indications ranged from congenital pediatric defects to reconstruction during abdominoplasty. CONCLUSIONS: Several surgical techniques were described for umbilicus reconstruction. While there is not a universal algorithm for the choice of the technique, the surgeon may decide which technique to use based on other surgeons' experiences reports. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Defining Outcomes Following Distal Radius Fractures: Correlation of Function, Pain, and Hand Therapy Utilization.

Background Distal radius fractures (DRF) is one of the most common fractures in clinical practice. Our objective was to study the role of early hand therapy and its impact on pain and return to daily activities. Methods The charts of patients with DRFs seen between January 2016 and November 2017 in the Hand Center of Mayo Clinic Florida were reviewed retrospectively. Forty-nine patients with DRFs who met inclusion criteria were included in the analysis. The variables collected included: age, gender, side of the fracture, surgery vs non-surgery, time to start hand therapy, number of visits, shortened disabilities of the arm, shoulder, and hand (QuickDASH) initial and discharge scores, and visual analog scale (VAS) initial and discharge. Results The patients' mean age was 67.90 years, (standard deviation (SD) 14.54), 38 (77.6%) were female, 28 (57.1%) had a right DRF, 21 (42.9%) had a left DRF, 38 (77.6%) had no surgery, 11 (22.4%) had surgery. The mean time from fracture to therapy is 32.41, (SD 24.13) days, and the mean total number of visits is 6.20 (SD 3.49). We noticed a statistically significant difference between the initial QuickDASH (59.27, SD 16.93) compared to the discharge QuickDASH (24.08, SD 12.77) (P-value <.001); and initial VAS (3.57, SD 1.71) with a discharge VAS (1.33, SD 0.97) (P-value <.001).  Conclusion This retrospective study found a statistically significant reduction in the QuickDASH and VAS scores after six hand therapy visits. The results suggest that early rehabilitation interventions lead to improvements in pain and return to daily activity following DRF.

Lymph node transfer combined with deep inferior epigastric perforators and transverse rectus abdominis myocutaneous procedures: a systematic review.

The surgical treatment of lymphedema can be conducted alone or in combination with microsurgical autologous breast reconstruction. We performed a systematic review of the literature at PubMed database regarding autologous breast reconstruction for deep inferior epigastric perforators (DIEP) or muscle-sparing transverse rectus abdominis myocutaneous (ms-TRAM) and vascularized lymph node transfer (VLNT) in patients with lymphedema following breast cancer surgery. We hypothesized that autologous breast reconstruction combined with VLNT has positive outcomes. Eligibility criteria included investigations reporting data studies evaluating female patients with lymphedema in an upper extremity after breast cancer who underwent autologous breast reconstruction combined with VLNT. The search resulted in 93 potential papers, but only 6 studies fulfilled the study eligibility criteria. The total number of patients was 103. Most of the studies evaluated the outcomes in patients treated with DIEP or ms-TRAM combined with VLNT. The studies described groin lymph node transfer as treatment for lymphedema. In most of the studies, all patients reported a reduction of arm circumference, volume, and symptoms of the upper extremity with lymphedema comparing the preoperative to the postoperative period. Overall, patients experienced successful breast reconstruction. All authors reported reduction of the circumferential size of the affected upper limb, as well as a decrease in cellulitis, in addition to favorable breast reconstruction results.

Lymphaticovenular anastomosis for breast cancer-related upper extremity lymphedema: a literature review.

Breast cancer-related lymphedema is a long-term condition that affects almost half of breast cancer survivors. Clinical studies have looked at the benefits of lymphaticovenular anastomosis (LVA) for the treatment of upper extremities lymphedema after breast cancer, however, there is still controversy if it improves lymphedema. This study aimed to analyze the studies and outcomes related to LVA for breast cancer-related lymphedema. A PubMed/Medline search was performed using "lymphovenous bypass", "upper extremity lymphedema", "arm lymphedema after breast cancer treatment", and "lymphaticovenular anastomosis" as key words. Only English articles reporting outcomes after LVA were included. We found 22 articles that met the inclusion criteria. Positive outcomes were found in 21 studies with an objective volume reduction and subjective symptoms relief after LVA. This literature review concluded that LVA has demonstrated a significant decrease in upper extremity volumes and an improvement in subjectively reporting symptoms in breast cancer-related lymphedema patients.

