Efferent Lymphaticovenular Anastomosis for Pelvic and Lower Extremity Lymphedema after Gynecologic Cancer Treatment: Indication and Timing Criteria Based on Nodal Function.

Early prevention of complex decongestive therapy and rehabilitation exercise for prevention of lower extremity lymphedema after operation of gynecologic cancer

Complete lymph flow reconstruction: A free vascularized lymph node true perforator flap transfer with efferent lymphaticolymphatic anastomosis

This study examined the effect of lymphedema self-care patient school education on patient functionality, quality of life, body value, and lymphedema volume in patients with lower extremity lymphedema. The study utilized a single-group quasi-experimental design. The study sample included 21 patients with primary and secondary lower extremity lymphedema. A multidisciplinary team created a face-to-face lymphedema self-care patient education program that lasted three weeks with four hours each week to enhance lymphedema self-care management. Data collected from participants prior to the program and then at third and sixth months via Lower Extremity Functional Scale (LEFS), Lymphedema Functionality, Disability and Quality of Life Scale in Lower Extremity Lymphedema (LYMPH-ICF-LL), Body Value Scale, and extremity volumes. The average age of the patients was 54.85±11.99 years and two-thirds had secondary lymphedema. A statistically significant difference was found in the mean scores of LEFS (p<0.001), LYMPH-ICF-LL total (p= 0.006) in the 3rd and 6th months after the completion of the program, and in the lymphedema volume change (p= 0.031) in the 6th month. It was found that the lymphedema self-care patient school improved functionality and quality of life in patients with lower extremity lymphedema and decreased lymphedema volume. This lymphedema self-care patient education program is a safe and effective educational method for self-care management in individuals with lower extremity lymphedema.

Summary:Efferent lymphatic vessel anastomosis (ELVA) is a microsurgical technique used to anastomose efferent lymphatic vessels from the inguinal lymph nodes (LNs) to the veins in patients with lower extremity lymphedema (LEL). Intraoperative detection of inguinal LNs is important when performing ELVA. Identifying inguinal LNs in patients with mild LEL is easy on palpation, ultrasonography, and indocyanine green (ICG) lymphography because the LNs are large and have good ICG uptake. In contrast, inguinal LNs of patients with advanced LEL are small and have minimal to no ICG uptake owing to lymphatic degeneration; thus, finding LNs in patients with advanced LEL is difficult, and novel techniques are required. This feasibility study evaluated the effectiveness of gamma probes and lymphoscintigraphy in these patients. Nineteen limbs were included in this study. Patients were injected with a Tc99m isotope 24 hours before ELVA and evaluated based on the Taiwan Lymphoscintigraphy Staging (TLS). Inguinal LNs with radioisotope accumulation were looked for intraoperatively using a gamma probe. Eleven of the 19 limbs were classified as partial obstruction according to the TLS. The detection of LNs using a probe was successful in all limbs classified as partial obstruction, excluding 1 case. However, the gamma probe did not respond to inguinal LNs in limbs classified as total obstruction. In this study, the gamma probe was useful in identifying suitable inguinal LNs for performing ELVA in patients with partial obstruction findings on TLS.

Combined secondary scrotal and lower extremity lymphedema is an infrequent complication of radical excision of urogenital cancers associated with pelvic lymphadenectomy. Scrotal lymphedema is usually psychologically distressing, and difficult to treat. We report a case of a 41-years old male who presented with scrotal and left lower extremity lymphedema after radical prostatectomy and pelvic lymphadenectomy successfully treated with pedicled superficial inguinal lymph node (SILN) transfer and lymphaticovenous anastomosis (LVA) restoring the lymphatic drainage. The flap consisted of subscarpal adipofascial tissue between the level of the inguinal ligament and the groin crease measuring 11 × 7 cm. The flap composed of afferent lymphatics from the lower abdomen, lymph nodes, and fatty tissue without skin, the right-sided flap was transposed to the root of scrotum while the left one to the proximal left thigh, then two-level LVA were performed in the left extremity. The surgery went uneventful with no postoperative complications. At a 9 month follow-up, there was a significant reduction of the scrotal volume with a reduction of excess volume of the lower extremity from 49.6 to 9.4% compared with the healthy side. No cellulitis was reported during the follow-up period with improvement in the patient's clinical symptoms and quality of life. We believe that pedicled superficial inguinal lymph node flap together with LVA is a reliable and safe treatment option for either scrotal or lower extremity lymphedema following pelvic cancer treatment.

