Multimodal Management of Upper and Lower Extremity Lymphedema

Description

In this concise, accessible, and comprehensive reference, world experts in the field of lymphedema detail all of the non-surgical and surgical approaches to the multidisciplinary management of patients with upper and lower extremity lymphedema. There is particular focus on the surgical treatments for lymphedema, where the reader is taken step-by-step through illustrated guides for each procedure by the leading experts in the field of lymphedema microsurgery; from patient selection, preoperative evaluation, surgical technique, and postoperative management. The book is strictly organized so that readers can quickly find content and provides readers with the necessary tools and framework to readily apply these innovative and state-of-the art techniques to their patients to optimize outcomes of surgical and non-surgical treatments for their lymphedema patients. Each chapter features a standardized content layout with full-color illustrations and clinical photographs to visually represent the content and includes key tips from experts in lymphedema, accompanied by key video contributions from the authors to demonstrate the surgical techniques. There is key emphasis on advances in our understand of the etiology of lymphedema, the most important surgical topics in lymphedema microsurgery, the current evidence available for the surgical treatment of lymphedema, and recent advances in lymphedema including new pharmacological treatments that target inflammation and fibrosis Edited by leaders in lymphedema microsurgery and contributed to by a multidisciplinary group of international experts to provide a full and comprehensive guide, Multimodal Management of Upper and Lower Extremity Lymphedema is aimed at a wide target audience that includes surgeons that perform lymphedema surgeries, other medical specialties that treat patients with cancer, lymphedema therapists, physical therapists, and occupational therapists, as well as nursing specialties and trainees. Preface Acknowledgments Contents Contributors 1: Introduction Overview Anatomophysiology of the Lymphatic System Pathophysiology of Lymphedema Lymphedema Classification Morbidity of Lymphedema Treatment of Lymphedema Conservative Therapy Surgical Treatment of Lymphedema New and Emerging Therapeutics Future Directions References 2: Anatomy of the Lymphatic System and Structural Changes in Lymphedema of the Extremities Current Understanding of Lymphatic Anatomy Imaging Options for the Diagnosis of Lymphedema Normal Lymphatic Anatomy in the Lower Extremity Anatomical Changes in Lower Extremity Lymphedema Normal Lymphatic Anatomy in the Upper Extremity Anatomical Changes in Upper Extremity Lymphedema Summary References 3: Pathophysiology and Molecular Research in Lymphedema Introduction Etiology and Staging of Lymphedema Pathophysiology of Lymphedema Chronic Inflammation and Fibrosis Inhibition of Functional Lymphatic Vessel Regeneration by Chronic Inflammation Adipose Deposition in Lymphedema Conclusions References 4: Lymphedema Prospective Surveillance and Risk Reduction Introduction Risk Factors Associated with Lymphedema Risk Reduction Prospective Surveillance for Lymphedema Detection Implementation into Practice Summary References 5: Key Topic: Multimodal Evaluation of the Lymphedema Patient Introduction Focused Clinical History Extremity Lymphedema Symptoms Physical Examination Findings Lymphedema Clinical Staging Scales Limb Volume Measurements Bioimpedance Spectroscopy (BIS) Magnetic Resonance Imaging/Angiography Computed Tomography/Venography Lymphoscintigraphy Indocyanine Green (ICG) Fluorescent Lymphography Magnetic Resonance Lymphangiography (MRL) Patient-Reported Outcome Measures (PROMs) and Limb Functional Assessment Instruments Lymphedema Physical Therapy Multidisciplinary Lymphedema Team References 6: Nonsurgical Management of the Lymphedema Patient Complete/Complex Decongestive Physical Therapy (CDT) Other Therapies Prehabilitation for Lymphedema Surgery References 7: Key Topic: Patient Selection and Evidence-Based Algorithmic Approach to Surgical Management of Lymphedema Introduction Diagnosis and Staging Patient Selection for Surgical Intervention Preclinical Lymphedema Prehabilitation Early-Stage Lymphedema Advanced-Stage Lymphedema Advanced-Stage Lymphedema with Fibroadipose Soft Tissue Excess Summary References 8: Step-by-Step Instruction: Lymphaticovenular Anastomosis (LVA) Assessment and Planning Introduction Assessment of Where to Perform the Lymphaticovenular Anastomosis (LVA) LVA for Primary Lower Extremity Lymphedema LVA for Secondary Lower Extremity Lymphedema LVA for Upper Extremity Lymphedema Planning Where to Make the Incisions for the Lymphaticovenular Anastomosis (LVA) Detection and Selection of the Lymphatic Vessels Using Conventional High-Frequency Ultrasound (CHFUS) Detection and Selection of the