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1.
J Surg Oncol ; 121(1): 91-99, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31650565

RESUMO

BACKGROUND: Lymphedema surgery was not widely known in Austria before the introduction of lymphovenous anastomosis (LVA) and vascularized lymph node transfer (VLNT) in 2014. This study shares the experience and process of establishing and institutionalizing lymphedema surgery service in Austria. METHODS: The purpose of introducing reconstructive lymphedema surgery in Austria was to improve lymphedema patients' quality of life and provide them surgical therapy as an adjuvant treatment to complete decongestive therapy. To initialize reconstructive lymphedema surgery in Austria, LVA and VLNT had to be presented and introduced, in the manner of branding and advertizing a new product. Surgeries were performed with quality control by standardized documentation, pre- and postoperatively. RESULTS: Aligned with branding and marketing, presentations were given externally and internally to share knowledge and experience of lymphedema surgery. Lymphedema surgery service was introduced as a new brand in the medical service in Austria. After several communications with the Austrian Health Insurance Fund and with the final application, LVA and VLNT were listed as novel surgical therapies in its 2020 reimbursement catalog. Since 2014, more than 300 lymphedema patients were consulted, and 102 reconstructive lymphedema surgeries were performed. Circumference reduction of extremities after surgery was between 20% and 43%, postoperatively. CONCLUSION: Acceptance of surgery in lymphedema patients varies among continents, hospitals, and surgeons. Evaluation of the requirement of the surgical setup and insurance conditions for lymphedema surgery is essential to establish lymphedema surgery, providing targeted marketing and branding to spread knowledge of the novel technique and grant patients access to therapeutic treatment of their chronic disease.


Assuntos
Cirurgia Geral/organização & administração , Linfedema/cirurgia , Adolescente , Adulto , Idoso , Anastomose Cirúrgica , Áustria , Criança , Feminino , Humanos , Linfonodos/transplante , Vasos Linfáticos/cirurgia , Linfedema/diagnóstico , Masculino , Pessoa de Meia-Idade , Qualidade de Vida , Procedimentos Cirúrgicos Reconstrutivos/métodos , Centro Cirúrgico Hospitalar , Adulto Jovem
2.
J Surg Oncol ; 121(1): 75-84, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31273800

RESUMO

BACKGROUND: Retroperitoneal lymphangiomatosis (RL) is a rare form of primary lymphedema featuring aberrant retroperitoneal lymphatic proliferation. It causes recurrent cellulitis, repeated interventions, and poor life quality. This study aimed to investigate proper diagnositc criteria and surgical outcomes for RL with extremity lymphedema. METHODS: Between 2012 and 2018, 44 primary lower-extremity lymphedema cases received lymphoscintigraphy, magnetic resonance imaging, and single-photon electron computed tomography to detect RL. RL patients underwent vascularized lymph node transfers (VLNT) for extremity lymphedema and intra-abdominal side-to-end chylovenous bypasses (CVB) for chylous ascites. Complications, CVB patency, and quality of life were evaluated postoperatively. RESULTS: Six RL patients (mean age of 30.3 years) had chylous ascites with five had lower-extremity lymphedema. All CVBs remained patent, though one required re-anastomosis, giving a 100% patency rate. Four unilateral and one bilateral extremity lymphedema underwent six VLNTs with 100% flap survival. Patients reported improved quality of life (P = 0.023), decreased cellulitis incidence (P = 0.041), and improved mean lymphedema circumference (P = 0.043). All patients resumed a normal diet and activity. CONCLUSIONS: Evaluating primary lower-extremity lymphedema patients with MRI and SPECT could reveal a 13.6% prevalence of RL and guide treatment of refractory extremity lymphedema. Intra-abdominal CVB with VLNT effectively treated RL with chylous ascites and extremity lymphedema.


