Efficacy and early results after combining laparoscopic harvest of double gastroepiploic lymph node flap and active physiotherapy for lower extremity lymphedema

Abstract

Background Lymph node flap transfer has gradually gained popularity for the treatment of upper and lower limb lymphedema. The aim of this study is to present the outcomes of an integrated treatment protocol based on double gastroepiploic lymph node flap (DG‐VLN) and active physiotherapy in patients affected by Stage II and III lower extremity lymphedema. Methods All Stage II and III lower limb lymphedema patients operated between September 2015 and December 2017 were retrospectively identified and only those treated with an integrated approach of DG‐VLN flap and active physiotherapy were included. Outcomes were assessed clinically with limb circumference measurement and radiologically with lymphoscintigraphy. Flap viability was evaluated through indocyanine green lymphography. Lymphedema related quality of life was evaluated preop and at 1 year follow up through LYMQOL questionnaire. Results Sixteen patients met inclusion criteria. Mean follow up was 26.2 months. Significant reduction in lower limb volume was observed for all patients from pre to post intervention. At 3 months of follow up, the mean CRR was 42.4% at below knee (BK) level and 25.4% at above knee (AK) level. At 12 months of follow up, the mean CRR was 58.3% at BK level (p = .001*) and 43.4% at AK level (p < .04*). LYMQOL metrics showed significantly better scores in all domains. Conclusions Patients with lower limb lymphedema can benefit from combined DG‐VLN flap and active physiotherapy, as this approach seem to fasten the onset of improvement and to have a positive impact on patients' quality of life.

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

“…VLNT from the gastroepiploic region has been previously described and is considered the first line of treatment for patients with moderate lymphedema in our center (Ciudad, Manrique, et al, 2017). The efficacy of VLNT in reduction of limb circumference has been examined by several authors (Becker et al, 2006; Cheng et al, 2020; Ciudad, Agko, et al, 2017; Ciudad, Manrique, et al, 2017; Maruccia et al, 2019). Our approach was recently evaluated in terms of long‐term outcomes and proved to determine a substantial reduction in circumference measurements and episodes of cellulitis (Ciudad, Manrique, Bustos, et al, 2020).…”

“…The circumference reduction rate (CRR) was used to compare preoperative and postoperative findings. The CRR was defined as the difference between the preoperative circumferences of the affected and healthy limbs minus the difference between the postoperative circumferences of the affected and healthy limbs, divided by the preoperative difference, ×100, as previously described (Di Taranto et al, 2020; Maruccia et al, 2019).…”

Intra‐abdominal vascularized lymph node transfer for treatment of lymphedema: A systematic literature review and meta‐analysis

“…Three hundred and fifty-one studies were retrieved in the database after removal of duplicates, 291 of which were excluded after title/ abstract screening. Of the remaining publications, 21 were eligible for analysis (Figure 1) Ciudad et al, 2020;Ciudad, Manrique, Adabi, et al, 2019;Ciudad, Manrique, Date, Agko, et al, 2017;Ciudad, Manrique, Date, Sacak, et al, 2017;Ciudad, Maruccia, Socas, Lee, et al, 2017;Coriddi et al, 2017;Di Taranto et al, 2020;Di Taranto et al, 2021;Frey et al, 2020;Johnson et al, 2019;Kaya et al, 2020;Kenworthy et al, 2018;Kraft et al, 2019;Manrique, Bustos, Kapoor, et al, 2020;Manrique, Bustos, Kuruoglu, et al, 2020;Maruccia, Pezzolla, et al, 2019;Mousavi et al, 2020;Nguyen et al, 2017). There was 1 non-randomized controlled trial, 3 retrospective cohort studies, 5 prospective case series, and 12 retrospective case series.…”

“…In total, 65 free omental VLN flaps (Di Taranto et al, 2020;Johnson et al, 2019;Kraft et al, 2019;Nguyen et al, 2017) and 362 free gastroepiploic VLN flaps were harvested Ciudad et al, 2020;Ciudad, Manrique, Date, Sacak, et al, 2017;Ciudad, Maruccia, Socas, Lee, et al, 2017;Kenworthy et al, 2018;Mousavi et al, 2020). One hundred and twenty-six free double omental/gastroepiploic VLN flaps Ciudad, Manrique, Adabi, et al, 2019;Ciudad, Manrique, Date, Agko, et al, 2017;Di Taranto et al, 2021;Frey et al, 2020;Kaya et al, 2020;Maruccia, Pezzolla, et al, 2019) and one free triple omental/gastroepiploic VLN flap (Kaya et al, 2020) were harvested, which involved splitting the flap into two or three lymph node flaps equally and transplanting them to multiple recipient sites to better improve the surgical outcome. Successful transfer of 45 free jejunal VLNT flaps (Coriddi et al, 2017;Kraft et al, 2019), 1 free appendicular VLN flap , and 2 free ileocecal VLN flaps has been reported.…”

“…The episode of cellulitis is another important prognosis indicator and it was reported in eight studies Ciudad, Manrique, Date, Agko, et al, 2017;Di Taranto et al, 2020;Di Taranto et al, 2021;Kenworthy et al, 2018;Maruccia, Pezzolla, et al, 2019;Mousavi et al, 2020). Complete reduction was achieved in two studies (Ciudad, Manrique, Date, Agko, et al, 2017;Di Taranto et al, 2020).…”