Lymphatic Tissue Transplant in Lymphedema—A Minimally Invasive, Outpatient, Surgical Method: A 10-Year Follow-up Pilot Study
Identifieur interne : 003F60 ( Istex/Corpus ); précédent : 003F59; suivant : 003F61Lymphatic Tissue Transplant in Lymphedema—A Minimally Invasive, Outpatient, Surgical Method: A 10-Year Follow-up Pilot Study
Auteurs : Gianni Belcaro ; Bruno M. Errichi ; M. Rosaria Cesarone ; Edmondo Ippolito ; Mark Dugall ; Andrea Ledda ; Andrea RicciSource :
- Angiology [ 0003-3197 ] ; 2008-02.
Abstract
Lymphedema is mainly characterized by swelling, fibrosis, and nonpitting edema. The aim of this study was evaluation of the long-term (10 years) effects of autologus lymphatic tissue implant in lymphedema. Lymphatic tissue from 9 patients (harvested form the same patient in areas not affected by lymphedema) was reimplanted into the affected limb, and these patients were followed for 10 years. Lymph nodes were harvested at the neck, axillary, or inguinal space (contralateral limb). Results showed that limb volume was decreased in the treatment group vs. controls. In ultrasound, black, low density, lymphatic spaces were visible in 100% of patients at inclusion but in only 23% of these subjects at 10 years. Thus, this early report proposes a new, minimally invasive method to improve lymphedema. Studies in progress will indicate the role of lymphatic transplant in the management of lymphedema and the best indications for this method.
Url:
DOI: 10.1177/0003319707308564
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<record><TEI wicri:istexFullTextTei="biblStruct"><teiHeader><fileDesc><titleStmt><title xml:lang="en">Lymphatic Tissue Transplant in Lymphedema—A Minimally Invasive, Outpatient, Surgical Method: A 10-Year Follow-up Pilot Study</title><author wicri:is="90%"><name sortKey="Belcaro, Gianni" sort="Belcaro, Gianni" uniqKey="Belcaro G" first="Gianni" last="Belcaro">Gianni Belcaro</name><affiliation><mods:affiliation>Irvine2 Vascular Lab, Department of Biomedical Sciences, Chieti-Pescara University, San Valentino, Italy,</mods:affiliation></affiliation><affiliation><mods:affiliation>E-mail: Cardres@abol.it</mods:affiliation></affiliation></author><author wicri:is="90%"><name sortKey="Errichi, Bruno M" sort="Errichi, Bruno M" uniqKey="Errichi B" first="Bruno M." last="Errichi">Bruno M. Errichi</name><affiliation><mods:affiliation>Irvine2 Vascular Lab, Department of Biomedical Sciences, Chieti-Pescara University, San Valentino, Italy</mods:affiliation></affiliation></author><author wicri:is="90%"><name sortKey="Cesarone, M Rosaria" sort="Cesarone, M Rosaria" uniqKey="Cesarone M" first="M. Rosaria" last="Cesarone">M. Rosaria Cesarone</name><affiliation><mods:affiliation>Irvine2 Vascular Lab, Department of Biomedical Sciences, Chieti-Pescara University, San Valentino, Italy</mods:affiliation></affiliation></author><author wicri:is="90%"><name sortKey="Ippolito, Edmondo" sort="Ippolito, Edmondo" uniqKey="Ippolito E" first="Edmondo" last="Ippolito">Edmondo Ippolito</name><affiliation><mods:affiliation>Irvine2 Vascular Lab, Department of Biomedical Sciences, Chieti-Pescara University, San Valentino, Italy</mods:affiliation></affiliation></author><author wicri:is="90%"><name sortKey="Dugall, Mark" sort="Dugall, Mark" uniqKey="Dugall M" first="Mark" last="Dugall">Mark Dugall</name><affiliation><mods:affiliation>Irvine2 Vascular Lab, Department of Biomedical Sciences, Chieti-Pescara University, San Valentino, Italy</mods:affiliation></affiliation></author><author wicri:is="90%"><name sortKey="Ledda, Andrea" sort="Ledda, Andrea" uniqKey="Ledda A" first="Andrea" last="Ledda">Andrea Ledda</name><affiliation><mods:affiliation>Irvine2 Vascular Lab, Department of Biomedical Sciences, Chieti-Pescara University, San Valentino, Italy</mods:affiliation></affiliation></author><author wicri:is="90%"><name sortKey="Ricci, Andrea" sort="Ricci, Andrea" uniqKey="Ricci A" first="Andrea" last="Ricci">Andrea Ricci</name><affiliation><mods:affiliation>Irvine2 Vascular Lab, Department of Biomedical Sciences, Chieti-Pescara University, San Valentino, Italy</mods:affiliation></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">ISTEX</idno><idno type="RBID">ISTEX:86DB79A1FA9CEE490115B8E0AEE15A163330C17A</idno><date when="2008" year="2008">2008</date><idno type="doi">10.1177/0003319707308564</idno><idno type="url">https://api.istex.fr/document/86DB79A1FA9CEE490115B8E0AEE15A163330C17A/fulltext/pdf</idno><idno type="wicri:Area/Istex/Corpus">003F60</idno><idno type="wicri:explorRef" wicri:stream="Istex" wicri:step="Corpus" wicri:corpus="ISTEX">003F60</idno></publicationStmt><sourceDesc><biblStruct><analytic><title level="a" type="main" xml:lang="en">Lymphatic Tissue Transplant in Lymphedema—A Minimally Invasive, Outpatient, Surgical Method: A 10-Year Follow-up Pilot Study</title><author wicri:is="90%"><name sortKey="Belcaro, Gianni" sort="Belcaro, Gianni" uniqKey="Belcaro G" first="Gianni" last="Belcaro">Gianni Belcaro</name><affiliation><mods:affiliation>Irvine2 Vascular Lab, Department of Biomedical Sciences, Chieti-Pescara University, San Valentino, Italy,</mods:affiliation></affiliation><affiliation><mods:affiliation>E-mail: Cardres@abol.it</mods:affiliation></affiliation></author><author wicri:is="90%"><name sortKey="Errichi, Bruno M" sort="Errichi, Bruno M" uniqKey="Errichi B" first="Bruno M." last="Errichi">Bruno M. Errichi</name><affiliation><mods:affiliation>Irvine2 Vascular Lab, Department of Biomedical Sciences, Chieti-Pescara University, San Valentino, Italy</mods:affiliation></affiliation></author><author wicri:is="90%"><name sortKey="Cesarone, M Rosaria" sort="Cesarone, M Rosaria" uniqKey="Cesarone M" first="M. Rosaria" last="Cesarone">M. Rosaria Cesarone</name><affiliation><mods:affiliation>Irvine2 Vascular Lab, Department of Biomedical Sciences, Chieti-Pescara University, San Valentino, Italy</mods:affiliation></affiliation></author><author wicri:is="90%"><name sortKey="Ippolito, Edmondo" sort="Ippolito, Edmondo" uniqKey="Ippolito E" first="Edmondo" last="Ippolito">Edmondo Ippolito</name><affiliation><mods:affiliation>Irvine2 Vascular Lab, Department of