Assuntos
Linfonodos/transplante , Linfangioma/cirurgia , Neoplasias Retroperitoneais/cirurgia , Adolescente , Adulto , Feminino , Humanos , Perna (Membro)/diagnóstico por imagem , Perna (Membro)/cirurgia , Linfangioma/diagnóstico por imagem , Imagem por Ressonância Magnética , Pessoa de Meia-Idade , Neoplasias Retroperitoneais/diagnóstico por imagem , Estudos Retrospectivos , Tomografia Computadorizada de Emissão de Fóton Único , Adulto Jovem
3.
J Surg Oncol ; 121(1): 138-143, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31276208

RESUMO

BACKGROUND: Vascularized lymph node transfer (VLNT) has become one of the effective surgical treatments for extremity lymphedema. This study was to evaluate the re-exploration and total complication rates of VLNT for lower extremity lymphedema between two different flap inset techniques. METHODS: Sixty-nine patients who underwent 74 submental VLNT transfers between 2008 and 2018 were retrospectively studied. Fifty-six flaps were inset using a new delayed primary retention suture (DPRS) technique and other 18 flaps using conventional interrupted sutures as the non-DPRS group. RESULTS: The overall flap success rate was 100%. The DPRS group was released at a mean of 1.7 ± 0.7 times and took a mean of 10.3 ± 3.3 days for wound closure. There were no statistical differences in demographics, mean symptom duration, and mean Cheng's Lymphedema Grading between two groups. Mean frequency of cellulitis of 2.5 ± 1.5 times/year in non-DPRS group was significantly greater than 1.4 ± 1.6 times/year in DPRS group (P = .01). The re-exploration and total complication rates were 5.4% and 7.1% in DPRS group, and 27.8% and 33.3% in non-DPRS group, respectively (P = .02 and .02, respectively). CONCLUSIONS: The DPRS technique is a safe, simple, and reliable method for insetting the submental VLNT, which statistically decreased the re-exploration and total complication rates.


Assuntos
Linfonodos/irrigação sanguínea , Linfonodos/transplante , Linfedema/cirurgia , Retalhos Cirúrgicos/cirurgia , Suturas , Adulto , Idoso , Idoso de 80 Anos ou mais , Extremidades/cirurgia , Feminino , Humanos , Pessoa de Meia-Idade , Estudos Retrospectivos , Técnicas de Sutura , Resultado do Tratamento
4.
J Surg Oncol ; 121(1): 25-36, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31264724

RESUMO

BACKGROUND: This high volume, single center study investigated the prevalence, bacterial epidemiology, and responsiveness to antibiotic therapy of cellulitis in extremity lymphedema. METHODS: From 2003 to 2018, cellulitis events from a cohort of 420 patients with extremity lymphedema were reviewed. Demographics, lymphedema grading, symptoms, inflammatory markers, cultures and antibiotic therapy regimens were compiled from cellulitis episodes data. Univariate and multivariate analyses were performed for detailed analysis. RESULTS: A total of 131 separate episodes of cellulitis were recorded from 43 (81.1%) lower limb and 10 (19.9%) upper limb lymphedema patients. The prevalence and recurrence rates for cellulitis in lymphedema patients were 12.6% (53 of 420) and 56.6% (30 of 53), respectively. The most common findings were increased limb circumference (127 of 131; 96.9%) and abnormal C-reactive protein (CRP) level (86 of 113; 76.1%). Blood cultures were obtained in 79 (60.3%) incidents, with 9 (11.4%) returning positive. Streptococcus agalactiae was the most isolated bacterium (5 of 9; 55.5%). CONCLUSIONS: The cellulitis prevalence and recurrence rate in extremity lymphedema were 12.6%, and 56.6%, respectively. Strongest indicators of cellulitis were increased affected limb circumference and elevated CRP level. Empiric antibiotic therapy began with coverage for Steptococcus species before broadening to anti-Methicillin-resistant Staphylococcus aureus and anti-Gram negatives if needed for effective treatment of extremity lymphedema cellulitis.


Assuntos
Infecções Bacterianas/tratamento farmacológico , Infecções Bacterianas/microbiologia , Celulite (Flegmão)/tratamento farmacológico , Celulite (Flegmão)/microbiologia , Linfedema/microbiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Antibacterianos/administração & dosagem , Infecções Bacterianas/epidemiologia , Infecções Bacterianas/patologia , Celulite (Flegmão)/epidemiologia , Celulite (Flegmão)/patologia , Estudos de Coortes , Extremidades/microbiologia , Extremidades/patologia , Feminino , Humanos , Linfedema/epidemiologia , Linfedema/patologia , Masculino , Pessoa de Meia-Idade , Prevalência , Estudos Retrospectivos
5.
J Surg Oncol ; 121(1): 129-137, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31246288