The basics of ultrasound elastography for diagnosis, assessment, and staging breast cancer-related lymphedema: a systematic review of the literature.

Breast cancer-related lymphedema (BCRL) incidence has been increasing overtime. Currently, there is not a preferred imaging tool for diagnosis, staging, and assessment of the disease. We aim to review the use of ultrasound elastography (UE) in BCRL patients. A systematic review was performed by querying PubMed, EMBASE, Ovid Healthstar, and Ovid Medline databases for studies that evaluated the use of UE in BCRL. The keywords "elastography" AND "lymphedema" in titles and abstracts were used for the search. The search retrieved 12, 12, 5 and 6 articles in each database, respectively. From these, only 4 met the inclusion criteria. UE methods included two-dimensional strain imaging, shear wave elastography (SWE), and global UE. Two of the studies evaluated the use of UE in the assessment of BCRL, while only 1 considered its use for diagnosis and staging. Based on our systematic review, UE appears to be a great tool in the assessment of BCRL to differentiate affected from non-affected arms.

Omental Lymph Node Transfer for Lymphedema Patients: A Systematic Review.

Lymph node transfer is a surgical treatment that is becoming more prevalent. The lymph nodes from the groin and neck are most frequently used. Iatrogenic lymphedema can be a consequence of the dissection of the groin nodes; thus, some surgeons prefer to use the neck as a donor site. Literature reporting surgical algorithms for the treatment of lymphedema is scarce. Thus, we conducted a systematic review of vascularized omentum lymph node transfer (VOLT) in patients with lymphedema to provide more information about this increasingly common procedure. We hypothesize that the analyzed studies will show that VOLT has positive outcomes. Two reviewers (G.J.C., D.B.) performed independent searches using the PubMed database without timeframe limitations initially through title and abstract descriptions and then by full-text review. The search was done using the following keywords: Breast cancer lymphedema OR lymphedema AND lymph node transfer OR lymph node flap OR lymph node graft AND omental OR omentum OR gastroepiploic. Eligibility criteria included publications evaluating patients with lymphedema in the upper extremity and lower extremity, who underwent VOLT. Our search yielded 35 potential papers in the literature, but only six studies fulfilled the study eligibility criteria. The total number of patients was 137. Three studies described single VOLT, two studies described double VOLT and one study described two cohort patients, one that was treated with single VOLT and another one that was treated with double VOLT. Postoperative reduction of arm circumference, arm volume, and symptoms of the upper extremity were reported in all patients. Nonetheless, in one study, seven patients did not notice any extremity circumference reduction during the follow-up period and four patients noticed an increase in arm volume. Flap loss was reported by two authors in a total of two patients. Overall, patients experienced successful lymphedema treatment with VOLT. All authors presented results with reduced circumferential size of the affected upper and lower limbs, as well as reduction of the infectious intercurrences, such as cellulitis, with a small incidence of associated complications.

Ultrasound Elastography Use in Lower Extremity Lymphedema: A Systematic Review of the Literature.

Lower extremity lymphedema (LEL) is mainly assessed clinically. Ultrasound elastography (UE) is a promising imaging tool to assess this disorder. We conducted a systematic literature review to describe the studies evaluating the use of UE in LEL. The PubMed database was queried for studies that evaluated the use of UE in LEL. The keywords "elastography" AND "lymphedema" were used for the search. Original articles in English were included in our study, whereas reviews were excluded. Our search resulted in 12 articles, 4 of which met the inclusion criteria. UE methods included free-hand real-time tissue elastography and UE with transducer in B mode. The imaging parameters applied were the tissue strains and the area of red region, respectively. All studies tested UE use in the assessment of LEL, and only one considered its use for staging. All studies but one found a difference in strain parameters for assessment of patients with LEL. Our systematic review has shown that UE appears to be a great tool in the assessment of LEL in moderate-to-advanced stages of disease. However, further studies using new effective methods are needed to evaluate patients with early lymphedema.

