Surgical Prevention of Arm Lymphedema After Breast Cancer Treatment

Purpose  

To prospectively assess the efficacy of the lymphatic microsurgical preventive healing approach (LYMPHA) to prevent lymphedema after axillary dissection (AD) for breast cancer treatment.     

An Effective Surgical Treatment for Repeatedly Leaking Duodenal Stumps

In spite of the overpowering advancements of surgery, that have occurred in the last decades, the optimal treatment of duodenal stump leakage remains uncertain. Between 1997 and 2015, 14 procedures were performed in 11 patients due to duodenal stump leakage, following subtotal gastric resection with Billroth II reconstruction for either ulcer perforation or bleeding. Seven patients underwent conventional surgery aimed at sealing the fistulas: five patients had resuture, one implantation of a Petzer catheter through a purse-string suture, and one percutaneous drainage. Seven patients underwent the so-called “double Roux-en-Y conversion” operation—four of whom underwent the procedure primarily and three following leakage after the first procedure—which consisted of a mucosal roof on duodenal stump seromuscular anastomosis formed between the duodenal stump and the side of an isolated jejunal loop, antegrade jejuno-duodenal drainage, and two end-to-side jejuno-jejunal anastomoses. The clinical course proved fatal in two cases (2/11 = 18%). One patient died following the insertion of a Petzer catheter and omental wrapping, and the other died after percutaneous drainage. Three of the five patients who underwent resuturing for a continued leak had the double Roux-en-Y reconstruction technique. Although this procedure is more extensive, it has proved superior in terms of major complications (2/7 vs 5/7), the number of hospital days (18 vs 23), and postoperative mortality rate (0/7 vs 2/7). The use of the double Roux-en-Y conversion, consisting of an anastomosis of the tension-free small bowel mucosa with appropriate blood supply to the duodenal stump, and jejuno-duodenal antegrade drainage is a useful alternative for the treatment of the challenging duodenal stump blow out and the more complex repeatedly leaking duodenal stumps.     

An Integrative Therapeutic Concept for Surgical Treatment of Severe Cases of Lymphedema of the Lower Extremity

Background

Lymphedema results from insufficient lymphatic drainage and typically affects the extremities. Recent studies revealed obesity as another cause of extremity lymphedema. Conservative treatment of patients with elephantiastic lymphedema of the lower extremity is limited and often inadequate. Resecting surgery plays an important role in these cases. Here, we investigated the effects of an integrated therapy concept on outcome and complication rates.

Methods

We retrospectively analyzed the clinical outcome of 26 patients with elephantiastic lymphedema of the lower limb who underwent a complex decongestive physical therapy (CDP) perioperatively and reduction surgery in our clinic between 1998 and 2011. We subsequently compared these patients (group A) with a control group of 30 patients (group B) who received medial thigh lift due to post-bariatric or aesthetic issues between 2011 and 2013. The incidence of complications, reoperations, blood transfusion, and duration of hospital stay was analyzed. All patients in group A received CDP perioperatively in a specialized lymphological clinic.

Results

Both groups are comparable in terms of age and sex. Patients significantly differ in terms of BMI (p?<?0.001). Thirty-six reductive procedures were performed in group A and 30 in group B. We did not see any significant difference in the incidence of complications (p?=?1.000) and the rate of postoperative blood transfusions (p?=?0.116).

Conclusions

We were able to show that an integrative concept including surgery is a good additional option for the treatment of severe cases of lymphedema in appropriate candidates. Furthermore, an adequate perioperative conservative setting helps to minimize possible complications.

     

Review of Current Surgical Treatments for Lymphedema

Background

The current mainstay of lymphedema therapy has been conservative nonsurgical treatment. However, surgical options for lymphedema have been reported for over a century. Early surgical procedures were often invasive and disfiguring, and they often had only limited long-term success. In contrast, contemporary surgical techniques are much less invasive and have been shown to be effective in reducing excess limb volume, the risk of cellulitis, and the need for compression garment use and lymphedema therapy. Microsurgical procedures such as lymphaticovenous anastomosis and vascularized lymph node transfer lymphaticolymphatic bypass can treat the excess fluid component of lymphedema swelling that presents as pitting edema. Suction-assisted protein lipectomy is a minimally invasive procedure that addresses the solid component of lymphedema swelling that typically occurs later in the disease process and presents as chronic nonpitting lymphedema. These surgical techniques are becoming increasingly popular and their success continues to be documented in the medical literature. We review the efficacy and limitations of these contemporary surgical procedures for lymphedema.

