Oscar J. Manrique

A head‐to‐head comparison among donor site morbidity after vascularized lymph node transfer: Pearls and pitfalls of a 6‐year single center experience

Between 2010 and 2016, 110 patients with extremity lymphedema underwent vascularized lymph node (VLN) transfer: groin (G‐VLN = 20), supraclavicular (SC‐VLN = 54), and right gastroepiploic (RGE‐VLN = 36) open and laparoscopic approach. Herein, we discuss the pearls and pitfalls for VLN harvest and compare donor site morbidity and complications. Lymphatic leakage: G‐VLN (n = 1) and SC‐VLN (n = 1) and one hematoma: SC‐VLN were found. Laparoscopic harvest of the RGE‐VLN reduces donor site morbidity. However, surgeons experience is imperative to minimize donor site morbidity and complications. J. Surg. Oncol. 2017;115:37–42.

Double gastroepiploic vascularized lymph node tranfers to middle and distal limb for the treatment of lymphedema

Vascularized lymph node (VLN) transfer for lymphedema treatment has shown promising results. Optimal donor and recipient sites remain a matter of debate. We describe the technique and outcomes of a laparoscopically harvested extended gastroepiploic VLN flap with two levels of inset.

Comparison of long-term clinical outcomes among different vascularized lymph node transfers: 6-year experience of a single center's approach to the treatment of lymphedema.

This study evaluated the long‐term clinical outcomes among different vascularized lymph node transfers (VLNT) used at our institution.

Vascularized appendicular lymph node transfer for treatment of extremity lymphedema: A case report

Vascularized lymph node transfer has demonstrated promising results for the treatment of extremity lymphedema. In an attempt to find the ideal donor site, several vascularized lymph nodes have been described. Each has a common goal of decreasing morbidity and avoiding iatrogenic lymphedema while obtaining good clinical results. Herein, we present the preliminary clinical outcomes of an intra‐abdominal lymph node flap option based on the appendicular artery and vein used for the treatment of extremity lymphedema. A 62 year‐old woman with moderate lower extremity lymphedema, on chronic antibiotics because of recurrent infections and unsatisfactory outcomes after conservative treatment underwent a vascularized appendicular lymph node (VALN) transfer. At a follow‐up of 6 months, the reduction rate of the limb circumference was 17.4%, 15.1%, 12.0% and 9% above the knee, below the knee, above the ankle and foot respectively. In addition, no further episodes of infection or other complications were reported after VALN transfer. Postoperative lymphoscintigraphy demonstrated that the VALN flap was able to improve the lymphatic drainage of the affected limb. According to our findings, the use of VALN transfer minimizes donor‐site morbidity, avoids iatrogenic lymphedema and may provide a strong clearance of infection because of the strong immunologic properties of the appendiceal lymphatic tissue in selected patients. Despite these promising results, further research with larger number of patients and longer follow‐ up is needed.

Ileocecal vascularized lymph node transfer for the treatment of extremity lymphedema: A case report

Vascularized lymph node (VLN) transfer has been of high interest in the past decade for the treatment of lymphedema, since it has been shown to be effective in reducing limb volumes, decreasing infectious episodes and improving quality of life. Multiple donor sites have been described in the quest for the optimal one. Herein, we describe a novel lymph node flap option based on the ileocolic artery and vein. The ileocecal vascularized lymph node (IC‐VLN) flap was used in the management of a 33‐year‐old male patient with lower extremity lymphedema secondary to left inguinal trauma. The patient had previously underwent a pedicled omentum flap transposition with minimal improvement in limb size and persistent episodes of infection. At 15 month follow‐up, the IC‐VLN flap improved the lymphatic drainage in the affected limb with a mean limb circumference reduction rate of 26.3%. No donor site complications or further episodes of infection were noted. According to our findings, the IC‐VLN flap may be another option for VLN transfer in very selected cases. Nevertheless, larger series with a longer follow‐up are required to analyze the efficacy and long‐term results of this flap.

Laparoscopic harvest of ileocolon flap in pharyngoesophageal reconstruction.

Dear Sir, The ileocolon flap is a well-known technique used for pharyngoesophageal reconstruction (Perrone et al., 2013). The cecum and part of the ascending colon are used to reconstruct the esophagus, while a segment of the terminal ileum is connected to the trachea, shunting air from the main airway to the neo-esophagus and making it resonate (Lo Torto et al., in press). Traditionally, it is a major procedure requiring a laparotomy and usually a long postoperative hospitalization. The aim of this letter is to report the first laparoscopic harvest of ileocolon flap for pharyngoesophageal reconstruction. Pharyngolaryngectomy with immediate reconstruction using an ileocolon flap was planned for a 57-year-old patient presenting with hypopharyngeal cancer (Figure 1A). The flap harvest was performed laparoscopically through 4 trocars. The intestines were mobilized from the terminal ileum up to the transverse colon. After division of the ileocolic pedicle and the right branch of the middle colic artery, the umbilical port was enlarged to deliver the specimen (Figure 1B). The proximal and distal ends of the flap were divided and intestinal continuity was restored with a functionally end-to-end stapled ileocolonic anastomosis. The recipient vessels for revascularization of the flap were the thoracoacromial artery and cephalic vein, as no other suitable vessels were found in the neck. The flap was inset in an isoperistatltic fashion. The cecum was anastomosed to the pharyngeal stump superiorly, while the asccending colon was anastomosed to the upper end of thoracic esophagus inferiorly. The ileal segment of the flap was then used for voice reconstruction with anastomosis to the side of tracheal stump. The total operative time was six hours including the one hour spent for the laparoscopic harvest of the flap. The postoperative course was uneventful. The patient was discharged at one month after tolerating oral feeding. Voice rehabilitation was initiated at 2 months. No perioperative donor or recipient site complication was noted. While the free ileocolon flap provides simultaneous restoration of speech and swallowing function, the traditional open approach might be associated with high donor site morbidity (Karri et al., 2011). The laparoscopic harvest can be a promising alternative that can avoid a large abdominal wound with its associated potential complications and decrease pain and hospitalization time (Ding et al., 2013). This is very important in this patient group due to their short life expectancy (Beauvillain et al., 1997). Laparoscopic harvesting of ileocolon flap is expected to provide all the advantages of a minimally invasive