Biomedical Sciences, Chieti-Pescara University, San Valentino, Italy</mods:affiliation></affiliation></author><author wicri:is="90%"><name sortKey="Dugall, Mark" sort="Dugall, Mark" uniqKey="Dugall M" first="Mark" last="Dugall">Mark Dugall</name><affiliation><mods:affiliation>Irvine2 Vascular Lab, Department of Biomedical Sciences, Chieti-Pescara University, San Valentino, Italy</mods:affiliation></affiliation></author><author wicri:is="90%"><name sortKey="Ledda, Andrea" sort="Ledda, Andrea" uniqKey="Ledda A" first="Andrea" last="Ledda">Andrea Ledda</name><affiliation><mods:affiliation>Irvine2 Vascular Lab, Department of Biomedical Sciences, Chieti-Pescara University, San Valentino, Italy</mods:affiliation></affiliation></author><author wicri:is="90%"><name sortKey="Ricci, Andrea" sort="Ricci, Andrea" uniqKey="Ricci A" first="Andrea" last="Ricci">Andrea Ricci</name><affiliation><mods:affiliation>Irvine2 Vascular Lab, Department of Biomedical Sciences, Chieti-Pescara University, San Valentino, Italy</mods:affiliation></affiliation></author></analytic><monogr></monogr><series><title level="j">Angiology</title><idno type="ISSN">0003-3197</idno><idno type="eISSN"></idno><imprint><publisher>Sage Publications</publisher><pubPlace>Sage CA: Los Angeles, CA</pubPlace><date type="published" when="2008-02">2008-02</date><biblScope unit="volume">59</biblScope><biblScope unit="issue">1</biblScope><biblScope unit="page" from="77">77</biblScope><biblScope unit="page" to="83">83</biblScope></imprint><idno type="ISSN">0003-3197</idno></series><idno type="istex">86DB79A1FA9CEE490115B8E0AEE15A163330C17A</idno><idno type="DOI">10.1177/0003319707308564</idno><idno type="ArticleID">10.1177_0003319707308564</idno></biblStruct></sourceDesc><seriesStmt><idno type="ISSN">0003-3197</idno></seriesStmt></fileDesc><profileDesc><textClass></textClass><langUsage><language ident="en">en</language></langUsage></profileDesc></teiHeader><front><div type="abstract" xml:lang="en">Lymphedema is mainly characterized by swelling, fibrosis, and nonpitting edema. The aim of this study was evaluation of the long-term (10 years) effects of autologus lymphatic tissue implant in lymphedema. Lymphatic tissue from 9 patients (harvested form the same patient in areas not affected by lymphedema) was reimplanted into the affected limb, and these patients were followed for 10 years. Lymph nodes were harvested at the neck, axillary, or inguinal space (contralateral limb). Results showed that limb volume was decreased in the treatment group vs. controls. In ultrasound, black, low density, lymphatic spaces were visible in 100% of patients at inclusion but in only 23% of these subjects at 10 years. Thus, this early report proposes a new, minimally invasive method to improve lymphedema. Studies in progress will indicate the role of lymphatic transplant in the management of lymphedema and the best indications for this method.</div></front></TEI><istex><corpusName>sage</corpusName><keywords><teeft><json:string>lymphatic</json:string><json:string>lymphedema</json:string><json:string>witte</json:string><json:string>belcaro</json:string><json:string>edema</json:string><json:string>lymphology</json:string><json:string>node</json:string><json:string>interstitial fluid</json:string><json:string>invasive</json:string><json:string>limb volume</json:string><json:string>ultrasound</json:string><json:string>lymphatic tissue</json:string><json:string>subcutaneous tissue</json:string><json:string>treatment group</json:string><json:string>clinical pictures</json:string><json:string>transplant</json:string><json:string>lymph</json:string><json:string>lymphatic disease</json:string><json:string>decongestive physiotherapy</json:string><json:string>contralateral limb</json:string><json:string>lymphatic tissue transplant</json:string><json:string>peripheral lymphedema</json:string><json:string>lymphedema belcaro</json:string><json:string>edema scale</json:string><json:string>control group</json:string><json:string>lymphatic channels</json:string><json:string>lymphatic transplant</json:string><json:string>limb</json:string><json:string>inclusion</json:string><json:string>interstitial</json:string><json:string>inguinal space</json:string><json:string>international society</json:string><json:string>same patient</json:string><json:string>gianni belcaro</json:string><json:string>nonpitting edema</json:string><json:string>pilot study</json:string><json:string>high resolution ultrasound</json:string><json:string>lymphonodal fragments</json:string><json:string>lymphatic spaces</json:string><json:string>comparison group</json:string><json:string>autologus lymphatic tissue implant</json:string><json:string>subsequent variations</json:string><json:string>early report</json:string><json:string>edema score</json:string><json:string>invasive method</json:string><json:string>progressive increase</json:string><json:string>lymph nodes</json:string><json:string>lymphatic microsurgery</json:string><json:string>best indications</json:string><json:string>cutaneous resection</json:string><json:string>imperial college press</json:string><json:string>edema tester</json:string><json:string>plasma lipoproteins</json:string><json:string>peripheral lymph</json:string><json:string>molecular regulation</json:string><json:string>vasc endovascular surg</json:string><json:string>lower limb</json:string><json:string>limited number</json:string><json:string>different populations</json:string><json:string>lymphatic edema</json:string><json:string>possible interventions</json:string></teeft></keywords><author><json:item><name>Gianni Belcaro MD</name><affiliations><json:string>Irvine2 Vascular Lab, Department of Biomedical Sciences, Chieti-Pescara University, San Valentino, Italy,</json:string><json:string>E-mail: Cardres@abol.it</json:string></affiliations></json:item><json:item><name>Bruno M. Errichi MD</name><affiliations><json:string>Irvine2 Vascular Lab, Department of Biomedical Sciences, Chieti-Pescara University, San Valentino, Italy</json:string></affiliations></json:item><json:item><name>M. Rosaria Cesarone MD</name><affiliations><json:string>Irvine2 Vascular