RESUMO

BACKGROUND: Vascularized submental lymph node (VSLN) transfer is an emerging approach for extremity lymphedema. This study investigated the long-term outcome and venous complications of VSLN for unilateral lower extremity lymphedema. METHODS: Between 2010 and 2018, patients who underwent VSLN for unilateral lower extremity lymphedema were retrospectively evaluated. Patient demographics, operative records, complications, circumferential improvement, and episodes of cellulitis were analyzed. Further comparisons were performed between different types, numbers, and techniques of venous anastomoses. RESULTS: A total of 75 VSLNs in 70 patients survived, giving a 100% success rate. Six flaps (8%) had venous complications (VC group) and 69 flaps (92%) did not (No-VC group). There were no statistical differences in types, numbers, and techniques of anastomoses between two groups (P = .65, 1, and .56, respectively). At a mean follow-up of 32.0 ± 23.0 months, mean circumferential improvement and episodes of cellulitis between two groups did not statistically differ significantly (P = .31 and .09, respectively). CONCLUSIONS: VSLN is an effective treatment for lower extremity lymphedema. The types, numbers of veins, and techniques of venous anastomoses did not statistically affect the venous complication rates. Functional outcomes of the VSLNs were not compromised if venous complications were salvaged promptly.


Assuntos
Linfedema/cirurgia , Linfonodo Sentinela/transplante , Retalhos Cirúrgicos/irrigação sanguínea , Retalhos Cirúrgicos/cirurgia , Celulite (Flegmão) , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Linfonodo Sentinela/irrigação sanguínea , Resultado do Tratamento
6.
J Surg Oncol ; 121(1): 67-74, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31209885

RESUMO

OBJECTIVES: This study aimed to identify the cognitive factors associated with the professional healthcare advice (PHCA) seeking behavior in breast cancer-related lymphedema (BCRL). METHODS: From January 2018 to December 2018, patients with BCRL were prospectively enrolled for a cross-sectional survey of lymphedema-related perceived risks, lymphedema quality of life (LYMQoL), knowledge scale of lymphedema, and PHCA behavior at first clinical visit, 3 and 6 months postbaseline. RESULTS: A total of 180 patients including 100 (55.6%) patients underwent a vascularized lymph node transfer (VLNT) and 80 (44.4%) patients received compressive decongestive therapy (CDT) were enrolled. At 6 months of follow-up, mean episodes of cellulitis (from 2.2 to 0.2 times/year), mean circumferential difference (7.8 ± 3.9%), wearing compression garments (from 29% to 0 %) in the VLNT group were statistically reduced than those in the CDT group (p = .01, <.01, and <.01, respectively). The overall LYMQoL had statistical improvement in VLNT group (p < .01). The short symptom duration, greater education level, less episodes of cellulitis, and higher knowledge of lymphedema were associated with increased adherence to PHCA (p = .03, .03, .02, and .01, respectively). CONCLUSION: BCRL patients who sought PHCA had great control of lymphedema and improve their quality of life.


Assuntos
Linfedema Relacionado a Câncer de Mama/psicologia , Comportamento de Busca de Informação , Educação de Pacientes como Assunto , Linfedema Relacionado a Câncer de Mama/cirurgia , Linfedema Relacionado a Câncer de Mama/terapia , Estudos Transversais , Feminino , Conhecimentos, Atitudes e Prática em Saúde , Pessoal de Saúde , Humanos , Estudos Longitudinais , Linfonodos/transplante , Pessoa de Meia-Idade , Estudos Prospectivos , Qualidade de Vida
7.
J Surg Oncol ; 121(1): 37-47, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31209893

RESUMO

Appropriate diagnosis, staging and a further selection of the best treatment are fundamental for the management of patients with extremity lymphedema. Several clinical and imaging tools have been described for these purposes. Lymphoscintigraphy is still considered the gold standard imaging modality for diagnosing lymphedema. However, protocol variability and poor image resolution can make the interpretation challenging. Here, we reviewed technical aspects of lymphoscintigraphy, interpretation of the lymphoscintigraphy findings, staging, and its clinical application.