Analysis of Melanoma in African American Patients in the United States.

BACKGROUND/AIM: To characterize the demographics, tumor staging and treatment of African American (AA) patients diagnosed with melanoma in the United States. PATIENTS AND METHODS: The National Cancer Database was used to extrapolate data from patients with melanoma between January 1, 2004, and December 31, 2015. The patients were then further divided based on ethnicity (AAs vs. Caucasians) to compare patient efficacy of treatment. RESULTS: The mean time for AA patients to receive treatment was 20.37 days compared with 11.25 days for Caucasians (p<0.001), while time to surgery was 38.86 days compared to 31.12 days for Caucasians (p<0.001). Moreover, AA race was a predictor of American Joint Committee on Cancer stage greater than II, tumor diagnosed at autopsy, presence of ulceration, and distribution in the extremities. CONCLUSION: AA patients with melanoma are more likely to have worse tumor staging, treatment delay, treatment at an Integrated Cancer Program, and diagnosis at autopsy.

Lipoaspiration and Controlled Compressive Therapy in Lymphedema of the Upper Extremity: A Comprehensive Systematic Review.

Lipoaspiration followed by controlled compression therapy has been used to treat lymphedema of the upper extremity. We aimed to describe the studies reporting on outcomes of this procedure, in addition to reporting the differences with patients that were treated only with compressive therapy. The PubMed database was queried for studies that evaluated the use of lipoaspiration for upper extremity lymphedema. The keywords "aspiration lipectomy" AND "lymphedema" and synonyms in different combinations were used for the search. From a total of 129 articles, 13 met inclusion criteria. Ten studies reported outcomes of patients treated with lipoaspiration followed by compressive therapy, and three studies compared this procedure with patients that had only compressive therapy. A complete reduction of the edema in the affected limb was found in all the studies. Better results were found in patients who had undergone both procedures. This systematic review suggests that lipoaspiration is recommended for patients with upper extremity lymphedema of any cause in stage two after a long period of compressive therapy that did not produce additional edema reduction.

Targeted Therapies in Surgical Treatment of Lymphedema: A Systematic Review.

Although physiologic surgeries for lymphedema (i.e., lymphovenous bypass, vascularized lymph node transplantation) are becoming well established, unpredictable outcomes have still been reported in some studies. Therefore, authors have investigated ways to improve these surgery outcomes. The goal of our study was to conduct a comprehensive systematic review of targeted therapy administration in the surgical treatment of lymphedema. We conducted a comprehensive systematic review of the published literature on targeted therapies associated with lymphedema surgery using the PubMed database. Eligibility criteria excluded papers that reported surgical treatment of lymphedema without the use of targeted therapies and also papers describing targeted therapies in nonsurgical treatment of lymphedema. Abstracts, presentations, reviews, and meta-analyses were also excluded. Extracted data included the year of study, country, lymphedema model, surgical technique, targeted therapy agent, therapy delivery, findings, and outcomes. From 823 potential papers found in the literature, 10 studies fulfilled the eligibility criteria. All papers were experimental, and most of them on small animal model (7/10). Different targeted therapies were proposed, but all of them were associated with lymph node transplantation. The most common targeted therapy proposed mechanism was growth factor delivery (8/10). However, one paper used adipose-stem cell, and one paper proposed the use of sterile inflammation. The pooled publications assessing targeted therapy administration in the surgical treatment of lymphedema demonstrate encouraging data for positive outcomes. To date, all studies were experimental and related to lymph node transfer.