Lab, Department of Biomedical Sciences, Chieti-Pescara University, San Valentino, Italy</json:string></affiliations></json:item><json:item><name>Edmondo Ippolito MD</name><affiliations><json:string>Irvine2 Vascular Lab, Department of Biomedical Sciences, Chieti-Pescara University, San Valentino, Italy</json:string></affiliations></json:item><json:item><name>Mark Dugall PhD</name><affiliations><json:string>Irvine2 Vascular Lab, Department of Biomedical Sciences, Chieti-Pescara University, San Valentino, Italy</json:string></affiliations></json:item><json:item><name>Andrea Ledda MD</name><affiliations><json:string>Irvine2 Vascular Lab, Department of Biomedical Sciences, Chieti-Pescara University, San Valentino, Italy</json:string></affiliations></json:item><json:item><name>Andrea Ricci MD</name><affiliations><json:string>Irvine2 Vascular Lab, Department of Biomedical Sciences, Chieti-Pescara University, San Valentino, Italy</json:string></affiliations></json:item></author><subject><json:item><lang><json:string>eng</json:string></lang><value>lymphatic tissue</value></json:item><json:item><lang><json:string>eng</json:string></lang><value>lymph nodes</value></json:item><json:item><lang><json:string>eng</json:string></lang><value>lymphedema</value></json:item><json:item><lang><json:string>eng</json:string></lang><value>leg swelling</value></json:item><json:item><lang><json:string>eng</json:string></lang><value>autologous tissue transplant</value></json:item><json:item><lang><json:string>eng</json:string></lang><value>edema</value></json:item></subject><articleId><json:string>10.1177_0003319707308564</json:string></articleId><language><json:string>eng</json:string></language><originalGenre><json:string>research-article</json:string></originalGenre><abstract>Lymphedema is mainly characterized by swelling, fibrosis, and nonpitting edema. 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Rosaria</forename><surname>Cesarone</surname></persName><roleName type="degree">MD</roleName><affiliation>Irvine2 Vascular Lab, Department of Biomedical Sciences, Chieti-Pescara University, San Valentino, Italy</affiliation></author><author xml:id="author-4"><persName><forename type="first">Edmondo</forename><surname>Ippolito</surname></persName><roleName type="degree">MD</roleName><affiliation>Irvine2 Vascular Lab, Department of Biomedical Sciences, Chieti-Pescara University, San Valentino, Italy</affiliation></author><author xml:id="author-5"><persName><forename type="first">Mark</forename><surname>Dugall</surname></persName><roleName type="degree">PhD</roleName><affiliation>Irvine2 Vascular Lab, Department of Biomedical Sciences, Chieti-Pescara University, San Valentino, Italy</affiliation></author><author xml:id="author-6"><persName><forename type="first">Andrea</forename><surname>Ledda</surname></persName><roleName type="degree">MD</roleName><affiliation>Irvine2 Vascular Lab, Department of Biomedical Sciences, Chieti-Pescara University, San Valentino, Italy</affiliation></author><author xml:id="author-7"><persName><forename type="first">Andrea</forename><surname>Ricci</surname></persName><roleName type="degree">MD</roleName><affiliation>Irvine2 Vascular Lab, Department of Biomedical Sciences, Chieti-Pescara University, San Valentino, Italy</affiliation></author></analytic><monogr><title level="j">Angiology</title><idno type="pISSN">0003-3197</idno><idno type="eISSN"></idno><imprint><publisher>Sage Publications</publisher><pubPlace>Sage CA: Los Angeles, CA</pubPlace><date type="published" when="2008-02"></date><biblScope unit="volume">59</biblScope><biblScope unit="issue">1</biblScope><biblScope unit="page" from="77">77</biblScope><biblScope unit="page" to="83">83</biblScope></imprint></monogr><idno type="istex">86DB79A1FA9CEE490115B8E0AEE15A163330C17A</idno><idno type="DOI">10.1177/0003319707308564</idno><idno type="ArticleID">10.1177_0003319707308564</idno></biblStruct></sourceDesc></fileDesc><profileDesc><creation><date>2008</date></creation><langUsage><language ident="en">en</language></langUsage><abstract xml:lang="en"><p>Lymphedema is mainly characterized by swelling, fibrosis, and nonpitting edema. The aim of this study was evaluation of the long-term (10 years) effects of autologus lymphatic tissue implant in lymphedema. Lymphatic tissue from 9 patients (harvested form the same patient in areas not affected by lymphedema) was reimplanted into the affected limb, and these patients were followed for 10 years. Lymph nodes were harvested at the neck, axillary, or inguinal space (contralateral limb). Results showed that limb volume was decreased in the treatment group vs. controls. In ultrasound, black, low density, lymphatic spaces were visible in 100% of patients at inclusion but in only 23% of these subjects at 10 years. Thus, this early report proposes a new, minimally invasive method to improve lymphedema. Studies in progress will indicate the role of lymphatic transplant in the management of lymphedema and the best indications for this method.</p></abstract><textClass><keywords scheme="keyword"><list><head>keywords</head><item><term>lymphatic tissue</term></item><item><term>lymph nodes</term></item><item><term>lymphedema</term></item><item><term>leg swelling</term></item><item><term>autologous tissue transplant</term></item><item><term>edema</term></item></list></keywords></textClass></profileDesc><revisionDesc><change when="2008-02">Published</change></revisionDesc></teiHeader></istex:fulltextTEI><json:item><extension>txt</extension><original>false</original><mimetype>text/plain</mimetype><uri>https://api.istex.fr/document/86DB79A1FA9CEE490115B8E0AEE15A163330C17A/fulltext/txt</uri></json:item></fulltext><metadata><istex:metadataXml wicri:clean="corpus sage not found" wicri:toSee="no header"><istex:xmlDeclaration>version="1.0" encoding="UTF-8"</istex:xmlDeclaration><istex:docType PUBLIC="-//NLM//DTD Journal Publishing DTD v2.3 20070202//EN" URI="journalpublishing.dtd" name="istex:docType"></istex:docType><istex:document><article article-type="research-article" dtd-version="2.3" xml:lang="EN"><front><journal-meta><journal-id journal-id-type="hwp">spang</journal-id><journal-id journal-id-type="publisher-id">ANG</journal-id><journal-title>Angiology</journal-title><issn pub-type="ppub">0003-3197</issn><publisher>