Assuntos
Linfedema/diagnóstico por imagem , Linfocintigrafia/métodos , Humanos , Linfocintigrafia/normas
9.
J Surg Oncol ; 121(1): 8-19, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31309553

RESUMO

The hands-on supermicrosurgery course provided participants a valuable learning experience of in-depth practices of supermicrosurgical skills with experts. Seven live surgeries were successfully demonstrated at 8th World Symposium for Lymphedema Surgery. Variable donor sites for vascularized lymph node transfer were the submental, supraclavicular, groin, and omental; while the recipient sites included the wrist and axilla in upper limb; and popliteal and groin in the lower limb. The therapeutic and preventive lymphovenous anastomosis was also satisfactorily performed.


Assuntos
Linfedema/cirurgia , Microcirurgia/educação , Microcirurgia/métodos , Adulto , Idoso , Feminino , Humanos , Linfedema/diagnóstico , Masculino , Pessoa de Meia-Idade , Adulto Jovem
10.
J Surg Oncol ; 121(1): 153-162, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31152457

RESUMO

BACKGROUND: Reported ischemia time of vascularized lymph nodes was 5 hours. This study investigated the effects of arterial ischemia and venous occlusion on vascularized lymph node function in rats. METHODS: Bilateral pedicled groin lymph node flaps were raised in 27 Lewis rats. Femoral artery and vein were separated and clamped for 1, 3, 4, or 5 hour(s). Lymph node flap perfusion and drainage were assessed by laser Doppler flowmetry and indocyanine green lymphography. Histologic changes were assessed using hematoxylin and eosin stain, terminal deoxynucleotidyl transferase-mediated dUTP nick end-labeling (TUNEL), and glutathione assays. RESULTS: Perfusion units of 2.84 ± 1.41, 2.46 ± 0.64, 2.42 ± 0.37, and 2.01 ± 0.90 were measured in arterial ischemia groups, and 1.71 ± 0.45, 2.20 ± 0.98, 1.49 ± 0.35, and 0.81 ± 0.20 in venous occlusion groups after 1, 3, 4, and 5 hours of clamping, respectively. Lymphatic drainage showed mean latency periods of 5.33 ± 0.88, 9.00 ± 3.21, 10.00 ± 2.08, and 24.50 ± 11.50 seconds in arterial clamping groups, and 25.00 ± 3.61, 26.00 ± 3.06, 23.33 ± 4.41, and 152.00 ± 0 seconds in venous clamping groups, respectively. Severe medullary and cortical congestion and hemorrhage on histology and cell damage by glutathione levels and TUNEL assay were found after 4 hours of venous clamping. CONCLUSIONS: Arterial ischemia and venous occlusion impact the function and viability of vascularized lymph node flaps differently. The critical venous occlusion time was 4 hours.


Assuntos
Isquemia/fisiopatologia , Linfonodos/irrigação sanguínea , Retalhos Cirúrgicos/irrigação sanguínea , Doenças Vasculares/fisiopatologia , Animais , Drenagem , Artéria Femoral/fisiopatologia , Virilha , Linfonodos/transplante , Masculino , Perfusão , Ratos , Ratos Endogâmicos Lew
11.
Laryngoscope ; 130(1): 101-107, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30786034

RESUMO

OBJECTIVE: There is no useful tool to clinically predict the occurrence of osteoradionecrosis (ORN) of the mandible quantitatively. The aim was to investigate the risk factors, including different modalities of radiotherapy, for developing mandibular ORN in patients undergoing marginal mandibulectomy and postoperative radiotherapy. METHODS: Between January 2006 and December 2012, 167 subjects who underwent marginal mandibulectomy and postoperative radiotherapy with different modalities were enrolled. The association of ORN with mandibular bone measurements and patient variables was analyzed, and a nomogram was established. RESULTS: Fifteen (8.98%) of the 167 patients developed ORN during the follow-up period, and ORN was significantly associated with diabetes mellitus (DM), body mass index (BMI), remaining bone height, remaining bone height to original bone height ratio, resected bone height to original bone height ratio, and mandibular dose (P: < 0.001, 0.004, 0.042, 0.018, 0.010, 0.020, respectively). Interestingly, the risk of ORN had no significant difference between conformal and intensity modulation radiation therapy (P = 0.407). Multivariate analysis revealed that DM and resected bone height to original bone height ratio ≥ 50% were independent risk factors for postoperative ORN. A nomogram consisting of BMI, DM, resected bone height to original bone height ratio, mandibulotomy, and mandibular dose for predicting the ORN-free probability was established; and the c-index of the nomogram for ORN status was 0.803. CONCLUSION: A nomogram based on the risk factors was plotted to strengthen the prediction of ORN quantitatively. Surgeons should be more discrete regarding the treatment plan for patients with higher probability of ORN. LEVEL OF EVIDENCE: 3b Laryngoscope, 130:101-107, 2020.