Lymphatic Vessels Using Ultrahigh-Frequency Ultrasound (UHFUS) Detection and Selection of the Venules Using Ultrasound References 9: Step-by-Step Instruction: Lymphaticovenular Anastomosis (LVA) Techniques Introduction Patient Selection and Preoperative Evaluation Incision Site Design Consideration of Anastomotic Configuration Step-by-Step Operative Techniques for Lymphaticovenular Anastomosis (LVA) (see supplementary material) Step 1: Skin Incision and Retraction Step 2: Dissection of a Recipient Vein Step 3. Exposure and Incision of the Superficial Fascia Step 4. Dissection of the Collecting Lymph Vessels Step 5. Preparation of the Vessels for LVA Step 6. “Intima-to-Intima Coaptation” Anastomosis Step 7: Protection of the Vessels and Anastomosis Site Step 8: Careful Skin Closure Postoperative Management and Follow-Up Complications References 10: Step-by-Step Instruction: Single Site Multiple Lymphatic-Venous Anastomosis Technique Introduction Typical Indications Anatomy Patient Selection and Preoperative Investigations Operative Techniques Principles Anesthesia Patient Positioning Recipient Site Preparation Loupes and Operating Microscope Surgical Procedure (Figs. 10.7 and 10.8) (see supplementary material) Postoperative Care Preoperative and Postoperative Conservative Treatment Additional Supplementary Minimally Invasive Procedures Complications Outcomes (Fig. 10.11) References 11: Reverse Lymphatic Mapping for Vascularized Lymph Node Transplant Introduction Indications Procedure Technique Principles Algorithm for Reverse Lymphatic Mapping Reverse Lymphatic Mapping Technique for Axillary Lymph Node Flap Harvest (Fig. 11.1) Reverse Lymphatic Mapping for Groin Lymph Node Harvest (Fig. 11.2) Postoperative Care Complications Pearls and Pitfalls References 12: Key Topic: Vascularized Lymph Node Transplant and Recipient Site Selection Introduction Patient Selection for Surgical Intervention Decision-Making for Proximal Anatomic (Orthotopic) Compared with Distal Non-anatomic (Heterotopic) Vascularized Lymph Node Transplant (VLNT) Placement Selection of Recipient Site and Vascularized Lymph Node Transplant (VLNT) for Anatomic (Orthotopic) Transfer Selection of Recipient Site and Vascularized Lymph Node Transplant (VLNT) for Non-anatomic (Heterotopic) Transfer Selection of Recipient Sites and Vascularized Lymph Node Transplants (VLNT) for Dual-Level Transfer Postoperative Management for the Vascularized Lymph Node Transplant (VLNT) Procedure References 13: Step-by-Step Instruction: Superficial Inguinal (Groin) Vascularized Lymph Node Transplant Procedure Introduction Typical Indications Anatomy Patient Selection Operative Technique Principles Recipient Site Flap Harvest: Skin Paddle (see supplementary material) Postoperative Care Complications References 14: Step-by-Step Instruction: Combined Microvascular Breast Reconstruction and Groin Vascularized Lymph Node Transplant Procedure Introduction Indications Anatomy Patient Selection and Preoperative Assessment Presurgical Markings Chest Abdomen Operative Techniques Flap Harvest Technique Recipient Site Preparation Revascularization and Flap Inset Donor Site Closure Postoperative Care Complications Pearls and Pitfalls References 15: Step-by-Step Instruction: Submental Vascularized Lymph Node Transplant Procedure Background Patient Selection Flap Markings Flap Dissection Donor Site Closure Insetting of the Flap at the Recipient Site Postoperative Care Key Points References 16: Step-by-Step Instruction: Supraclavicular Vascularized Lymph Node Transplant Procedure Introduction Typical Indications Anatomy Patient Selection and Preoperative Investigations Presurgical Markings Operative Technique (see supplementary material) Principles Recipient Site Preparation Supraclavicular Flap Harvest Technique Revascularization and Inset Postoperative Care Complications Pearls and Pitfalls References 17: Step-by-Step Instruction: Lateral Thoracic Vascularized Lymph Node Transplant Procedure Introduction Typical Indications Anatomy Patient Selection Operative Technique Principles Recipient Site Preparation Flap Harvest Technique (see supplementary material) Revascularization and Inset Postoperative Care Complications Pearls and Pitfalls References 18: Step-by-Step Instruction: Omental Vascularized Lymph Node Transplant Procedure: Laparoscopic and Open Harvest Techniques Introduction Typical Indications Anatomy Patient Selection Surgical Techniques Principles Recipient Site Preparation Algorithm for Flap Harvest Technique (see supplementary material) Laparoscopic Flap Harvest Technique Open Flap Harvest Technique Revascularization and Inset Postoperative Care Complications Future Directions References 19: Step-by-Step Instruction: Jejunal Mesenteric Vascularized Lymph Node Transplant Procedure Introduction Typical Indications Anatomy Patient Selection Operative Technique Principles Flap Harvest Technique (see supplementary