<publisher-name>Sage Publications</publisher-name>
<publisher-loc>Sage CA: Los Angeles, CA</publisher-loc>
</publisher></journal-meta><article-meta><article-id pub-id-type="doi">10.1177/0003319707308564</article-id><article-id pub-id-type="publisher-id">10.1177_0003319707308564</article-id><article-categories><subj-group subj-group-type="heading"><subject>Articles</subject></subj-group></article-categories><title-group><article-title>Lymphatic Tissue Transplant in Lymphedema—A Minimally Invasive, Outpatient, Surgical Method: A 10-Year Follow-up Pilot Study</article-title></title-group>
<contrib-group><contrib contrib-type="author" xlink:type="simple"><name name-style="western"><surname>Belcaro</surname><given-names>Gianni</given-names></name><degrees>MD</degrees><aff>Irvine2 Vascular Lab, Department of Biomedical Sciences, Chieti-Pescara University, San Valentino, Italy, <email xlink:type="simple">Cardres@abol.it</email></aff></contrib></contrib-group>
<contrib-group><contrib contrib-type="author" xlink:type="simple"><name name-style="western"><surname>Errichi</surname><given-names>Bruno M.</given-names></name><degrees>MD</degrees><aff>Irvine2 Vascular Lab, Department of Biomedical Sciences, Chieti-Pescara University, San Valentino, Italy</aff></contrib></contrib-group>
<contrib-group><contrib contrib-type="author" xlink:type="simple"><name name-style="western"><surname>Cesarone</surname><given-names>M. Rosaria</given-names></name><degrees>MD</degrees><aff>Irvine2 Vascular Lab, Department of Biomedical Sciences, Chieti-Pescara University, San Valentino, Italy</aff></contrib></contrib-group>
<contrib-group><contrib contrib-type="author" xlink:type="simple"><name name-style="western"><surname>Ippolito</surname><given-names>Edmondo</given-names></name><degrees>MD</degrees><aff>Irvine2 Vascular Lab, Department of Biomedical Sciences, Chieti-Pescara University, San Valentino, Italy</aff></contrib></contrib-group>
<contrib-group><contrib contrib-type="author" xlink:type="simple"><name name-style="western"><surname>Dugall</surname><given-names>Mark</given-names></name><degrees>PhD</degrees><aff>Irvine2 Vascular Lab, Department of Biomedical Sciences, Chieti-Pescara University, San Valentino, Italy</aff></contrib></contrib-group>
<contrib-group><contrib contrib-type="author" xlink:type="simple"><name name-style="western"><surname>Ledda</surname><given-names>Andrea</given-names></name><degrees>MD</degrees><aff>Irvine2 Vascular Lab, Department of Biomedical Sciences, Chieti-Pescara University, San Valentino, Italy</aff></contrib></contrib-group>
<contrib-group><contrib contrib-type="author" xlink:type="simple"><name name-style="western"><surname>Ricci</surname><given-names>Andrea</given-names></name><degrees>MD</degrees><aff>Irvine2 Vascular Lab, Department of Biomedical Sciences, Chieti-Pescara University, San Valentino, Italy</aff></contrib></contrib-group>
<pub-date pub-type="ppub"><month>2</month><year>2008</year></pub-date><volume>59</volume><issue>1</issue><fpage>77</fpage><lpage>83</lpage><abstract><p>Lymphedema is mainly characterized by swelling, fibrosis, and nonpitting edema. The aim of this study was evaluation of the long-term (10 years) effects of autologus lymphatic tissue implant in lymphedema. Lymphatic tissue from 9 patients (harvested form the same patient in areas not affected by lymphedema) was reimplanted into the affected limb, and these patients were followed for 10 years. Lymph nodes were harvested at the neck, axillary, or inguinal space (contralateral limb). Results showed that limb volume was decreased in the treatment group vs. controls. In ultrasound, black, low density, lymphatic spaces were visible in 100% of patients at inclusion but in only 23% of these subjects at 10 years. Thus, this early report proposes a new, minimally invasive method to improve lymphedema. Studies in progress will indicate the role of lymphatic transplant in the management of lymphedema and the best indications for this method.</p></abstract><kwd-group><kwd>lymphatic tissue</kwd>
<kwd>lymph nodes</kwd>
<kwd>lymphedema</kwd>
<kwd>leg swelling</kwd>
<kwd>autologous tissue transplant</kwd>
<kwd>edema</kwd></kwd-group><custom-meta-wrap><custom-meta xlink:type="simple"><meta-name>sagemeta-type</meta-name><meta-value>Journal Article</meta-value></custom-meta><custom-meta xlink:type="simple"><meta-name>cover-date</meta-name><meta-value>February/March 2008</meta-value></custom-meta><custom-meta xlink:type="simple"><meta-name>search-text</meta-name><meta-value>77 Lymphatic Tissue Transplant in Lymphedema—A Minimally Invasive, Outpatient, Surgical Method: A 10-Year Follow-up Pilot Study SAGE Publications, Inc.200810.1177/0003319707308564 GianniBelcaro MD Irvine2 Vascular Lab, Department of Biomedical Sciences, Chieti-Pescara University, San Valentino, Italy, Cardres@abol.it Bruno M.Errichi MD Irvine2 Vascular Lab, Department of Biomedical Sciences, Chieti-Pescara University, San Valentino, Italy M. RosariaCesarone MD Irvine2 Vascular Lab, Department of Biomedical Sciences, Chieti-Pescara University, San Valentino, Italy EdmondoIppolito MD Irvine2 Vascular Lab, Department of Biomedical Sciences, Chieti-Pescara University, San Valentino, Italy MarkDugall PhD Irvine2 Vascular Lab, Department of Biomedical Sciences, Chieti-Pescara University, San Valentino, Italy AndreaLedda MD Irvine2 Vascular Lab, Department of Biomedical Sciences, Chieti-Pescara University, San Valentino, Italy AndreaRicci MD Irvine2 Vascular Lab, Department of Biomedical Sciences, Chieti-Pescara University, San Valentino, Italy Lymphedema is mainly characterized by swelling, fibrosis, and nonpitting edema. The aim of this study was evaluation of the long-term (10 years) effects of autologus lymphatic tissue implant in lymphedema. Lymphatic tissue from 9 patients (harvested form the same patient in areas not affected by lymphedema) was reimplanted into the affected limb, and these patients were followed for 10 years. Lymph nodes were harvested at