Ciudad, Pedro

Abstract Background Lymphedema is an accumulation of protein-rich fluid in the interstitial spaces resulting from impairment in the lymphatic circulation that can impair quality of life and cause considerable morbidity. Lower extremity lymphedema (LEL) has an overall incidence rate of 20%. Conservative therapies are the first step in treatment of LEL; however, they do not provide a cure because they fail to address the underlying physiologic dysfunction of the lymphatic system. Among several surgical alternatives, lymphaticovenous anastomosis (LVA) has gained popularity due to its improved outcomes and less invasive approach. This study aims to review the published literature on LVA for LEL treatment and to analyze the surgical outcomes. Methods PubMed database was used to perform a comprehensive literature review of all articles describing LVA for treatment of LEL from Novemeber 1985 to June 2019. Search terms included “lymphovenous” OR “lymphaticovenous” AND “bypass” OR “anastomosis” OR “shunt” AND “lower extremity lymphedema.” Results A total of 95 articles were identified in the initial query, out of which 58 individual articles were deemed eligible. The studies included in this review describe notable variations in surgical techniques, number of anastomoses, and supplementary interventions. All, except one study, reported positive outcomes based on limb circumference and volume changes or subjective clinical improvement. The largest reduction rate in limb circumference and volume was 63.8%. Conclusion LVA demonstrated a considerable reduction in limb volume and improvement in subjective findings of lymphedema in the majority of patients. The maintained effectiveness of this treatment modality in long-term follow-up suggests great efficacy of LVA in LEL treatment.

Background: Prepectoral implant-based breast reconstruction has gained popularity because of advantages over the subpectoral technique. Acellular dermal matrix use with implant-based breast reconstruction has become common because of its perceived superior aesthetic outcome. Matrices are expensive, however, and recent evidence has pointed to several potential complications. This article reports a series of prepectoral implant-based breast reconstructions with and without acellular dermal matrix and compared their outcomes. Methods: This is a single-surgeon retrospective review of patients who underwent staged prepectoral implant-based breast reconstruction following nipple-sparing mastectomy over two periods. Patients with well-perfused mastectomy skin flaps with a homogeneous thickness underwent reconstruction with acellular dermal matrix initially. On evolution of the practice, it was not used. Patient demographics, operative data, and complications were analyzed. Aesthetic outcome was measured by the BREAST-Q survey and the Aesthetic Item Scale. A cost analysis was also performed. Results: Forty patients were included (acellular dermal matrix group, n = 19; non–acellular dermal matrix group, n = 21). The nonmatrix group had one case (5 percent) of seroma and one case (5 percent) with hematoma; there were none in the acellular dermal matrix group. Average BREAST-Q and Aesthetic Item Scale scores were 82.3 versus 81.6 (p = 0.954) and 20.98 versus 20.43 (p = 0.640) for the matrix and nonmatrix groups, respectively. The direct cost savings for the authors’ institution over 1 year if matrix was not used in all cases of implant-based breast reconstruction would be estimated at $3,105,960 to $6,211,920 for unilateral and bilateral cases, respectively, for Medicare reimbursement. Conclusions: With adequate patient selection, acellular dermal matrix is not always required during two-stage prepectoral implant-based breast reconstruction for good aesthetic outcomes. The economic burden on patients and the health care system could be lessened with selective matrix use. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

AbstractBackgroundVascularized lymph node transfer (VLNT) is an emerging surgical treatment for lymphedema. However, literature‐comparing outcomes of upper limb lymphedema (ULL) and lower limb lymphedema (LLL) is limited. Hence, the aim of this study is to compare the long‐term clinical outcomes on ULL versus LLL in patients treated with VLNT.MethodsA retrospective study retrieving data from patients with International Society of Lymphology (ISL) stages II–III who underwent different VLNTs from July 2010 to July 2016 in our institution was performed. Demographics preoperatively, and clinical data (limb circumference, infectious episodes, lymphoscintigraphic studies) preoperatively and postoperatively were recorded. Clinical outcomes by extremity were also analyzed.ResultsA total of 83 patients with lymphedema (ULL: n = 30, LLL: n = 53) were included. Mean follow‐up time was 32.8 months (range 24–49 months). Mean circumference reduction was higher in patients with ULL compared to with LLL (28.6 ± 8.6 vs. 22.3 ± 10.1, p < .001), and for patients with secondary lymphedema (24.8 ± 9.6, p < .001) than for patients with primary lymphedema (18.9 ± 14, p > .05). Infectious episodes per year preoperative and postoperative showed that LLL patients had higher reduction on infection rate compared with ULL patients (2.4 ± 1.1 vs. 1.9 ± 1.2, p < .001).ConclusionVLNT is a promising surgical treatment option for patients with lymphedema. This study suggests that VLNT may have a more beneficial outcome in patients with ULL and with secondary lymphedema.