The retrograde transverse cervical artery as a recipient vessel for free tissue transfer in complex head and neck reconstruction with a vessel-depleted neck.

Reconstruction in a vessel‐depleted neck is challenging. The success rates can be markedly decreased because of unavailability of suitable recipient vessels. In order to obtain a reliable flow, recipient vessels away from the zone of fibrosis, radiation, or infection need to be explored. The aim of this report is to present our experience and clinical outcomes using the retrograde flow coming from the distal transverse cervical artery (TCA) as a source for arterial inflow for complex head and neck reconstruction in patients with a vessel‐depleted neck.

The split vein graft “splint” to avoid kinking and compression of the vascular pedicle

Dear Sirs, Kinking and compression of the vascular pedicle is one of the most common causes leading to compromise of the blood flow and eventual loss of a free flap (Cheung, Zhang, Bosch, Buncke, & Lineaweaver, 1996; Kim, Kim, & Kim, 2016; Williams, French, & Lalonde, 2004). Predisposing factors include anatomic areas prone to excessive movement, effect of gravity, redundant pedicle, and length mismatch between the artery and the vein. Veins and vein grafts are especially predisposed due to the intrinsic weakness of their walls and tendency to engorge and elongate after restoration of the blood flow. Strategical positioning, cushioning with fat pads, muscle or fascia, microsurgical fixation of the vessel wall are some of the commonly employed, but of questionable efficacy, strategies as they may themselves predispose to compression. Tissue sealants have also been used, but they come at an additional cost (Kim et al., in press). We have used split vein grafts as “splints” to flatten sharp curves along the pedicle and reinforce the resistance of the vessel to compression. An appropriate length of donor vein can be harvested solely for this purpose or a remnant of greater saphenous vein graft can be employed. In our experience, saphenous vein is ideal due to its wall thickness. However, any piece of redundant vessel with suitable thickness and dimensions could be adapted for this purpose. The vein is split longitudinally and wrapped as a cuff around the area prone to kinking. The cuff can envelop the “inner vessel” either partially or completely (Figure 1a). The two edges of the venous cuff are reapproximated with fine microvascular sutures while avoiding compression of the “inner vessel.”

Free Tissue Transfers for Head and Neck Reconstruction in Patients with End-Stage Renal Disease on Dialysis: Analysis of Outcomes Using the Taiwan National Health Insurance Research Database.

Background Patients diagnosed with end‐stage renal disease (ESRD) are increasing at around 5% annually. Some of these patients will require free tissue transfers to reconstruct their body after trauma or cancer resection. Comorbidities can increase the level of complexity during reconstruction. Aim Our goal is to describe the outcomes of ESRD patients under dialysis who underwent free tissue transfer for head and neck reconstruction. Methods Two cohorts were analyzed: ESRD group on dialysis and a non‐ESRD control group after free tissue transfer for head and neck reconstruction. Postoperative complications and mortality were recorded. For coexisting comorbidities, we determine the presence of diabetes mellitus (DM) and peripheral vascular disease (PVD). Results In this study, 85 cases with ESRD on dialysis and 841 controls were analyzed. Most patients were aged ≤ 65 years (82.5%) and nearly 92.9% of them were men. Types of head and neck cancer were neoplasm of other and unspecified parts of the mouth followed by neoplasm of tongue, the gingiva, hypopharynx, and floor of mouth. Patients with ESRD tended to have higher rates of DM and PVD (p < 0.001) and were significantly associated with an increased risk of stroke and increased risk of 30‐day mortality. However, there was no significant difference regarding flap failure among groups. Conclusion Despite greater preoperative risk factors, patients with renal failure on hemodialysis do not appear to have a higher rate of free flap failure following head and neck reconstruction. However, other complications can be minimized by optimizing patients medical condition to succeed with this reconstructive effort.

Re: Impact of the method and success of pharyngeal reconstruction on the outcome of treating laryngeal and hypopharyngeal cancers with pharyngolaryngectomy: A national analysis

Abstract Life expectancy is crucial to evaluate in patients that undergo pharyngolaryngectomy, in order to be able to choose the best reconstructive strategy for each case. Ileocolon free flap represents our preference when voice reconstruction is aimed, especially in patients with long life expectancy.