the neck, axillary, or inguinal space (contralateral limb). Results showed that limb volume was decreased in the treatment group vs. controls. In ultrasound, black, low density, lymphatic spaces were visible in 100% of patients at inclusion but in only 23% of these subjects at 10 years. Thus, this early report proposes a new, minimally invasive method to improve lymphedema. Studies in progress will indicate the role of lymphatic transplant in the management of lymphedema and the best indications for this method. lymphatic tissue lymph nodes lymphedema leg swelling autologous tissue transplant edema n late stages, lymphedema is mainly character- Iized by swelling and fibrosis and usually affects one extremity. The condition may appear with- out a previous medical history and is classically characterized by nonpitting edema. In some cases, previous, recurrent episodes of lymphangitis and cellulitis can be identified. Edema due to lymphatic disease generally does not effectively respond to leg elevation.1-3 The accumulation of interstitial fluid is caused either by congenital lymphatic abnormalities or by severe lymphatic destruction (ie, following surgery or radiotherapy) or obstruction. Clinical pictures of lymphedema may have several possible causes and aspects, types of progression, and expla- nations.4-11 The clinical picture may be more evident in areas of the body where gravity affects its action more significantly. Developmental abnormalities of lymphatics and hypoplasia may be present in 55% of the affected subjects; varicose dilatation of lymphat- ics may be observed in about 24% of lymphatic patients. Lymphatic aplasia is observed in a very limited number of patients. Lymphatic obstruction (which may also be functional due to compression) is rarely seen. In some patients the dilatation of lymphatic vessels causes incompetence with reverse flow (reflux).1-4 The exact distribution in different populations of these clinical abnormalities leading to disease is unknown. In differ- ent geographical areas, different frequencies of disease can be observed (ie, in relation to parasitic infestations). The treatment and control of lymphatic edema is based on a number of possible interventions. However, none is completely effective and most are temporary (ie, com- pression) unless used with great consistency.12-15 No specific drug for lymphedema has been developed so far. True lymphedema is a rare disease, and therefore very limited specific clinical and commercial interest is linked to this condition.16-25 Development of new methods of treatment for the more severe cases has recently stimulated new interest in this field.25-29 78 The aim of this pilot study was evaluation of the long term (at least 10 years) effects of autologus lymphatic tissue implant in patients with lym- phedema. The lymphatic tissue (harvested from the same patient in areas not affected by lymphedema) was reimplanted into the affected limb. Patients and Methods Nine subjects (7 females) with lymphedema—occurring at variable distance (5 to 8 years) after a documented episode of lymphangitis—affecting a single limb (the other limb was normal as a selection criterion) were fol- lowed for at least 10 years after the surgical procedure. Lymphedema was present only distally, below the knee. The age at inclusion was between 20 and 43 (average 38.8 years, SD ±9). No other clinically significant vas- cular disease, metabolic or bone/joint abnormality, or condition requiring any drug treatment was present at inclusion. The swelling had been present for at least 5 years (with different levels of swelling and discomfort). None of these subjects had oncological problems or had been treated with radio or chemotherapy.18-26 An important exclusion point was the absence of available lymph nodes for harvesting the tissue to be transplanted. Surgical Technique Lymph nodes (1 to 3) were harvested at the neck (2 patients), axillary space (2 patients), or in the inguinal space at the contralateral limb (6 patients). They were precisely localized by high resolution ultrasound to allow only minimal surgical cuts during harvesting. The procedure minimized—by careful dissection, coagulation, and skin closure—any risk of lymphatic or blood leak and infection. `On table' microtomic sec- tion of nodes producing `slices' of about 0.5 to 1 mm thickness were manually produced. Lymphonodal slices were temporarily placed in a bath at 40° with antibiotic solution (cephalosporin). Reimplant in the lymphedematous area was also performed with `minimal' (3 mm) cuts. The lym- phonodal fragments were placed at least 3 to 4 mm in depth within the subcutaneous tissue and at some distance (at least 0.5 cm) from vascular structures such as arteries or veins after evaluating the reim- plant areas by high resolution ultrasound. The lym- phonodal fragments were reimplanted along the course of a main vein segment (long saphenous vein and its distal branches or veins of the dorsum of the foot). All surgical wounds (between 3 and 8 implants in each case) ranging in length between 2 and 4 mm were closed without stitches but rather with plaster strips. A moderate compression with an adhesive bandage and elastic stockings (25 mmHg at the ankle) was used for 4 weeks following the transplant. A 5-step posttransplant period was based on the following prescriptions: (1) avoid very strong (>30 mmHg) compression on the transplanted islands, (2) avoid water retention and edema on the trans- plants, (3) control salt (NaCl) in the diet, (4) antibi- otic coverage for at least 2 weeks and in any case of suspected inflammation or infection (redness, swelling, pain), and (5) leg elevation, when possible, constant exercise (mainly walking) and massage (mainly on the areas proximal and distal to the trans- planted islands with minimal manipulation of the surgical implants). High resolution ultrasound checks were per- formed every 2 weeks to identify any localized edema or infections (for 6 months).6,11 Only one pro- cedure was performed in each patient. Comparison Group A comparison group of 8 subjects (age range 22 to 42, average 39.4, SD ±7.3) was