Orthotopic transfer of vascularized groin lymph node flap in the treatment of breast cancer-related lymphedema: Clinical results, lymphoscintigraphy findings, and proposed mechanism.

INTRODUCTION: Vascularized lymph node transfer (VLNT) has become very popular in the treatment of secondary lymphedema. However, the mechanism has not been clearly elucidated. The purpose of this study was (1) to evaluate the outcome of vascularized groin lymph node (VGLN) transfer using axilla as a recipient site in patients with breast cancer-related lymphedema (BCRL) and (2) to provide radiological evidence of lymphangiogenesis in VLNT. METHODS: Between August 2013 and June 2016, 30 consecutive patients with a mean age of 60 years underwent VGLN transfer for BCRL. A skinless VGLN flap nourished by the superficial circumflex iliac vessels was transferred to the axillary region of the lymphedematous limb. The outcomes were assessed clinically with limb circumference measurement and radiologically with lymphoscintigraphy. RESULTS: At a mean follow-up of 22.11 ± 7.83 months, 21 (70%) patients had reduction in limb circumference. The mean circumference reduction rate of the lymphedematous limb was 47.06% ± 27.92% (range, 0% to 100%). Eleven (37%) patients showed radiological improvement in postoperative lymphoscintigraphy that included 7 cases of faster contrast transport and 4 cases of visualization of transplanted lymph node. CONCLUSION: Patients with BCRL can benefit from orthotopic VGLN transfer. Lymphangiogenesis is supported by the appearance of transplanted lymph nodes in postoperative lymphoscintigraphy.

The use of a microscope with near-infrared imaging function in indocyanine green lymphography and lymphaticovenous anastomosis.

BACKGROUND: Indocyanine green (ICG) lymphography has become an important investigation in lymphaticovenous anastomosis (LVA). Near-infrared (NIR) imaging systems are available in the market for the production of ICG lymphography. These machines, however, may be difficult to obtain owing to their costs. In our institute, these NIR imaging devices are not available. Alternatively, microscopy with NIR imaging function was used for LVA. The experiences of the production of ICG lymphography with an NIR microscope are described. METHODS: For the production of preoperative ICG lymphography, ICG solution was injected subdermally to the web spaces of the lymphoedema limb. The NIR mode of the microscope was used for the lymphatic mapping. Black and white images and videos of the ICG lymphography were then produced. Intra-operatively, the NIR function was used for the localisation of lymphatic vessels and confirmation of the patency of the LVA. RESULTS: Between February 2013 and May 2013, 24 ICG lymphographies were performed in 20 female patients as a preoperative investigation for LVA. All four ICG lymphography patterns (linear, splash, stardust and diffuse patterns) were demonstrated. CONCLUSIONS: In institutes where NIR imaging devices are not available, we believe that a microscope with an NIR imaging function is a reasonable alternative for the production of ICG lymphography.

Quality of life of patients after salvage nasopharyngectomy for recurrent nasopharyngeal carcinoma.

BACKGROUND: The objective of this study was to examine the quality of life (QOL) of patients who underwent salvage nasopharyngectomy for residual or recurrent nasopharyngeal carcinoma and to justify the value of the procedure. METHODS: A self-reported, health-related QOL questionnaire was used to assess the QOL of patients after salvage nasopharyngectomy. The effects of potential complications after surgery also were evaluated. RESULTS: Between 2003 and 2011, 185 patients underwent salvage nasopharyngectomy using the maxillary swing approach. Curative resection was achieved in 80% of patients. There were no significant changes in mean global health system scores after surgery, except after palliative resection requiring postoperative adjuvant chemoradiation. Social functioning scores were the lowest of the 5 functioning scales in all patient groups. Palatal fistula significantly affected social eating and weight loss, and osteoradionecrosis caused more pain and nasal discharge, severely affecting the social life of patients. CONCLUSIONS: The QOL of patients after maxillary swing salvage nasopharyngectomy was good. The current results indicated that attention must be paid to the factors that adversely affect QOL after surgery, such as palliative resection, and complications like trismus, palatal fistula and osteoradionecrosis.

Extracapsular lymph node spread in recurrent nasopharyngeal carcinoma.

OBJECTIVES/HYPOTHESIS: To study the efficacy of combined neck dissection and brachytherapy for nodal metastasis with extracapsular spread (ECS) in recurrent nasopharyngeal carcinoma (NPC). STUDY DESIGN: Prospective. METHODS: Between 1990 and 2010, we recruited patients who had regional recurrent NPC after radiotherapy. The prevalence of ECS, the type of treatments, and the postoperative complications were noted. Nodal tumor control and disease-free survival were compared between patients with or without ECS. RESULTS: Macroscopic ECS was seen in 25.9% of our series of 158 patients. They were treated by extended radical neck dissection (RND) followed by brachytherapy. The rest of the patients without ECS were treated by RND alone. Median follow-up duration was 62 months. With such aggressive treatment, there was no significant difference in the 5-year actuarial nodal control (62% and 65%, P = .18) and 5-year disease-free survival (38% and 44%, P = .08) between those with or without ECS. Regional flaps were employed (deltopectoral flap: 24 patients; pectoralis major flap: 17 patients) to prevent wound necrosis and carotid blowout after brachytherapy. The rate of delayed vagal and hypoglossal nerve palsy after brachytherapy was 2.4% and 4.8%, respectively. None of our patients developed cerebral ischemia secondary to accelerated atherosclerosis from brachytherapy after previous external radiotherapy. CONCLUSIONS: With combined surgery and brachytherapy, satisfactory results can be achieved in patients with ECS in recurrent NPC. Reconstruction with regional flaps is mandatory to prevent serious complications like wound necrosis and carotid artery blowout.

