Current Issue

The online formats of SRGS include access to What You Should Know (WYSK): commentaries on articles published recently in top medical journals. These commentaries, written by practicing surgeons and other medical experts, focus on the strengths and weaknesses of the research, as well as on the articles' contributions in advancing the field of surgery.

Below is a sample of one of the commentaries published in the current edition of WYSK.

Citation of Articles Reviewed:

Brown S, Mehrara BJ, Coriddi M, McGrath L, Cavalli M, Dayan JH. A Prospective Study on the Safety and Efficacy of Vascularized Lymph Node Transplant. Ann Surg. 2022;276(4):635-653. doi:10.1097/SLA.0000000000005591

Commentary by: Amanda K. Silva, MD

Lymphedema, a chronic and debilitating disease frequently caused by iatrogenic injury during cancer treatment in developed nations, can reach such severity that amputation was once proposed as the only viable solution.¹ While standard modern-day treatment involves non-surgical complex decongestive therapy, it focuses on symptom management rather than the root pathology. Furthermore, this treatment can be time-consuming, costly, and detrimental to patients’ quality of life.

The development of microsurgical and super-microsurgical techniques has opened the door to surgical interventions that directly address the underlying pathology of lymphedema. Vascularized lymph node transfer (VLNT), a procedure involving the microsurgical transfer of healthy, vascularized lymph nodes to the affected limb,² has shown promising results. While studies confirm its effectiveness,³ the standardization of outcome measures for VLNT remains an area for further development.

This prospective study sought to evaluate multiple outcome measures in lymphedema patients treated with VLNT. The authors analyzed 89 patients who underwent VLNT at Memorial Sloan Kettering Cancer Center from 2014 to 2020. Patients who underwent combined lymphatic surgeries, including lymphovenous (LV) bypass and liposuction, were excluded.

The patient cohort was predominantly female (98.9%). Lymphedema was primarily located in the upper extremity and stemmed from breast cancer treatment (73%). The majority of patients presented with International Society of Lymphology stage II lymphedema (89%), marked by limb swelling and developing fibrosis.

The omentum served as the most commonly used donor site (73%). Lymph node placement was either anatomical (at the site of prior lymph node dissection) or heterotopic (distally on the limb, proximal to the most pronounced swelling), contingent upon the patient’s specific symptoms. Notably, the omental flap’s capacity for splitting and proximal/distal placement offers a unique advantage;⁴ this technique was utilized in 21 (23.6%) patients.

The authors evaluated a range of outcomes: patient-reported quality of life, limb volume (using perometry and circumferential measurements), limb bioimpedance, the need for compression garments, and episodes of cellulitis. Significant improvements were observed across all outcomes at the two-year follow-up.¹ Complication rates were low, with no incidence of donor-site lymphedema.

It is important to note that while the majority of patients in this study were diagnosed with breast cancer, their breast status and history of reconstruction were not reported. Although the omentum may be a viable option for patients who underwent breast-conserving treatment, implant-based reconstruction, or flat closure, an alternative surgical approach exists. This technique combines breast reconstruction with VLNT, using an abdominal-based free flap and incorporating superficial groin lymph nodes. Such a procedure may be particularly suitable for breast cancer patients desiring both reconstruction and surgical management of lymphedema.⁵

This study indicates that VLNT is a safe and effective lymphedema treatment with long-term benefits, particularly with the omentum. To maximize outcomes, future research should prioritize the following: improved patient selection, optimization of surgical technique variations, identification of the best lymph node harvest sites and placement strategies, and investigation of potential synergies between VLNT and LV bypass.⁶

References

1. Handley WS. Lymphangioplasty: a new method for the relief of the brawny arm of breast-cancer and for similar conditions of lymphatic oedema J. The Lancet. 1908;171(4411):783-5.
2. Silva AK, Chang DW. Vascularized lymph node transfer and lymphovenous bypass: Novel treatment strategies for symptomatic lymphedema. J Surg Oncol. 2016;113(8):932-939. doi:10.1002/jso.24171
3. Winters H, Tielemans HJP, Paulus V, Hummelink S, Slater NJ, Ulrich DJO. A systematic review and meta-analysis of vascularized lymph node transfer for breast cancer-related lymphedema. J Vasc Surg Venous Lymphat Disord. 2022;10(3):786-795.e1. doi:10.1016/j.jvsv.2021.08.023
4. Kenworthy EO, Nelson JA, Verma R, Mbabuike J, Mehrara BJ, Dayan JH. Double vascularized omentum lymphatic transplant (VOLT) for the treatment of lymphedema. J Surg Oncol. 2018;117(7):1413-1419. doi:10.1002/jso.25033
5. Forte AJ, Cinotto G, Boczar D, et al. Lymph node transfer combined with deep inferior epigastric perforators and transverse rectus abdominis myocutaneous procedures: a systematic review. Gland Surg. 2020;9(2):521-527. doi:10.21037/gs.2020.02.11
6. Chang DW, Dayan J, Greene AK, et al. Surgical Treatment of Lymphedema: A Systematic Review and Meta-Analysis of Controlled Trials. Results of a Consensus Conference. Plast Reconstr Surg. 2021;147(4):975-993. doi:10.1097/PRS.0000000000007783

The SRGS Recommended Reading List is a summary of the most pertinent articles cited in each issue; the editor has carefully selected a group of current, classic, and seminal articles for further study in certain formats of SRGS. The citations below are linked to their abstracts on PubMed, and free full texts are available where indicated.

SRGS has obtained permission from journal publishers to reprint these articles. Copying and distributing these reprints is a violation of our licensing agreement with these publishers and is strictly prohibited.

Almadani YH, Vorstenbosch J, Davison PG, Murphy AM. Wound Healing: A Comprehensive Review. Semin Plast Surg. 2021;35(3):141-144. doi:10.1055/s-0041-1731791

Almandani and coauthors provide a comprehensive overview of the wound healing process, outlining its three main phases and emphasizing their interconnectedness. It highlights the role of nutrition, glycemic control, and avoidance of smoking and excessive alcohol in promoting optimal healing. Additionally, it explores the potential negative impacts of radiation and medications on wound healing and discusses genetic factors that can predispose individuals to complications.

Cancio LC. Topical Antimicrobial Agents for Burn Wound Care: History and Current Status. Surg Infect (Larchmt). 2021;22(1):3-11. doi:10.1089/sur.2020.368

Cancio offers a valuable historical overview of topical antimicrobial agents for burn wound care, highlighting how their development has significantly improved patient survival rates. The article emphasizes that while early excision and grafting have reduced the reliance on these agents, they remain crucial, particularly in complex cases like fungal infections and in patients where early excision is not feasible.

Park PK, Napolitano LM. Modern mechanical ventilation strategies for the acute care surgeon: What you need to know. J Trauma Acute Care Surg. 2024;96(4):523-536. doi:10.1097/TA.0000000000004194

Park and Napolitano review mechanical ventilation strategies for acute care surgeons. They emphasize the importance of understanding respiratory failure and mechanical ventilation to improve patient outcomes. The authors also discuss advanced ventilation modes and the use of parameters like driving pressure and transpulmonary pressure to optimize ventilation and minimize complications. The article provides practical guidance for acute care surgeons in managing patients requiring mechanical ventilation.