Objective To investigate the multiple risk factors for lower extremity lymphedema in patients following treatment of common gynecologic cancers by meta-analysis for systematic analysis and comprehensive quantitative study. Methods Clinical trials published up until August 2016 were retrieved from PubMed, Embase, and the Cochrane Library. The quality of the included studies was assessed by the Newcastle-Ottawa Scale, and data analysis was performed using Stata 14.0 and RevMan 5.3. The strength of the associations between risk factors and gynecologic cancer-related lower extremity lymphedema was described as odds ratio (OR) and 95% confidence intervals (CI). Results Eighteen studies were included in the meta-analysis, and 8 relevant factors were identified. The risk factors for lower extremity lymphedema after treatment of gynecologic cancer mainly included radiotherapy (OR=2.45, 95%CI: 2.05-2.95, P=0.000), FIGO stage (OR=2.29, 95%CI: 1.66-3.14, P=0.000), and pelvic lymph node dissection (OR=2.00, 95%CI: 1.02-3.91, P=0.040). Conclusions Radiotherapy, FIGO stage, and pelvic lymph node dissection are the main risk factors for lower extremity lymphedema after treatment of gynecologic cancers. Key words: Gynaecological neoplasms; Lower extremity lymphedema; Risk factors

BACKGROUND: Lymphedema results from inadequate transport of lymphatic fluid, and typically affects the extremities. The condition may be caused by maldevelopment of lymphatics or by injury to lymph nodes or vessels. Recently, obesity has been recognized as a novel cause of extremity lymphedema. The purpose of this study was to characterize patients with obesity-induced lymphedema. METHODS: Patients referred to our Lymphedema Program between 2009 and 2013 with possible lower extremity lymphedema were reviewed. Individuals with a body mass index (BMI) >30 who underwent lymphoscintigraphy to assess lymphatic function were studied. Patients with a history of primary lymphedema, lymphadenectomy, or nodal radiation were excluded. Gender, age, BMI at the time of lymphoscintigraphy, and maximum BMI history were recorded. RESULTS: Forty patients met inclusion criteria; mean age was 54.6 years (range 14-85 years). Lymphoscintigraphy showed that 27 patients had normal lymphatic function, and 13 (7 females, 6 males) had lymphatic dysfunction consistent with obesity-induced lymphedema. Obese patients with normal lymphoscintigraphy findings had a BMI at the time of their study of 38.5 (range 30.3-56.8), and a maximum BMI history of 44.4 (range 30.3-85.4). Individuals with lower extremity lymphedema had a greater BMI at the time of lymphoscintigraphy (64.1; range 43.9-83.0) (p<0.0001), and a higher maximum BMI history (76.1; range 60.5-105.6) (p<0.0001). The patient with the highest BMI history of 105.6 also had bilateral upper extremity lymphedema confirmed by lymphoscintigraphy (Figure 1).Figure 1: Obesity-induced lower extremity lymphedema; a BMI threshold appears to exist between 53-59 when lymphatic dysfunction occurs. (Left) Adult female with a BMI of 53.3. Lymphoscintigraphy illustrates normal transit to inguinal nodes 20 minutes following injection. (Right) Adult female with a BMI of 78.3. Lymphoscintigram shows delayed transit of tracer to inguinal nodes 3 hours following injection, tortuous collateral lymphatic channels, and dermal backflow consistent with lymphedema. Arrows indicate inguinal nodes, black arrowheads show tortuous lymphatic channels and dermal backfl ow, and white arrowheads mark the feet where the radiolabelled tracer was injected.CONCLUSIONS: Massive obesity can cause extremity lymphatic dysfunction. A BMI threshold appears to exist at which point lower extremity lymphedema occurs, followed by upper extremity disease. Patients with obesity- induced lymphedema are referred to a bariatric center because weight loss appears to improve lymphatic function, but may not reverse the condition.

