Comprehensive multimodal surgical treatment of end‐stage lower extremity lymphedema with toe management: The combined Charles,’ Homan’s, and vascularized lymph node transfer (CHAHOVA) procedures

Abstract

Background End‐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. Methods Between 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. Results A 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. Conclusion The combine CHAHOVA in a single‐stage procedure is an effective and safe approach in the end‐stage LEL.

A prospective study on combined lymphedema surgery: Gastroepiploic vascularized lymph nodes transfer and lymphaticovenous anastomosis followed by suction lipectomy

“…In their work, they found a strong association between the staging classification of lymphedema by ISL and the composition of lymphatic tissues in terms of changes occurring on the histological level of the collective vessels analyzed. They proved that in advanced stages lymphatic vessels become sclerotic, less functional, and this may be the reason for the reduction in the efficacy of the LVA approach (Ciudad, Agko, et al, 2017; Ciudad, Agko, et al, 2019; Di Taranto et al, 2018; Di Taranto et al, 2020; Inserra et al, 2016). According to Cheng, different stages of lymphedema require different treatments.…”

“…In the early stages of pathological process, conservative and nonsurgical treatment can be advised, but in more advanced stages the surgical treatment becomes necessary (Bolletta, Di Taranto, Chen, et al, 2020; Ciudad et al, 2019; Di Taranto, Chen, Elia, et al, 2020). Early proposed surgical procedures were often invasive and disfiguring.…”

Comparisons in long‐term clinical outcomes among patients with upper or lower extremity lymphedema treated with diverse vascularized lymph node transfer

“…Consequently, our group recently proposed an assessment and treatment algorithm for lower and upper extremity lymphedema representing our current approach based on our previous experience (Agko, Ciudad, & Chen, ; Ciudad, Agko, et al, ; Ciudad, Date, et al, ; Ciudad et al, , ; Ciudad, Manrique, Adabi, et al, ; Ciudad, Manrique, Agko, et al, ; Ciudad, Manrique, Date, et al, ; Ciudad, Manrique, Date, et al, ; Ciudad, Sze‐Wei Yeo, Sapountzis, et al, ; Sapountzis et al, ; Sapountzis, Ciudad, et al, ; Yeo, Lim, Kiranantawat, Ciudad, & Chen, ). Our current trend is to use combined physiologic and excisional approaches for late stages, which have evidenced encouraging results (Agko et al, ; Ciudad et al, ; Ciudad, Manrique, Adabi, et al, ; Sapountzis, Ciudad, et al, ).…”

Lower Limb Lymphedema Patients Can Still Benefit from Supermicrosurgical Lymphaticovenous Anastomosis (LVA) after Vascularized Lymph Node Flap Transfer (VLNT) as Delayed Lymphatic Reconstruction—A Retrospective Cohort Study

“…To optimize postoperative outcomes for moderate-to-severe lymphedema for VLNT, multiple modalities, such as one- and two-stage approaches with the use of VLNT, were proposed. One-stage approaches include the concurrent use of triple inset VLNT [ 9 ], VLNT and LVA [ 10 , 11 ]; VLNT and the Charles procedure [ 12 , 13 ]; and VLNT with the establishment of a lymph node (LN) efferent lymphatic vessel outflow [ 14 , 15 ]. For two-stage approaches, liposuction before VLNT [ 16 , 17 ] or VLNT after liposuction, with a 1–3-month interval, have been advised.…”