12.
J Surg Oncol ; 121(1): 57-66, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31197837

RESUMO

INTRODUCTION: Patients with pre-existing lymphedema who undergo total knee arthroplasty (TKA) for osteoarthritis (OA) are at high risk for periprosthetic joint infection. This complication usually requires removal of the implant. This study aimed to investigate whether surgical treatment of lymphedema reduces the rate of prosthesis removal in such patients. MATERIALS AND METHODS: We retrospectively reviewed our prospective database of patient information collected between January 2009 and December 2018. A total of 348 cases of lower extremity lymphedema were reviewed, and those who underwent total knee TKA for OA of the knee were included. Patient demographics, clinical data, lymphedema surgical history, and TKA surgical history including any episodes of removal were collected and analyzed. RESULTS: There were nine of 15 lymphedema patients with knee OA who subsequently underwent TKA. The mean patient age was 70.4 ± 7.1 years. A total of 18 TKAs were performed in nine patients. The knee prosthesis removal rate was 66.7% (12/18). The prosthesis removal rate was 40% (2/5) in patients who underwent lymphedema microsurgery vs 76.9% (10/13) for those who did not (P = .03). CONCLUSIONS: Pre-existing lymphedema is associated with a high rate of knee prosthesis removal. Lymphedema microsurgery reduced the removal rate of knee prostheses. We recommend that lymphedema microsurgery be considered for patients who require TKA as a treatment for of the knee.


Assuntos
Artroplastia do Joelho/efeitos adversos , Remoção de Dispositivo , Prótese do Joelho , Linfedema/cirurgia , Osteoartrite do Joelho/cirurgia , Infecções Relacionadas à Prótese/prevenção & controle , Idoso , Artroplastia do Joelho/métodos , Feminino , Humanos , Linfedema/fisiopatologia , Microcirurgia/métodos , Pessoa de Meia-Idade , Estudos Retrospectivos
13.
J Surg Oncol ; 121(3): 422-434, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31875981

RESUMO

BACKGROUND: This study was to investigate the lymphoscintigraphy findings for the diagnosis and severity in unilateral gynecological cancer-related lymphedema (GCRL) and to correlate lymphoscintigraphy stages with the clinical findings. METHODS: Patients with unilateral GCRL who underwent lymphoscintigraphy were staged using the presence of ileo-inguinal lymph nodes, distal-lymphatic ducts, and dermal backflow findings. Taiwan Lymphoscintigraphy Staging (TLS) was divided into three patterns and seven stages: normal drainage (L-0); partial obstruction (P-1, P-2, and P-3); and total obstruction (T4, T-5, and T-6). Correlations between clinical lymphedema severity and TLS were evaluated using analysis of variance and multivariable linear regression analyses. RESULTS: A total of 141 patients with unilateral GCRL were divided as follows: 6 (4.3%) in normal drainage, 56 (39.7%) in partial-obstruction, and 79 (56%) in total obstruction. Cellulitis episodes, circumferential difference, and computed tomography (CT) volumetric difference were shown to be statistically different between TLS stages (P < .001 for all). Total obstruction stages were the most significant factors associated with the severity of circumferential difference (ß = 19.72, 25.54, 32.42, respectively; P < .05) and CT volumetric difference (ß = 36.04, 45.12, 52.78, respectively; P < .01). CONCLUSIONS: Total lymphatic obstruction was present in 56% of unilateral GCGL. Lymphoscintigraphy stages were statistically correlated with episodes of cellulitis, circumferential difference and CT volumetric difference in unilateral GCRL.