included in the 10 year study. Education, compression, exercise, lymphatic drainage when available, edema control, and hygienic procedure to avoid new episodes or foot infections or lymphangitis were intensively used in both groups of patients. Evaluation Evaluation of the affected limb was performed only with noninvasive tests and clinical evaluation. Lymphoscintigraphy was considered not useful and potentially damaging for the residual lymphatics.1-3,6-11 Seven patients had scintigraphy performed (in differ- ent centers) at least 1 year before inclusion with dif- ferent standards and operational procedures, basically showing an alteration of the lymphatic flow (much slower than within the healthy, contralateral limb or almost absent at the level affected by edema). Patients were asked to avoid any invasive procedure (including scintigraphy) during the follow-up. The presence of arterial or venous disease or other severe clinical condition which may have had an influence on distal edema (ie, hypertension requiring treatment or diabetic microangiopathy) 79 Table 1. The Edema Scale was excluded with specific vascular or metabolic tests. Development of venous thrombosis, phlebitis, or arterial disease during the study was also consid- ered exclusion criteria. Limb volume. Limb volume was measured with immersion in a container with water. Water dis- placement level at inclusion was indicated as 100%, and subsequent variations in volume were adapted to this percentage.1-3 The limb volume was measured at the upper, proximal tibial margin. Edema scale. The edema scale (Table 1) includes 5 items concerning the type of edema and 4 concern- ing the localization of edema. The sum of the 2 scores constituted the edema score. The lower level of lymphedema was observed in patients with a score of 2 (1 for localization and 1 for type of edema). This study included patients with edema scores ranging between 3 and 5 excluding very mild (<3) or very severe (5 to 8).6 Proteins in interstitial fluid. Proteins in the intersti- tial fluid were measured with a 23G size butterfly needle inserted 2 to 3 mm in depth at the dorsum of the foot. The interstitial fluid collecting in the tube should have, under normal conditions, a protein concentration lower than or equal to the concentra- tion of proteins in blood (which was considered equal to 100%). An increased concentration indi- cates an abnormal accumulation of proteins in the interstitial fluid and is usually clinically associated with lymphatic edema.1-3,7-10 Ultrasound. Black, low density (water density) oblong spaces parallel to the skin layers were demonstrated for the first time by Cesarone in 1995.11 These spaces, mainly due to the accumulation of interstitial fluids, are associated with documented (clinically and by lymphoscintigraphy) lymphedema and tend to disappear in postlymphedema patients.1-3,11 Size of limb—sections. Circumference measurements at the middle foot, ankle, and at the maximum calf circumference were added into a sum which was con- sidered to be 100% at inclusion. Subsequent varia- tions were measured as percentages.1-3 Ultrasound skin thickness. The thickness of the skin plus subcutaneous tissue at the pretibial space (at the median level of the tibia) was measured by high resolution, longitudinal section at the internal bor- der of the tibia. Normal thickness of the skin plus subcutaneous tissue (in comparable subjects of com- parable age) is between 1.8 and 3.2 mm depending on height, weight, and several other factors. In these patients at inclusion the values were between 3.5 and 4.2 mm, almost double in comparison with the con- tralateral measurement which was considered the `normal' value of 100% and taken as the comparative baseline. Transversal, supramalleolar sections of skin plus subcutaneous tissue are also useful to measure the level of edema, but the measurements are less consistent (2.3 to 2.5 mm) and are more dif- ficult to standardize.11 Biopsy. Biopsies—originally planned to evaluate histology—were not performed in this study in order to keep the study as minimally invasive as possible and also to avoid possible infections which may have complicated the clinical pictures. Compliance and BMI. All patients were able to fol- low instructions; exercise along with compliance and interest in the study were satisfactory. At inclu- sion average body mass index was below 28 (range 80 Table 2. Variation of the Evaluated Parameters Over 10 Years Note: P = # difference between groups (P < .05); *= difference before−after; parameter difference in ten years: + indicates increase, - indicates decrease; ns, not significant; T, treatment group; C, control group; SD, standard deviation. 24.3 to 31.5; SD ±2.2). The variation of BMI is very important in these measurements as it may signifi- cantly affect all measurements concerning swelling, edema, and volume. Statistics. Nonparametric tests (Mann-Whitney) and analysis of variance were used for statistical analysis because the included parameters do not have a nor- mal distribution. Results All patients in the 2 groups completed the full 10 years of the follow-up. No major increase in body weight (which may have affected measurements) was recorded. The average BMI in the treatment group at inclusion was 24.3, SD ±2 and at the end of the study was 25.3, SD ±1.7. In the control group BMI average was 24.9 ± 2.1 at inclusion versus 25.5 ± 2.2 at 10 years. Side effects. No significant side effects were observed after the transplants. Limb volume. The 100% value at inclusion was increased (median) to 11% (range −11 to +22) at 5 years and 13% (−8 to 14) at 10 years in the treatment group (P < .05). The progressive increase in volume was much larger (P < .05) in controls (Table 2). Edema scale. The edema score was an average of 4.3 at inclusion and 3.9 at 10 years in the treatment group. A significant variation in score, progressively increasing, was seen in controls (P < .05). Proteins in the interstitial fluid. This value was 53% greater than the value of plasma proteins at inclusion and decreased to 34% at 10 years. This value and its decrease at 10 