Objective To investigate outcome and clinical value of liposuction in primary lymphedema of lower extremities. Methods Thirty patients with primary lymphedema in unilateral lower extremity were recruited in this study from July 2016 to August 2017 in Beijing Shijitan Hospital. There were 13 male and 17 female patients, with the average age of (36±16.3) years. All the patients were underwent liposuction. The volume of hemorrhage and lipid, operation time and the volume changes of affected extremity were recorded. The subjective evaluation of the patients were also proceed. The patients were divided into different groups according to gender, stage and erysipelas history. Results Total lipid volume is 900-3 900 ml. The hemorrhage volume is 160-1 100 ml during liposuction. The ipsilateral-contralateral percent volume of lower extremity was decreased immediately after surgery (6.6%±10.0%, t=7.050, P=0.000), and 3 months postoperatively (12.2%±10.7%, t=5.365, P=0.000), when compared with preoperative (31.4%±16.4%). However, the percent volume was increased 3 months after surgery, compared to immediately postoperative measurements (t=-2.088, P=0.041). Female patients had more lipid volume and higher liposuction rate than males, whereas male patients show more affected extremities volume before, after and in 3-month follow-up. The hemorrhage volume was also higher in male than female patients. Patients with erysipelas had higher volume of hemorrhage, with lower lipid volume and liposuction rate. Stage Ⅱpatients show higher lipid volume and liposuction rate than stage Ⅲ patients in operation, with lower hemorrhage and affected extremity volume changes in before, after and 3-month follow-up. In subjective assessment, the experienced heaviness and fatigue was alleviated in all patients, while the pain and tightness was increased. Conclusions Liposuction is an effective therapy for primary lymphedema in lower extremity. It is necessary to combine with other therapies to improve lymph circulation. Patients′ gender, stage and the history of erysipelas are the main influencing factors of operation difficulty and prognosis. Key words: Lymphedema; Lower extremity; Tumescent liposuction; Primary

The authors analyze the outcomes of simultaneous vascularized lymph node transplant and lymphovenous bypass for treatment of primary and secondary lymphedema. To the best of their knowledge, this is the largest study to date with long-term outcome data of this novel approach. Three hundred twenty-eight patients who underwent physiologic surgical treatment over a 5.5-year period were evaluated using a prospective database and chart review. Preoperative characteristics, operative details, and postoperative outcomes (volume difference change, Lymphedema Life Impact Scale score) were assessed. Statistical analysis including multivariate regression was performed. Two hundred twenty patients (67.1 percent) underwent simultaneous vascularized lymph node transplant and lymphovenous bypass. Mean body mass index was 26.9 ± 4.7 kg/m 2 . Ninety-two patients (41.8 percent) had lymphedema of the lower extremity, 121 (55.0 percent) had upper extremity involvement, and seven had lymphedema of upper and lower extremities (3.2 percent). Average duration of lymphedema was 95.4 ± 103.6 months. Thirty patients (13.6 percent) had primary lymphedema and 190 patients (86.4 percent) had secondary lymphedema. The majority improved and experienced volume reduction of an average 21.4 percent at 1 year ( p < 0.0001), 36.2 percent at 2 years ( p < 0.0001), 25.5 percent at 3 years ( p = 0.1), and 19.6 percent at 4 years. Median Lymphedema Life Impact Scale scores were 7.0 points lower ( p < 0.0001) at 3 months and improved progressively over time to 27.5 points lower at 3 years postoperatively ( p < 0.005). Simultaneous vascularized lymph node transplant and lymphovenous bypass is an appropriate and effective approach for both early and advanced stages of primary and secondary lymphedema, with significant objective and subjective improvements. Volume reduction in the affected limb was observed at all time points postoperatively, with significant improvement in Lymphedema Life Impact Scale scores. Therapeutic, III.

Simultaneous multi-site lymphaticovenular anastomoses for primary lower extremity and genital lymphoedema complicated with severe lymphorrhea

Lymphedema most commonly occurs after cancer treatment and can affect limbs and genitalia. Genital lymphedema (GL) is a rare condition and can be disabling psychologically and physically. It often occurs along with lower extremity lymphedema (LEL). Conservative and physiologic reconstructive surgery such as lymphaticovenous anastomosis (LVA) offer good treatment options for LEL. GL however remains a reconstructive dilemma. The most effective surgical therapies in advanced GL are still debulking procedures in properly selected patients. Here, we present the surgical treatment of a 51 -year-old male patient with advanced and combined genital and right lower extremity lymphedema after Hodgkin lymphom treatment in the childhood. We performed multiple LVA to the right ankle joint, distal lower leg and lateral knee and 2 months later patient reported a significant decrease of pain and pressure in affected limb while the scrotal and penis lymphedema did not show any signs of improvement at all. Four months later, 4.9 kg of excessive lymphedematous tissue from the genital area was resected and covered by split-thickness skin grafts from the unaffected left upper thigh. The postoperative course was uneventful and 3 weeks postoperatively the skin graft healed completely. Follow up at 6 months showed reasonable cosmetic and functional outcomes and the patient reported a significant improvement of quality of life. We believe that debulking procedures and LVA may be combined in advanced GL and LEL and may provide good outcomes.