Assuntos
Neoplasias dos Genitais Femininos/diagnóstico por imagem , Sistema Linfático/diagnóstico por imagem , Linfedema/diagnóstico por imagem , Linfocintigrafia/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Neoplasias dos Genitais Femininos/complicações , Humanos , Linfedema/etiologia , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos
14.
Microsurgery ; 2019 Dec 10.
Artigo em Inglês | MEDLINE | ID: mdl-31821621

RESUMO

BACKGROUND: The medial sural artery perforator (MSAP) flap is an increasingly versatile and reliable flap for soft tissue reconstruction. This study investigates complication rates and long-term outcomes of the MSAP flap. METHODS: A retrospective review was performed on consecutive patients undergoing MSAP flap reconstruction at Chang Gung Memorial Hospital from 2006 through 2017. Patient demographics were assessed. Flap failure and wound complications were the outcome measures. RESULTS: In the cohort of 246 patients that underwent a total of 248 MSAP flap reconstructions were identified. The average age was 47.5 years (range 15-76). Of the 248 flaps, 170 were used for reconstruction of the head and neck, 48 for upper extremity reconstruction, and 30 for lower extremity reconstruction. The average MSAP flap size was 5.2 × 11.8 cm. 31 (12.5%) of the flaps developed arterial occlusion, venous insufficiency, or a hematoma postoperatively requiring re-exploration. Nineteen were successfully salvaged, yielding an overall failure rate of 4.8%. Minor complications included the need for flap debridement in 18 cases (7.3%) and need for donor site debridement in eight cases (3.2%). CONCLUSIONS: The MSAP flap can be used in a versatile fashion to reconstruct defects of the head and neck, upper extremity, and lower extremity with minimal complication rates.

15.
Plast Surg (Oakv) ; 27(4): 297-304, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31763329

RESUMO

Purpose: The differentiation of arterial versus venous occlusion in free tissue transfers has rarely been described. This study investigated changes in blood flow caused by arterial and venous occlusion and the potential for laser Doppler flowmetry to distinguish between these 2 conditions for better clinical assessment and management of free tissue transfer. Methods: Six patients with a mean age of 43.5 years underwent microsurgical free tissue transfer. The venous and arterial blood flow of the vessels and skin flap were monitored using laser Doppler flowmetry with high-frequency pulsed Doppler transducers for vessels and skin before, during, and after clamping the vessels for 10 minutes. Results: The average decreases in blood flow in the artery and vein caused by clamping were 94.4% and 93.8%, respectively. On average, arterial occlusion demonstrated a sudden drop of 67.7% and venous occlusion caused a decrease of 26.6% on laser Doppler flowmetry in free tissue skin. Conclusion: Using a vessel-holding probe, laser Doppler flowmetry could be used to differentiate between arterial and venous occlusion in free tissue transfer, thereby aiding decision-making for better clinical management.

16.
Plast Reconstr Surg Glob Open ; 7(10): e2431, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31772880

RESUMO

Background: Lymphedema is a debilitating condition characterized by swelling from lymph fluid exceeding transport capacity. A gold standard for arm measurement is not established, and measurement methods vary. This study evaluates the comparability of the tape measure and Analytic Morphomics in deriving limb circumference measurements in patients with upper extremity lymphedema. Methods: Fifteen participants with diagnosed upper limb lymphedema were included between July 2013 and June 2017 at Chang Gung Memorial Hospital in Taipei, Taiwan. Affected and unaffected arm circumferences were measured using a flexible tape or morphomic measurement at 10 cm above and below the elbow. Computed tomography scans were standardized, processed, smoothed with a piecewise polynomial algorithm for Analytic Morphomics of arm circumference. Comparative plots, mean percent difference, and adjusted coefficient of determination (R 2) were utilized to compare the consistency of both measurement procedures. Results: The tape measure and Analytic Morphomics demonstrated consistent measures of arm circumference. On the affected arm, the mean (95% CI) difference in arm circumference between methods was 1.60 cm (0.99-2.20) above, and 0.57 cm (0.23-0.91) below the elbow. Mean percent differences in circumference was 6.65% (SD 3.52%) above and 1.38% (SD 2.11%) below the elbow. The adjusted R 2 for both methods was 94% above and 96% below the elbow. Conclusions: Analytic Morphomics showed strong consistency with the manual tape measure of arm circumference measurement in those with upper extremity lymphedema. Analytic Morphomics present an opportunity for a precise, granular measurement of limb composition for assessment of disease state and patient planning.