IntroductionManagement after total pharyngolaryngectomy with free ileocolon flaps can be challenging. Adequate postoperative surgical guidelines are essential to avoid complications. Factors, such as agitation, hypotension, or prolonged mechanical ventilation, might compromise final outcomes. Herein, we describe our experience in the early postoperative care of patients after total pharyngolaryngectomy with immediate reconstruction using the free ileocolon flap.MethodsThis is a retrospective review of all patients who underwent total pharyngolaryngectomy and immediate reconstruction using the free Ileocolon flap. Demographics, etiology of resection, neoadjuvant therapy, surgical time, method of sedation, postoperative use of vasopressors, length of intensive care unit (ICU) stay, time of discontinuation of mechanical ventilation, and complications were recorded and analyzed.ResultsBetween 2010 and 2015, a total of 34 patients underwent total pharyngolaryngectomy and immediate reconstruction using the free Ileocolon flap. The most common cause of total pharyngolaryngectomy was cancer. Twenty-eight patients had neoadjuvant therapy (radiation). The average surgical time was 11.5 hours (range, 8–14.5 hours), average length of ICU stay was 3 days (range, 2–15 days) with an average time for mechanical ventilation cessation of 3 days (range, 1–20 days). Midazolam and dexmedetomidine were the most common sedatives used during surgery and in the ICU period. Three patients required vasopressors due to hypotension, 2 had unplanned self-extubation from the tracheostomy site, 2 experienced postoperative bleeding, 1 had pneumonia, 4 required unplanned return to the operating room, 2 had partial flap loss, and 1 had complete flap loss.ConclusionsOverall, a majority of patients recovered well postoperatively with minimal complications and low rate of reoperation. Our research provides a foundation to develop a risk-stratified approach to determine the need for an ICU admission or early transfer to floor care.

Abstract Lymphedema refers to the accumulation of protein-rich fluid in the interstitial spaces. This can occur secondary to congenital malformation of the lymphatic channels or nodes or as a result of an insult that damages appropriately formed channels and nodes. Stagnant, protein-rich lymph initiates an inflammatory response that leads to adipocyte proliferation, fibrous tissue deposition, and increased susceptibility to infections. The end result is permanent disfigurement and dermal changes. Early and accurate diagnosis is essential, since lymphedema is a chronic and progressive problem. When lymphedema affects the lower extremity, it is important to manage it in a way that preserves function and mobility. Early diagnosis also allows for a proactive rather than reactive approach to treatment and utilization of novel physiologic procedures, such as lymphovenous anastomosis and vascularized lymph node transfer. Such interventions slow down disease progression and reduce morbidity by allowing the surgeon to salvage the remaining functional lymphatic channels. When physiologic procedures fail or when faced with a delayed presentation, the addition of excisional procedures can provide a more comprehensive treatment of this debilitating disease. The aim of this article is to review the most current concepts in the surgical management of lower extremity lymphedema.

BackgroundEnd‐stage lower extremity lymphedema (LEL) poses a particularly formidable challenge to surgeons as multiple pathological processes are at work. Because single modality treatment is often unsuccessful, we devised a comprehensive multimodal surgical treatment. The aim of this study is to share the technical considerations and examine the clinical outcomes of this combined approach.MethodsBetween 2013 and 2017, patients with International Society of Lymphology stage III, who underwent the combination treatment of Charles,’ Homan’s procedure with toe management and vascularized lymph node transfer (CHAHOVA), were included in this retrospective study. Outcomes evaluated were limb size, number of infectious episodes, compression garment usage, and rate of complications.ResultsA total of 68 patients were included. With a mean follow‐up of 29 months, the overall circumference reduction rate for the upper thigh and the rest of the extremity was 67.4% (48.2‐88.2%) and 98.1% (88‐100%), respectively. During the follow‐ups, 2 (2.9%) patients experienced episodes of cellulitis and the average number of yearly infections decreased from 4.2 to 1.2 episodes per person. All patients were able to discontinue compression therapy without recurrence of lymphedema. Nine (13.2%) patients reported minor complications.ConclusionThe combine CHAHOVA in a single‐stage procedure is an effective and safe approach in the end‐stage LEL.

BackgroundTreatment of advanced lymphedema requires not only restoration of physiological lymph drainage, but also excision of fibrotic tissue and excess skin. The aim of this study is to show how the combination of double vascularized lymph node transfers (VLNTs) and a modified radical reduction with preservation of perforators (RRPP) can accomplish both of these treatment goals.MethodsBetween 2010 and 2016, 16 patients (15 female and one male) with extremity lymphedema underwent a combined double gastroepiploic VLNTs and modified RRPP. Demographics, outcomes including circumference reduction rates, preoperative and postoperative lymphoscintigraphy, complications, and responses to the Lymphedema Quality of Life (LYMQOL) questionnaire were analyzed.ResultsAll flaps survived. The mean follow‐up period was 14.2 months (range, 12‐19). The mean circumference reduction rate was 74.5% ± 6.9% for the upper limb and 68.0% ± 4.2% for the lower limb. There were no major complications. Minor complications, including numbness and hyperesthesia, were treated conservatively. LYMQOL showed a 2.7‐fold quality‐of‐life improvement (P < 0.01). Postoperative lymphoscintigraphy showed improved lymphatic drainage in all cases.ConclusionCombined double VLNTs and modified RRPP safely and effectively improves lymphatic drainage, reduces fibrotic tissue and excess skin, decreases episodes of infections, and improves patients’ quality of life in the advanced stages of lymphedema.