Risk factors for lower extremity lymphedema after inguinal lymphadenectomy in melanoma patients: A retrospective cohort study

ObjectiveTo develop an algorithmic quantitative skin and subcutaneous tissue volume measurement protocol for lower extremity lymphedema (LEL) patients using computed tomography (CT), to verify the usefulness of the measurement techniques in LEL patients, and to observe the structural characteristics of subcutaneous tissue according to the progression of LEL in gynecologic cancer.MethodsA program for algorithmic quantitative analysis of lower extremity CT scans has been developed to measure the skin and subcutaneous volume, muscle compartment volume, and the extent of the peculiar trabecular area with a honeycombed pattern. The CT venographies of 50 lower extremities from 25 subjects were reviewed in two groups (acute and chronic lymphedema).ResultsA significant increase in the total volume, subcutaneous volume, and extent of peculiar trabecular area with a honeycombed pattern except quantitative muscle volume was identified in the more-affected limb. The correlation of CT-based total volume and subcutaneous volume measurements with volumetry measurement was strong (correlation coefficient: 0.747 and 0.749, respectively). The larger extent of peculiar trabecular area with a honeycombed pattern in the subcutaneous tissue was identified in the more-affected limb of chronic lymphedema group.ConclusionCT-based quantitative assessments could provide objective volume measurements and information about the structural characteristics of subcutaneous tissue in women with LEL following treatment for gynecologic cancer.

In lower extremity lymphedema secondary to pelvic cancer treatments, lymphedema develops despite that the inguinal lymph nodes (LNs) are preserved. Obstruction of the efferent lymphatic vessels of the inguinal LNs causes lower extremity lymphedema, and it is considered a radical treatment to bypass the efferent lymphatic vessel. Efferent lymphatic vessel anastomosis, supermicrosurgical efferent lymphatic vessel-to-venous anastomosis, was performed on 14 legs with subclinical lymphedema [leg dermal backflow (LDB) stage I]. Efferent lymphatic vessel anastomosis was performed under local anesthesia at the groin region, and an efferent lymphatic vessel of the inguinal LN is anastomosed to a recipient vein. Feasibility and postoperative results were evaluated. All 14 efferent lymphatic vessel anastomoses were successfully performed without perioperative complication. All legs could be free from lymphedematous symptoms without perioperative compression at postoperative 1 year. Postoperative LDB stage included LDB stage 0 (n = 8) and LDB stage I (n = 6), which was significantly downstaged compared with preoperative LDB stage (P < 0.001). Efferent lymphatic vessel anastomosis allowed lymph flow bypass after filtration by the superficial inguinal LN through a skin incision along the inguinal crease, and was effective to prevent development of symptomatic lymphedema in subclinical lymphedema cases.

Background: Lower extremity lymphedema (LEL) is a common complication following gynecological cancer treatment, characterized by the accumulation of protein-rich fluid owing to lymphatic system insufficiency. This condition manifests as in skin thickening, soft tissue swelling, and other complications. Therefore, this study proposes an automatic method for measuring skin thickness in lower extremity computed tomography (CT) images and assessing its effectiveness in diagnosing LEL. Methods and Results: We selected 56 patients with unilateral LEL based on specific diagnostic criteria, including clinical evaluation, lymphoscintigraphy, indocyanine green lymphography, and a noncontrast CT scan, which included the entire lower extremities. The CT images had a pixel spacing ranging from 0.723 to 0.976 mm, with a slice thickness of 10.0 mm. Our skin thickness measurement method involves preprocessing, such as extracting the leg, bone, muscle, and subcutaneous fat regions, defining the target slice range, and measuring the skin thickness. The lower extremity was divided into eight subregions, and the skin thickness was measured across these subregions. The overall median skin thicknesses were 0.883 ± 0.201 and 1.536 ± 0.487 mm in normal and positive subregions, respectively. The classification of LEL was based on the Z-score calculated for each subregion, with the median skin thickness from normal legs serving as a reference. Our classification method demonstrated an overall accuracy of 0.839, sensitivity of 0.703, and specificity of 0.937. Conclusions: Our automated method for measuring skin thickness in CT images shows promise in diagnosing LEL, with high accuracy and specificity. This approach enables a comprehensive evaluation of the entire leg, potentially enhancing the diagnostic process for LEL.