17.
J Surg Oncol ; 120(7): 1162-1168, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31556139

RESUMO

BACKGROUND: Vascularized lymph node transfer (VLNT) is an effective surgery for extremity lymphedema. This study evaluated a lymphatic drainage device (LDD) for the drainage of accumulated fluid into the venous system. METHODS: Micropore filtering membranes with pore sizes of 5, 0.65, and 0.22 µm polyvinylidene difluoride, and 0.8 µm Nylon Net Filter were evaluated to determine the in vitro efficiency of drainage flow of an LDD. The two superior membranes were further used for the evaluation of the inflow and outflow of the LDD in vivo using 5% albumin. RESULTS: At 5 minutes, the volumes drained with 5, 0.65, and 0.22 µm polyvinylidene difluoride and 0.8 µm nylon membranes were 15.2, 2.77, 2.37, and 0.59 mL, respectively (P < .01). At 10 minutes, the collected volumes of 5 and 0.65 µm polyvinylidene difluoride were 1788 and 1051 µL (P = .3). The indocyanine green fluorescence was detected at 50 seconds for the 5 µm polyvinylidene difluoride membrane but not for the 0.65 µm membrane. CONCLUSIONS: The study successfully demonstrated the proof-of-concept of the LDD prototype that mimicked VLNT with drainage of 5% albumin into the venous system in a rat model.


Assuntos
Modelos Animais de Doenças , Drenagem/instrumentação , Drenagem/métodos , Linfedema/terapia , Animais , Desenho de Equipamento , Verde de Indocianina/metabolismo , Bombas de Infusão Implantáveis , Masculino , Ratos , Ratos Sprague-Dawley , Recuperação de Função Fisiológica
18.
BMC Med Imaging ; 19(1): 68, 2019 08 16.
Artigo em Inglês | MEDLINE | ID: mdl-31420022

RESUMO

BACKGROUND: The aim of this study was to compare non-contrast-enhanced 3D phase contrast magnetic resonance angiography (3D PC-MRA) and conventional intravenous administration of contrast media, i.e., contrast-enhanced MRA (CE-MRA), to evaluate the courses of facial arteries for the preparation of vascularized submental lymph node flap (VSLN flap) transfer. METHODS: The head and neck regions of 20 patients with limb lymphedema were imaged using a 3 T MRI scanner. To improve the evaluation of facial artery courses, MRA was fused with anatomical structures generated by high-resolution T1-weighted imaging. The diagnostic and image qualities of facial arteries for VSLN flap planning were independently rated by two radiologists. Interobserver agreement was evaluated using Cohen's kappa. Differences between 3D PC-MRA and CE-MRA in terms of the diagnostic quality of facial arteries were evaluated using McNemar's test. RESULTS: Cohen's kappa indicated fair to good interobserver agreement for the diagnostic and image qualities of the bilateral facial arteries. No significant difference in terms of the diagnostic quality of the left and right facial arteries between 3D PC-MRA and CE-MRA, respectively, was identified. CONCLUSIONS: Non-contrast 3D PC-MRA is a reliable method for the evaluation of facial artery courses prior to VSLN flap transfer and could serve as an alternative to CE-MRA for patients with renal insufficiency or severe adverse reactions to contrast media.


Assuntos
Face/irrigação sanguínea , Linfonodos/irrigação sanguínea , Linfedema/diagnóstico por imagem , Angiografia por Ressonância Magnética/instrumentação , Adolescente , Adulto , Idoso , Criança , Pré-Escolar , Meios de Contraste/administração & dosagem , Face/diagnóstico por imagem , Feminino , Humanos , Linfonodos/cirurgia , Linfedema/cirurgia , Angiografia por Ressonância Magnética/métodos , Masculino , Pessoa de Meia-Idade , Variações Dependentes do Observador , Período Pré-Operatório , Interpretação de Imagem Radiográfica Assistida por Computador , Retalhos Cirúrgicos , Adulto Jovem
19.
Plast Reconstr Surg ; 144(2): 486-496, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31348365