material) Recipient Site Preparation, Flap Revascularization, and Inset Postoperative Care Complications References 20: Step-by-Step Instruction: Suction-Assisted Lipectomy Procedure with Controlled Compression Therapy Introduction Typical Indications Excess Subcutaneous Adiposity and Chronic Lymphedema How to Assess the Efficacy of Liposuction Preoperative Planning for Arm Liposuction Operative Technique (see supplementary material) Postoperative Care Complications Controlled Compression Therapy (CCT) Volume Measurements Lymphedema Team How Liposuction Helps Lymph Transport System and Liposuction When to Use Liposuction to Treat Lymphedema When Liposuction Should Never Be Used Can the Outcome Be Reproduced References 21: Step-by-Step Instruction: Suction-Assisted Protein Lipectomy Procedure Combined with Vascularized Lymph Node Transfer and/or Lymphaticovenous Anastomosis Surgery as Part of an Integrated Lymphedema Treatment System Introduction Two-Phase Approach Key Points Indications and Patient Selection for Two-Phase Approach Phase One: Suction-Assisted Protein Lipectomy (SAPL) Surgery Phase Two: Vascularized Lymph Node Transfer (VLNT) and/or Lymphaticovenous Anastomosis (LVA) Surgery Postoperative Care Complications References 22: Step-by-Step Instruction: Direct Excision Combined with Lymphatic Microsurgery Introduction Typical Indications Surgical Techniques Vascularized Lymph Node Flap Transfer (VLNT) Donor Site Options Intra-abdominal Lymph Node Flaps Gastroepiploic Lymph Node Flap Laparoscopic Flap Harvest Modification Double Gastroepiploic Lymph Node Flaps Combination Flaps and Special Indications Peripheral Lymph Node Flaps Groin Lymph Node Flap Supraclavicular Lymph Node Flap and Other Options Other Lymph Node Flaps Excisional Procedures and Their Combination with Lymphatic Microsurgery Radical Reduction of Lymphedema with Preservation of Perforators (RRPP) Lower Extremity Upper Extremity Hung-Chi Chen (HCC)-Modified Charles Procedure Surgical Technique Therapeutic Liposuction Combined Procedures Complications Special Indications Pearls and Pitfalls References 23: Step-by-Step Instruction: Immediate Lymphatic Reconstruction for Lymphedema Risk Reduction in Breast Cancer Management Introduction Typical Indications Anatomy Patient Selection Surgical Candidacy Preoperative Measurements Preoperative Indocyanine Green (ICG) Lymphography Operative Technique (see supplementary material) Postoperative Care Complications Outcomes Pearls and Pitfalls References 24: Key Topic: Evidence-Based Outcomes of Lymphedema Microsurgery Background Lymphovenous Bypass (LVB) Procedure Systematic Reviews Prospective Cohort or Comparative Studies Retrospective Cohort or Comparative Studies Vascularized Lymph Node Transplant (VLNT) Procedure Systematic Reviews Randomized Controlled Trials Prospective Cohort or Comparative Studies Retrospective Comparative Studies Retrospective Cohort Studies Suction-Assisted Lipectomy (SAL) Debulking Systematic Reviews Prospective Cohort or Comparative Studies Retrospective Cohort or Comparative Studies Combined Procedures Excisional Procedures Immediate Lymphatic Reconstruction (ILR) Systematic Reviews Randomized Controlled Trials Retrospective Comparative Studies Retrospective Cohort Studies Conclusions References 25: Key Topic: Evaluating Outcomes of Lymphedema Surgery Introduction Lymphedema-Specific Symptoms Episodes of Lymphedema-Related Cellulitis Detailed Treatment History Degree of Pitting Edema Limb Volume Measurement Bioimpedance Spectroscopy (L-Dex Score) Patient-Reported Outcome Measures (PROMs) Physiological Restaging Imaging Limb Functional Assessment Instruments References 26: New and Emerging Therapies for Lymphedema: Part I Introduction Lymphangiogenic Therapeutic Approaches Vascular Endothelial Growth Factor (VEGF) Fibroblast Growth Factor-2 (FGF-2) and Hepatocyte Growth Factor (HGF) Neuropilin-2 (NRP-2) Notch-1 and Ephrin B2 (EPB2) Sphingosine-1-Phosphate (S1P) Hyaluronic Acid Transforming Growth Factor-Beta (TGF-β) Bone Morphogenetic Protein-9 (BMP-9) and Activin Receptor-Like Kinase 1 (ALK-1) Interleukin-8 (IL-8) 9-cis Retinoic Acid (9-cis RA) Stem Cells Anti-inflammatory and Anti-fibrotic Therapeutic Approaches Ketoprofen Tacrolimus Sodium Selenite Pirfenidone Discussion Conclusions References 27: New and Emerging Therapies for Lymphedema: Part II Introduction The Key Targets of Inflammation and Fibrosis in Lymphedema Vascular Endothelial Growth Factor (VEGF)-C, Cytokines, and Leukotriene B4 (LTB4) T Cells Macrophages Fibrosis and the Extracellular Matrix Adipose Deposition Summary of Key Targets Anti-inflammatory and Anti-fibrotic Therapies Ketoprofen Ubenimex Tacrolimus Atorvastatin Hyaluronidase Benzopyrones A Few Notes on Non-pharmacologic Therapies References 28: Lymphatic Education and Research Network Centers of Excellence: A Multidisciplinary Approach to Lymphatic Care Summary References Index