years were also significantly lower in transplanted patients than in controls. Ultrasound. Black, low density, lymphatic spaces were visible in 100% of patients at inclusion but only in 23% of these subjects at 10 years. This value was also better than what was observed in controls (P < .05). Limb size. The initial total circumference (foot plus ankle plus calf circumference) had a minimal increase in 10 years (median +8% versus a 23% increase in controls) (P < .05). Skin thickness. There was a significant difference between the pretibial thickness in patients treated with transplants compared to the control group. The transplant patients had a significant median decrease in thickness (39%) while in controls there was a progressive increase with a 15% increase and a comparative difference of +59% versus transplant subjects. Compliance and BMI. All patients were compliant and able/willing to follow prescription and instructions. The BMI at the end of 10 years was not significantly differ- ent from the initial values. Therefore, changes (ie, in volume and edema) could not be attributed to signifi- cant weight variations. Evaluation of costs. This limited, minimally invasive outpatient procedure had a limited cost. The treat- ment that patients received/used was on average 32% less than controls (including physiotherapy, massages, bandages, stockings) and consumed a sig- nificantly less amount of time (38%). This difference 81 may also be significant when translated into specific costs (which will be presented and discussed in a forthcoming report). Discussion and Conclusions The idea behind lymphatic transplant is that most lym- phatic tissue is vasculogenic and may produce new lymphatic channels. However, very limited experience has been reported and none in a clinical setting. The lymphatic components—when reimplanted—tend to create structures in the form of tubules, but it is unclear whether these structures actually constitute new lymphatic channels or link their lumen to the preexisting residual lymphatic network facilitating new flow lines. It is also possible that the lymphatic tissue elements induce generic angiogenesis and that some new channels may become predominantly lymphatic when the local lymphatic pressure or the accumulation of proteins in the interstitial fluid are very high. Histology and in vivo, invasive micro- scopic studies are in progress and will be available in the near future. It has been shown17 that the vascular endothelial growth factor (VEGF; glycoproteins) induce angio- genesis and lymphangiogenesis. These proteins are potential therapeutic agents able to modulate the growth of blood vessels and lymphatics in tumors, inhibiting cancer growth. VEGFs are also used to stimulate angiogenesis in ischemic disease and lym- phangiogenesis in the treatment of lymphedema.12,30 On the basis of these observations, pure lymph, obtained by percutaneous needle suction from inguinal lymph nodes, had also been used in early `lymph-fluid transplants' with the aim of stimulating expansion or growth of lymphatic channels in areas affects by lymphedema. At present, this technique— less invasive than lymphatic tissue transplant—is under development. The treatment and control of lymphatic edema is based on a number of possible interventions of which, at present, none seem to be definitive.27-32 Subcutaneous tissue liposuction—particularly for very advanced stages and postsurgical cases—may play a very significant role.26-29 However, the varia- tions in clinical pictures and the relative rarity of this disease—in our populations—make it difficult to complete studies with groups of comparable patients. All studies should be long-term (>5 years) as the disease shows its worst characteristics of progression over time. An important target could be improvement in limb volume but also no progression (controlling the volume increase) could be an important aim in many patients.33-37 The control of lymphedema has been defined by Foldi and colleagues.37-39 An impor- tant step in lymphedema—to avoid progression—is the prevention of recurrent infections which prevent further lymphatic damage. However, prevention of infections does not improve the established disease.37-39 Conservative treatment4,23-25,31,37-39 and control of lym- phedema is generally moderately effective (but almost never satisfactory) in many moderate initial cases of swelling; however, there are no management stan- dards. Limb elevation can be a limited tool even when repeated several times during the day. Elastic compression—and other forms of compression (ie, sequential/intermittent compression)—are usually temporarily effective and prevent accumulation of proteins and fibrosis in the interstitial spaces. However, in very hot climates compression is often a difficult option. The different surgical methods tested in different populations do not offer unequivocal, long-lasting, and effective solutions and are actually possible only in a limited number of patients and when deformity and handicaps become unbearable. Excisional procedures (ie, resurfacing, elimination of the subcutaneous tis- sue, skin grafts, and liposuction) may produce sen- sory loss and, in time, further swelling due to destruction of the limited, remaining lymphatic network.27-29 Lympho−venous anastomosis and lymphatic microsurgery may offer a limited range of solutions in specific patients. Thompson proce- dures, the enteromesenteric bridge technique, and omental pedicle flaps have been used but not widely accepted.4,23-29,31 Treatment of lymphedema23-25,31 is also based on `decongestive physiotherapy' including low stretch bandages.4 Even huge lymphedema treated with cuta- neous resection after decongestive physiotherapy have been improved. According to Lee,8 lymphatic malfor- mations (LM) are the most common form of congeni- tal vascular malformation. The important aspect of Lee's report is the stressing of the multidisciplinary team approach, essential for the best management. The social aspects are also relevant considering the cost and the time needed for treatment.40 One of the problems of lymphedema is the qual- ity and value of imaging.1-4,33,34-37 Physiology, histol- ogy, and images often do not match, thus it is important to define accurate diagnostic standards. In conclusion, with this early report we have proposed a new, minimally invasive method to improve lymphedema. These positive results may be confined to this type of patient, and lager samples 82 including a wider range of clinical pictures may be needed for conclusions. Studies in progress will indi- cate the role of lymphatic transplant in the manage- ment of lymphedema and the best indications for this method. Early experience in postmastectomy lym- phedema and in the treatment of venous ulcers (lym- phatic tissue seems to produce very fast healing) is under evaluation and results will be available soon. References Belcaro G., Nicolaides AN, Veller M. Venous Disorders. 