RESUMO

BACKGROUND: Lymphovenous anastomosis is technically challenging and can be successfully performed with an advanced operating microscope, supermicrosurgical instruments, and indocyanine green lymphography. This study compared the outcomes between side-to-end and end-to-end lymphovenous anastomosis configurations for unilateral extremity lymphedema. METHODS: Between April of 2013 and June of 2017, lymphovenous anastomosis was indicated for 58 patients who preoperatively had patent lymphatic ducts by indocyanine green lymphography, including 20 patients with upper limb lymphedema and 38 patients with lower limb lymphedema. Either an end-to-end or a side-to-end lymphovenous anastomosis was used to anastomose the subdermal venule to the lymphatic duct. The circumferential difference and episodes of cellulitis were used as outcome measurements. RESULTS: Twenty-three patients underwent an end-to-end lymphovenous anastomosis and 35 patients underwent side-to-end lymphovenous anastomosis. All patients had an immediate patency evaluated by indocyanine green lymphography and patent blue assessments. All patients returned to their daily routine without the use of any compression garments. At an average follow-up of 16.5 months (range, 13.4 to 19.6 months), the improvement of circumferential difference (3.2 percent; range, 1.8 to 4.6 percent) in the side-to-end group was statistically greater than that in the end-to-end group (2.2 percent; range, 1 to 3.4 percent; p = 0.04). The overall episodes of cellulitis were significantly reduced from 1.7 times/year (range, 1.3 to 2.1 times/year) to 0.7 times/year (range, 0.3 to 1.1 times/year; p < 0.001), but no difference was observed between the two groups. CONCLUSIONS: Both side-to-end and end-to-end lymphovenous anastomosis configurations were effective surgical approaches for improving early-grade extremity lymphedema. Side-to-end lymphovenous anastomosis has the advantages of having greater efficacy for lymph drainage, requiring only one anastomosis and eliminating the need to use compression garments. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.


Assuntos
Linfedema/diagnóstico por imagem , Linfedema/cirurgia , Microcirurgia/métodos , Procedimentos Cirúrgicos Vasculares/métodos , Adulto , Idoso , Anastomose Cirúrgica , Distribuição de Qui-Quadrado , China , Estudos de Coortes , Feminino , Humanos , Extremidade Inferior/cirurgia , Vasos Linfáticos/diagnóstico por imagem , Vasos Linfáticos/cirurgia , Linfografia/métodos , Masculino , Pessoa de Meia-Idade , Prognóstico , Recuperação de Função Fisiológica , Estudos Retrospectivos , Medição de Risco , Índice de Gravidade de Doença , Estatísticas não Paramétricas , Extremidade Superior/cirurgia , Grau de Desobstrução Vascular/fisiologia
20.
Plast Reconstr Surg ; 2019 May 10.
Artigo em Inglês | MEDLINE | ID: mdl-31188305

RESUMO

BACKGROUND: Lymphovenous anastomosis (LVA) is technically challenging and could be successfully performed with advanced operating microscope, super-microsurgical instruments, and indocyanine green (ICG) lymphography. This study was to compare the outcomes between side-to-end and end-to-end LVA configurations for unilateral extremity lymphedema. METHODS: Between April 2013 and June 2017, 58 patients who preoperatively had patent lymphatic ducts by ICG lymphography were indicated for LVA, including 20 upper limb lymphedema and 38 lower limb lymphedema. Either an end-to-end or a side-to-end LVA was used to anastomose the subdermal venule to lymphatic duct. The circumferential difference and episodes of cellulitis were used as outcome measurements. RESULTS: Twenty-three patients underwent an end-to-end LVA, and 35 patients had a side-to-end LVA. All cases had an immediate patency evaluated by ICG lymphography and patent blue assessments. All patients returned to their daily routine without the use of any compression garments. At an average follow-up of 16.5 (13.4-19.6) months, the improvement of circumferential difference 3.2 (1.8-4.6)% in side-to-end group was statistically greater than 2.2 (1-3.4)% in end-to-end group (p= 0.04). The overall episodes of cellulitis were significantly reduced from 1.7 (1.3-2.1) to 0.7 (0.3-1.1) times per year (p< 0.001), but no difference was observed between the two groups. CONCLUSIONS: Both side-to-end and end-to-end LVA configurations were effective surgical approaches for improving early-grade extremity lymphedema. Side-to-end LVA has the advantages of having a greater efficacy for lymph drainage while requiring only one anastomosis and eliminating the need to use compression garments.

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