Methods

A Medline literature review was performed of lymphedema surgery, vascularized lymph node transfer, lymphaticovenous anastomosis, lymphatic liposuction, and lymphaticolymphatic bypass with particular emphasis on developments within the past 10 years. A literature review of technique, indications, and outcomes of the surgical treatments for lymphedema was undertaken.

Results

Surgical treatments have evolved to become less invasive and more effective.

Conclusions

With proper diagnosis and the appropriate selection of procedure, surgical techniques can be used to treat lymphedema safely and effectively in many patients when combined with integrated lymphedema therapy.     

Suction-Assisted Lipectomy for Treatment of Lower-Extremity Lymphedema

Lymphedema typically occurs on the extremities and affects millions of people throughout the world. Although currently there is no single treatment proven effective for lymphedema in every patient, suction-assisted lipectomy has been shown to be effective in some patients. Suction-assisted lipectomy offers patients with lower-extremity lymphedema a less invasive, less morbid surgical option compared with traditional excisional techniques. In this article we present a case of lymphedema reduction with suction-assisted lipectomy in a patient with bilateral lower-extremity lymphedema.     

Effectiveness of Decongestive Lymphatic Therapy in Patients with Lymphedema Resulting from Breast Cancer Treatment Regardless of Previous Lymphedema Treatment

Decongestive lymphatic therapy (DLT) has gained wide acceptance as an effective treatment for patients with lymphedema resulting from breast cancer treatment. It is unclear whether DLT is effective for patients with lymphedema who have received lymphedema treatment previously. Our purpose was to compare the effectiveness of DLT in patients who had received lymphedema treatment previously with those who had never received treatment. We retrospectively reviewed the medical records of 98 patients who received outpatient lymphedema therapy for upper extremity lymphedema following surgery. Seventy‐two eligible patients with a breast cancer diagnosis and complete medical records were divided into two groups: group 1; previously treated (PT) patients (n = 38, 53%) had previously received lymphedema treatment, while group 2 (no PT, n = 34, 47%) had never received lymphedema treatment. The primary outcome was the percent change in volume in the lymphedematous arm, measured by perometer, after DLT treatment. The two groups did not differ significantly in age, comorbidities, body mass index, and median time from surgery to current treatment, surgical procedure, previous radiation treatment, or history of cellulitis/lymphangitis. DLT significantly reduced arm volume in both groups (group 1, p < 0.001; group 2, p = 0.003). The mean percent volume reduction did not differ significantly between the groups (p = 0.619). This study is the first to show that, DLT reduce limb volume significantly with post‐mastectomy lymphedema, regardless of previous lymphedema therapy.     

Prevention and Management of Lymphedema after Breast Cancer Treatment

Lymphedema of the arm after breast cancer treatment continues to challenge clinicians worldwide. In this review, we examine the main modalities, both nonsurgical and surgical, to prevent and treat this as yet incurable condition.     

Microsurgical Techniques for Lymphedema Treatment: Derivative Lymphatic-Venous Microsurgery