Anatomical study and clinical applications of free posterior tibial flap in the head and neck region.

BACKGROUND: The purpose of this study was to examine the anatomical features, clinical applications, and donor-site morbidities of the free posterior tibial flap. METHODS: The posterior tibial vascular system was examined in 30 fresh cadaver legs. This was followed by a clinical study involving patients with free posterior tibial flap reconstruction of defects in the head and neck region after tumor extirpation. Potential donor-site morbidities were studied at 1 year after surgery. RESULTS: The mean caliber of the posterior tibial artery and the venae comitantes in the cadaveric limbs was 2.7, 2.9, and 2.17 mm, respectively. The mean number of septocutaneous perforators was 2.85 per leg, clustering in the middle and distal thirds of the medial surface of the leg. The mean thickness of the skin and subcutaneous fat in the region was 4.43 mm. In the clinical study, 64 patients with superficial cutaneous and mucosal defects were recruited. The majority of the patients had carcinoma of the oral cavity. All flaps survived. Three patients (4.7 percent) developed mild infection of the donor site. None of the patients have problems walking on level ground. There was no significant reduction in range of ankle movement, nor was there evidence of vascular compromise of the lower limb, either at rest or after exercise. CONCLUSIONS: The free posterior tibial flap is reliable because of its constant vascular anatomy. It is thin and pliable, making it particularly suitable for resurfacing superficial cutaneous and mucosal defects. Although skin grafting is required to repair the donor site, the associated morbidity is low. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Manubrial resection and anterior mediastinal tracheostomy: friend or Foe?

OBJECTIVES/HYPOTHESIS: To review our experience with manubrial resection and anterior mediastinal tracheostomy and formulate operative guidelines to improve the surgical outcome. STUDY DESIGN: Retrospective study. METHODS: Between January 1980 and June 2010, we performed 38 manubrial resections. The indications of the procedure, reconstructive methods, and operative outcomes were analyzed. RESULTS: Fourteen patients had tumors of the hypopharynx/cervical esophagus, eight had parastomal recurrences of laryngeal tumor, four had recurrent esophageal tumors, four had postirradiation sarcoma, four suffered from subglottic/upper tracheal tumors, three had thyroid malignancy, and the remaining patient had tumor recurrence at the previous tracheostomy site. The hospital mortality rate was 5.3% due to bleeding from major vessel erosion. The mean length of the tracheal stump was 5.4 cm, of which 81.6% required relocation inferior to the innominate artery for construction of the mediastinal tracheostomy. Among the different reconstructive methods for the pharyngoesophageal defects, the anastomotic leakage rate was 17.6%, the majority of which required exteriorization followed by second stage reconstruction. The long-term tracheostomy stenosis rate was 47.4%, the risk of which was significantly increased by anastomotic leakage and necrosis of distal trachea. The use of a pectoralis major flap was shown to protect against this complication. The overall survival was 80.6% at 1 year and 55.6% at 5 years after surgery. CONCLUSIONS: With attention to operative details, manubrial resection and anterior mediastinal tracheostomy is a safe procedure with acceptable outcome. It should be performed when indicated to facilitate tumor resection in the cervicothoracic region.

Reconstruction of circumferential pharyngeal defects after tumour resection: reference or preference.

BACKGROUND: Reconstruction of circumferential hypopharyngeal defects is often challenging. The aim of the study is to examine the result of our experience and to formulate improved management guidelines. METHOD: Between 1980 and 2009, all patients who have circumferential pharyngectomy were recruited. Data were recorded prospectively for analysis. RESULTS: A total of 202 patients were recruited. Majority had primary tumour in the hypopharynx (n=165), and the remaining patients had recurrent laryngeal carcinoma. Radiotherapy was given preoperatively in 72 patients and postoperatively in 108 patients. A pectoralis major (PM) flap was used in 92 (45.5%) patients, a free anterolateral thigh (ALT) flap in 24 (11.9%) patients and a free jejunal flap in 86 (42.6%) patients. Early fistula rate was 23.9% in the PM flap group, 12.5% in the ALT group and 4.6% in the jejunum group. Late anastomotic stricture rate was 27.2% in the PM flap group, 12.5% in the free ALT group and 2.3% in the jejunum group. Early fistula formation significantly increased the risk of subsequent anastomotic stricture (p=0.023). In patients with no stricture, 61.9% of them in the jejunal group were able to resume solid diet, compared with 35.8% and 38.1% in the PM and ALT groups. After PM flap harvesting, 34.8% of the chest wall defects could not be closed primarily, which were best repaired using the lateral thoracic flap. The donor-site morbidity of ALT and jejunal flap was low. CONCLUSION: In suitable patients, free jejunal flap reconstruction of circumferential pharyngectomy defects achieves the best functional outcome with minimal donor-site morbidity.

Lateral thoracic flap for donor site repair of pectoralis major myocutaneous flap.

OBJECTIVE: To study the use of the lateral thoracic flap to repair a pectoralis major flap donor site defect when primary closure is not possible. STUDY DESIGN: Prospective study. SUBJECTS AND METHODS: All patients requiring pectoralis major flap reconstruction after tumour extirpation in the head and neck region, whose chest wall donor defects could not be closed primarily, were recruited to the study; lateral thoracic flaps were performed to close the wounds. RESULTS: Ten patients were recruited between July 2005 and November 2007. The patients were between 48 and 76 years of age. The lateral thoracic flap size ranged from 5 x 8 cm to 9 x 12 cm. All secondary donor sites in the lateral chest wall were closed primarily. There was no flap necrosis and the secondary donor sites healed without complications. CONCLUSION: The lateral thoracic flap is safe and reliable technique for reconstructing the chest wall donor defect from the pectoralis major flap when primary closure is not possible.