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</ref-list></back></article></istex:document></istex:metadataXml><mods version="3.6"><titleInfo lang="en"><title>Lymphatic Tissue Transplant in Lymphedema—A Minimally Invasive, Outpatient, Surgical Method: A 10-Year Follow-up Pilot Study</title></titleInfo><titleInfo type="alternative" lang="en" contentType="CDATA"><title>Lymphatic Tissue Transplant in Lymphedema—A Minimally Invasive, Outpatient, Surgical Method: A 10-Year Follow-up Pilot Study</title></titleInfo><name type="personal"><namePart type="given">Gianni</namePart><namePart type="family">Belcaro</namePart><namePart type="termsOfAddress">MD</namePart><affiliation>Irvine2 Vascular Lab, Department of Biomedical Sciences, Chieti-Pescara University, San Valentino, Italy,</affiliation><affiliation>E-mail: Cardres@abol.it</affiliation></name><name type="personal"><namePart type="given">Bruno M.</namePart><namePart type="family">Errichi</namePart><namePart type="termsOfAddress">MD</namePart><affiliation>Irvine2 Vascular Lab, Department of Biomedical Sciences, Chieti-Pescara University, San Valentino, Italy</affiliation></name><name type="personal"><namePart type="given">M. Rosaria</namePart><namePart type="family">Cesarone</namePart><namePart type="termsOfAddress">MD</namePart><affiliation>Irvine2 Vascular Lab, Department of Biomedical Sciences, Chieti-Pescara University, San Valentino, Italy</affiliation></name><name type="personal"><namePart type="given">Edmondo</namePart><namePart type="family">Ippolito</namePart><namePart type="termsOfAddress">MD</namePart><affiliation>Irvine2 Vascular Lab, Department of Biomedical Sciences, Chieti-Pescara University, San Valentino, Italy</affiliation></name><name type="personal"><namePart type="given">Mark</namePart><namePart type="family">Dugall</namePart><namePart type="termsOfAddress">PhD</namePart><affiliation>Irvine2 Vascular Lab, Department of Biomedical Sciences, Chieti-Pescara University, San Valentino, Italy</affiliation></name><name type="personal"><namePart type="given">Andrea</namePart><namePart type="family">Ledda</namePart><namePart type="termsOfAddress">MD</namePart><affiliation>Irvine2 Vascular Lab, Department of Biomedical Sciences, Chieti-Pescara University, San Valentino, Italy</affiliation></name><name type="personal"><namePart type="given">Andrea</namePart><namePart type="family">Ricci</namePart><namePart type="termsOfAddress">MD</namePart><affiliation>Irvine2 Vascular Lab, Department of Biomedical Sciences, Chieti-Pescara University, San Valentino, Italy</affiliation></name><typeOfResource>text</typeOfResource><genre type="research-article" displayLabel="research-article"></genre><originInfo><publisher>Sage Publications</publisher><place><placeTerm type="text">Sage CA: Los Angeles, CA</placeTerm></place><dateIssued encoding="w3cdtf">2008-02</dateIssued><copyrightDate encoding="w3cdtf">2008</copyrightDate></originInfo><language><languageTerm type="code" authority="iso639-2b">eng</languageTerm><languageTerm type="code" authority="rfc3066">en</languageTerm></language><physicalDescription><internetMediaType>text/html</internetMediaType></physicalDescription><abstract lang="en">Lymphedema is mainly characterized by swelling, fibrosis, and nonpitting edema. The aim of this study was evaluation of the long-term (10 years) effects of autologus lymphatic tissue implant in lymphedema. Lymphatic tissue from 9 patients (harvested form the same patient in areas not affected by lymphedema) was reimplanted into the affected limb, and these patients were followed for 10 years. Lymph nodes were harvested at the neck, axillary, or inguinal space (contralateral limb). Results showed that limb volume was decreased in the treatment group vs. controls. In ultrasound, black, low density, lymphatic spaces were visible in 100% of patients at inclusion but in only 23% of these subjects at 10 years. Thus, this early report proposes a new, minimally invasive method to improve lymphedema. Studies in progress will indicate the role of lymphatic transplant in the management of lymphedema and the best indications for this method.</abstract><subject><genre>keywords</genre><topic>lymphatic tissue</topic><topic>lymph nodes</topic><topic>lymphedema</topic><topic>leg swelling</topic><topic>autologous tissue transplant</topic><topic>edema</topic></subject><relatedItem type="host"><titleInfo><title>Angiology</title></titleInfo><genre type="journal">journal</genre><identifier type="ISSN">0003-3197</identifier><identifier type="eISSN"></identifier><identifier type="PublisherID">ANG</identifier><identifier type="PublisherID-hwp">spang</identifier><part><date>2008</date><detail type="volume"><caption>vol.</caption><number>59</number></detail><detail type="issue"><caption>no.</caption><number>1</number></detail><extent unit="pages"><start>77</start><end>83</end></extent></part></relatedItem><identifier type="istex">86DB79A1FA9CEE490115B8E0AEE15A163330C17A</identifier><identifier type="DOI">10.1177/0003319707308564</identifier><identifier type="ArticleID">10.1177_0003319707308564</identifier><recordInfo><recordContentSource>SAGE</recordContentSource></recordInfo></mods></metadata><serie></serie></istex></record>Pour manipuler ce document sous Unix (Dilib)
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