We analyzed clinicopathologic and imaging features of chronic peripheral lymphedema to identify imaging findings indicative of its exact etiopathogenesis and to establish the optimal treatment strategy. One of the main problems of microsurgery for lymphedema is the discrepancy between the excellent technical possibilities and the subsequently insufficient reduction of the lymphedematous tissue fibrosis and sclerosis. Appropriate treatment based on pathologic studies and surgical outcome have not been adequately documented. Over the past 25 years, 676 patients with peripheral lymphedema have been treated with microsurgical lymphatic-venous anastomoses. Of these patients, 447 (66%) were available for long-term follow-up study. Objective assessment was undertaken by water volumetry and lymphoscintigraphy. Objectively, volume changes showed a significant improvement in 561 patients (83%), with an average reduction of 67% of the excess volume. Of the 447 patients followed, 380 (85%) have been able to discontinue the use of conservative measures, with an average follow-up of more than 7 years and average reduction in excess volume of 69%. There was an 87% reduction in the incidence of cellulitis after microsurgery. Microsurgical lymphatic-venous anastomoses have a place in the treatment of peripheral lymphedema and should be the therapy of choice in patients who are not sufficiently responsive to nonsurgical treatment. Improved results can be expected with operations performed early, during the first stages of lymphedema.     

Outcomes of Vascularized Lymph Node Transplantation for Treatment of Lymphedema

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A Novel Two‐Stage Surgical Approach to Treat Chronic Lymphedema

Surgical treatment of chronic lymphedema has seen significant advances. Suction‐assisted protein lipectomy (SAPL) has been shown to safely and effectively reduce the solid component of swelling in chronic lymphedema. However, these patients must continuously use compression garments to control and prevent recurrence. Microsurgery procedures, including lymphaticovenous anastomosis (LVA) and vascularized lymph node transfer (VLNT), have been shown to be effective in the management of the fluid component of lymphedema and allow for decreased garment use. SAPL and VLNT were applied together in a two‐stage approach in two patients with chronic lymphedema after treatment for breast cancer. SAPL was used first to remove the chronic, solid component of the soft‐tissue excess. Volume excess in our patients' arms was reduced an average of approximately 83% and 110% after SAPL surgery. After the arms had sufficiently healed and the volume reductions had stabilized, VLNT was performed to reduce the need for continuous compression and reduce fluid re‐accumulation. Following the VLNT procedures, the patients were able to remove their compression garments consistently during the day and still maintain their volume reductions. Neither patient had any postoperative episodes of cellulitis. SAPL and VLNT can be combined to achieve optimal outcomes in patients with chronic lymphedema.     

An Effective Extraction Technique for the Treatment of Closed Macrocomedones

BACKGROUND: Closed macrocomedones are unsightly lesions that may be resistant to medical treatments and comedone extractors. Light cautery has been used to treat macrocomedones, which are 1 to 3 mm in size; however, its success in larger and chronic lesions is limited. OBJECTIVE: To introduce an alternative treatment technique for this neglected problem. METHODS: We treated these lesions by using cautery and standard dissecting forceps. After puncturing the macrocomedones in the center using the sharp-tipped cautery point, we grasped the base of the comedone using standard dissecting forceps and squeezed and pulled out the contents. RESULTS: Twelve patients were treated with this technique, all of whom tolerated the procedure well and judged the cosmetics results as very good. CONCLUSION: We recommend this procedure for patients who have closed macrocomedones larger than 3 mm in size, although it is an effective treatment for macrocomedones of any size.     

An Effective LDL Removal Filter for the Treatment of Hyperlipidemia

Abstract: On-line membrane plasma fractionation techniques have made semiselective removal of pathological macromolecules practical. However, several problems such as cryogel formation exist when the procedure is performed at ambient temperature. Cryogel formation takes place when heparinized plasma is cooled below 35°C and when it tends to occlude the pore structure of the secondary filter membrane resulting in a poor molecular cut off of the macromolecular filter. Thermofiltration is one of the on-line plasma fractionation techniques used when warming plasma from 37 to 42°C to prevent cryogel formation. Thermofiltration enhanced the performance of the lipofilter (Kuraray 4A) and demonstrated better molecular cut off between low density lipoprotein (LDL) cholesterol and high density lipoprotein (HDL) cholesterol than double filtration plasmapheresis (DFPP). An improved lipofilter (Kuraray 5A) has been developed and has shown better molecular cut off between LDL cholesterol and HDL cholesterol than the 4A filter. However, cryogel formation still occurred even using the 5A filter during the DFPP procedure. Thermofiltration maintains the performance of the secondary filter by preventing cryogel formation. Further studies are required to evaluate the enhanced performance of the 5 A filter by thermofiltration.