Search

Background:. Circumferential difference of lymphedematous limbs at designated anatomic distances has been the primary mode for measuring lymphedematous extremities. Computed tomography (CT) imaging produces accurate, consistent, hygienic volume measurements and a direct limb representation. This study compares these 2 main modalities and assesses their correlation. Methods:. CT and circumferential difference measurements, costs, and correlation of patient limbs that received vascularized lymph node transfer were compared. Results:. Mean circumferential difference by tape measurement pre- and postoperatively was 31.4% ± 19.1% and 17.4% ± 8.8% for upper limbs and 43.2% ± 16.1% and 22.4% ± 12% for the lower limbs, respectively. Mean CT volumetric difference pre- and postoperatively were 36.1 ± 4.1% and 27.2 ± 2.8% for the upper limb and 46.2 ± 3.2% and 33.2 ± 2.1% for the lower limbs, respectively. CT volume measurements significantly correlated with their respective circumferential difference with Pearson correlation coefficient of r = +0.7, which was statistically significant (P = 0.03), indicating a strong positive correlation between circumferential difference and actual limb volume changes as determined by CT imaging. Circumferential differences are more cost effective than CT volume assessments in the domains of measurement frequency (P = 0.03), fee (P < 0.01), time (P = 0.03), total cost per year (P < 0.01), and cost/minute (P = 0.03). Conclusions:. Standardized circumferential differences that are currently used are comparable to unbiased CT volumetric measurements and can be used as a reliable, reproducible, minimally invasive, low cost, and accurate method of measuring the lymphedematous limbs.

Background:. Primary lymphedema is a debilitating disease. This study was to investigate the outcomes between vascularized lymph node transfer (VLNT) and lymphovenous anastomosis (LVA) for treating primary lymphedema. Methods:. Between January 2010 and December 2016, 17 patients with mean age of 31.5 ± 15.5 (ranged, 2–57) years diagnosed with 19 primary limb lymphedema were recruited. Patients with patent lymphatic ducts on indocyanine green lymphography were indicated for LVA, whereas those without patent lymphatic ducts were indicated for VLNT. Circumferential limb measurements, body weight, episodes of cellulitis and Lymphedema Quality-of-Life (LYMQoL) questionnaire were compared between preoperatively and postoperatively. Results:. Fifteen lymphedematous limbs underwent VLNT (79%) and 4 underwent LVA (21%). All VLNT flaps survived. At a mean follow-up of 19.7 ± 8.5 months, mean reduction of limb circumference, body weight, and episodes of cellulitis were 3.7 ± 2.9 cm and 1.9 ± 2.9 cm (P = 0.2); 6.6 ± 5.9 kg and 1.7 ± 0.6 kg (P < 0.05); 5.1 ± 2.8 times/y and 4.2 ± 0.5 times/y in VLNT and LVA groups, respectively (P = 0.7). Improvements in overall score (from 3.9 ± 1.2 to 6.4 ± 1.1, P < 0.05) of the LYMQoL in VLNT group had statistical significant difference than that (from 3.0 ± 1.4 to 5.0 ± 2.4, P = 0.07) in LVA group. Conclusions:. Both VLNT and LVA can effectively treat primary lymphedema patients. The reduction of above-knee circumference, body weight, episodes of cellulitis, and the improvement of LYMQoL was significantly greater in LVNT compared with LVA.

Background:. The vascularized groin and submental lymph node (VGLN and VSLN) flaps are valuable options in the treatment of lymphedema. This study was to compare outcomes between VGLN and VSLN transfers for breast cancer–related lymphedema. Methods:. Between January 2008 and December 2016, VGLN and VSLN transfers for upper limb lymphedema were compared including flap characteristics, flap elevation time, complications, and limb circumference changes. Results:. All flaps survived. Similar vein (2.6 versus 3.2 mm; P = 0.3) and artery diameter (2.1 versus 2.8 mm; P = 0.3) and number of lymph nodes (3 versus 4; P = 0.4) were found between VGLN and VSLN groups, respectively. Circumferential reduction rate was higher in VSLN than VGLN (P = 0.04) group. Vascular complication rate with salvage rate was not statistically different between the 2 groups. Donor-site complication and total complication rates were statistically higher in VGLN than VSLN flaps (7.7% versus 0%, P = 0.004; 46.2% versus 23.3%, P = 0.002). At a mean 39.8 ± 22.4 months, the circumferential reduction rate was statistically higher in VSLN than in the VGLN group (55.5 ± 14.3% versus 48.4 ± 23.9%, P = 0.04). Both flaps were effectively decreased in the episodes of cellulitis. Conclusions:. Both VGLN and VSLN flaps are valuable surgical options in treating breast cancer–related lymphedema. However, the VSLN flap for breast cancer–related lymphedema is better in providing more significant improvements in limb circumference, a faster flap harvest time, decreased complication rates, and minimal donor-site iatrogenic lymphedema.

Background:. Submental lymph node transfer has proved to be an effective approach for the treatment of lymphedema. This study was to investigate the anatomy and distribution of vascularized submental lymph node (VSLN) flap using magnetic resonance imaging (MRI) and their clinical outcome. Methods:. Fifteen patients who underwent 19 VSLN flap transfers for upper or lower limb lymphedema were retrospectively analyzed. The number of submental lymph nodes was compared among preoperative MRI, preoperative sonography, intraoperative finding, postoperative sonography, and postoperative computed tomography angiography. The outcome was compared between preoperatively and postoperatively. Results:. All 19 VSLN flaps survived. Two hundred fifteen lymph nodes were identified in 30 submandibular regions by MRI. The mean number of submental lymph nodes on preoperative MRI was 7.2 ± 2.4, on preoperative sonography was 3.2 ± 1.1, on intraoperative finding was 3.1 ± 0.6, postoperative sonography was 4.6 ± 1.8, and postoperative CTA was 5.2 ± 1.9. Sixty-one percent of the lymph nodes were located in the central two-quarters of the line drawn from the mental protuberance to the mandibular angle. The actual harvest rate of submental lymph nodes was 72.2%. At a 12-month follow-up, mean episodes of cellulitis were improved from 2.7 ± 0.6 to 0.8 ± 0.2 (P < 0.01); mean of circumferential difference was improved 3.2 ± 0.4 cm (P < 0.03). The overall lymphedema quality-of-life was improved 4.9 ± 0.3 (P < 0.04). Conclusions:. The preoperative MRI is a useful tool for the detection of mean 7.2 submental lymph nodes. Mean 72.2% of submental lymph nodes can be successfully transferred for extremity lymphedema with optimal functional recovery.

Background:. We examined the associations of surgeon and hospital volume with total cost, length of stay (LOS), and cost per day for free tissue transfer (FTT) surgeries. Evidence demonstrates a higher likelihood of success for FTT in higher volume hospitals. Little, however, is known about volume-outcome associations for surgical costs and LOS. We hypothesized that higher provider volume is associated with lower cost and shorter LOS. Methods:. Using Taiwan’s national data (2001–2012), we conducted a retrospective cohort study of all adults 18–64 years of age who underwent FTT during the study period. We used hierarchical regression modeling for our analyses. Our 3 outcome variables were total cost of FTT surgery, LOS in hospital, and cost per day. Results:. Except for functional muscle flap, in which LOS was 12 days shorter in high-volume compared with low-volume hospitals (P = 0.017), no association between hospital volume and LOS was found. Contrary to our hypothesis, our results for all FTT cases demonstrate positive associations of medium-volume hospitals (OR = 1.31; CI, 1.11–1.55) and high-volume surgeons (OR = 1.16; CI,1.03–1.32) with total cost and cost per day, respectively. The interactions of hospital volume and surgeon volume show that in medium- and high-volume hospitals, surgeons with the highest volume had the lowest predicted cost per day among hospitals in that category; but all differences in cost were small. Conclusions:. There were no substantial variations based on different hospital or surgeon volume in LOS, total cost, or cost per day for FTT operations performed in Taiwan.

Background: As experience with vascularized lymph node (VLN) transfer has grown, new VLN sources have become apparent. Descriptive studies have elucidated variable lymph node presence in these donor basins. Yet, no study has evaluated preoperative imaging evaluation between donor sites in patients undergoing VLN transfer. This study was to compare the findings on duplex ultrasonography of the submental, groin, and supraclavicular lymph node basins in patients undergoing VLN transfer. Methods: A review of a prospective database was performed for patients who had undergone preoperative planning for VLN transfer with duplex ultrasonography to provide objective donor-site characteristics. Multiple regression analysis was used to identify factors that correlated with specific flap characteristics. A P value less than 0.05 was considered statistically significant. Results: Sixty-eight patients (28 upper extremities and 40 lower extremities) were identified as undergoing preoperative duplex ultrasonography for VLN transfer. Little variation was seen when evaluating donor sites for laterality in patients. Groin and submental VLN sites had 3.1 and 3.3 lymph nodes, respectively, compared with 0.9 lymph nodes in the supraclavicular donor site (p < 0.01). Increasing age had an inverse relationship with estimated flap volume, whereas higher body mass index correlated with increasing flap thickness. Conclusions: Preoperative imaging with duplex ultrasonography before VLN transfer may allow for accurate identification of specific VLN donor-site characteristics. When considering lymph node–specific characteristics, higher quantity of lymph nodes were found on the groin and submental flap axis compared with the transverse cervical artery axis.