Publications by authors named "Ming-Huei Cheng"

242 Publications

Use of urinary hippuric acid and o-/p-/m-methyl hippuric acid to evaluate surgical smoke exposure in operating room healthcare personnel.

Ecotoxicol Environ Saf 2021 Jul 13;217:112231. Epub 2021 Apr 13.

Department of Respiratory Therapy, College of Medicine, Chang Gung University, Taoyuan, Taiwan; Department of Respiratory Care, Chang Gung University of Science and Technology, Chiayi, Taiwan; Department of Obstetrics and Gynaecology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan; Center for Environmental Sustainability and Human Health, Ming Chi University of Technology, Taishan, New Taipei, Taiwan. Electronic address:

Toluene and xylene are common components of surgical smoke, whereas hippuric acid (HA) and methylhippuric acid (MHA) are the products of toluene and xylene metabolism in humans, respectively. HA and MHA can be used as indicators to evaluate the exposure hazards of toluene and xylene. In this study, we used liquid chromatography tandem mass spectrometry (LC-MS/MS) to simultaneously analyze the HA, o-/m-/p-MHA, and creatinine contents in the urine of healthcare personnel. Concentrations of HA and o-/m-/p-MHAs were normalized to those of creatinine and used to analyze urine samples of 160 operating room (OR) healthcare personnel, including administrative staff, surgical nurses, nurse anesthetists, and surgeons. The results showed that the five analytes could be accurately separated and exhibited good linearity (r > 0.9992). The rate of recovery was between 86% and 106%, and the relative standard deviation was less than 5%. Urine from administrative staff presented the highest median concentration of hippuric acid (0.25 g/g creatinine); this was significantly higher than that found in the urine of surgeons (0.15 g/g). The concentrations of urinary o-/m-/p-MHAs in surgical nurses were higher than those in administrative staff, nurse anesthetists, and surgeons. Furthermore, the type, sex, and age of healthcare personnel were associated with changes in urine HA and o-/m-/p-MHA concentrations. Healthcare personnel should be aware of the risk of exposure to surgical smoke.
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http://dx.doi.org/10.1016/j.ecoenv.2021.112231DOI Listing
July 2021

Response to letter to the editor: Evidence of lymph flow amelioration on indocyanine green lymphography after vascularized lymph node transfer.

Authors:
Ming-Huei Cheng

J Surg Oncol 2021 Apr 7. Epub 2021 Apr 7.

Department of Plastic Surgery, Center of Lymphedema Microsurgery, Center of Tissue Engineering, Chang Gung Memorial Hospital, Taoyuan, Taiwan.

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http://dx.doi.org/10.1002/jso.26489DOI Listing
April 2021

Sources and components of volatile organic compounds in breast surgery operating rooms.

Ecotoxicol Environ Saf 2021 Feb 29;209:111855. Epub 2020 Dec 29.

Department of Respiratory Therapy, College of Medicine, Chang Gung University, Taoyuan, Taiwan; Department of Respiratory Care, Chang Gung University of Science and Technology, Chiayi, Taiwan; Department of Obstetrics and Gynaecology, Taipei Chang Gung Memorial Hospital, Taipei, Taiwan; Center for Environmental Sustainability and Human Health, Ming Chi University of Technology, Taishan, New Taipei, Taiwan. Electronic address:

Objectives: The composition and concentration distribution of volatile organic compounds (VOCs) in surgical smoke had seldomly been reported. This study aimed to investigate the profile of VOCs and their concentration in surgical smoke from breast surgery during electrocautery in different tissues, electrosurgical units, and electrocautery powers.

Methods: Thirty-eight surgical smoke samples from 23 patients performed breast surgery were collected using evacuated stainless steel canisters. The concentrations of 87 VOCs in surgical smoke samples were analyzed by gas chromatography-mass spectrometry. The human tissues, electrosurgical units, and electrocautery power were recorded.

Results: The median level of total VOCs concentrations in surgical smoke samples from mammary glands (total VOCs: 9953.5 ppb; benzene: 222.7 ppb; 1,3-butadiene: 856.2 ppb; vinyl chloride: 3.1 ppb) using conventional electrosurgical knives were significantly higher than that from other tissues (total VOCs: 365.7-4266.8 ppb, P < 0.05; benzene: 26.4-112 ppb, P < 0.05; 1,3-butadiene: 15.6-384 ppb, P < 0.05; vinyl chloride: 0.6-1.8 ppb, P < 0.05) using different electrosurgical units. A high methanol concentration was found in surgical smoke generated during breast surgery (641.4-4452.5 ppb) using different electrosurgical units. An electrocautery power of ≥ 27.5 watts used for skin tissues produced a higher VOCs concentration (2905.8 ppb).

Conclusions: The surgical smoke samples collected from mammary glands using conventional electrosurgical knives had high VOCs concentrations. The carcinogens (including benzene, 1,3-butadiene, and vinyl chloride) and methanol were found in the surgical smoke samples from different electrosurgical units. The type of electrosurgical unit and electrocautery power used affected VOCs concentrations in surgical smoke.
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http://dx.doi.org/10.1016/j.ecoenv.2020.111855DOI Listing
February 2021

Comparisons Between Normal Body Mass Index and Overweight Patients Who Underwent Unilateral Microsurgical Breast Reconstructions.

Ann Surg Oncol 2021 Jan 8;28(1):353-362. Epub 2020 Sep 8.

Center of Lymphedema Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, 5, Fu-Hsing Street, Kweishan, Taoyuan, 333, Taiwan, ROC.

Background: This study compared the outcomes of unilateral microsurgical breast reconstructions using abdomen-based flaps between normal body mass index (BMI; 18.5 < BMI < 24.9 kg/m) and overweight (25 < BMI < 29.9 kg/m) patients.

Methods: Between March 2000 and December 2015, patients who underwent unilateral breast reconstructions using abdomen-based flaps were retrospectively evaluated. Outcomes variables evaluated included the flap-used weight, flap-used/flap-harvested percentage, flap-used/specimen percentage, complication rates, revision procedures, and quality of life using the Breast-Q questionnaires.

Results: A total of 415 patients with a mean age of 45.3 ± 8.2 years underwent 418 abdomen-based flaps. The overall success rate was 98.8%, with 99.1% and 97.9% of patients included in the normal BMI and overweight groups, respectively (p = 0.36). The mean flap-used weight and flap-used/flap-harvested values of 461 ± 132.1 g and 82.2 ± 11.6%, respectively, in the normal BMI group were statistically different from values of 610 ± 148.9 g and 71.4 ± 14.1% in the overweight group (both p < 0.01). The mean flap-used/specimen percentage was 118.5 ± 32.9 and 111.7 ± 36.6 in the normal BMI and overweight groups, respectively (p = 0.26). At a mean follow-up of 135 ± 55.4 months, there were no statistical differences between the two groups in terms of total complication rates (25.7% vs. 29.2%; p = 0.30), revision times (36.1% vs. 36.5%; p = 0.91) and all four domains (all p > 0.05) of the Breast-Q.

Conclusions: Patients with a normal BMI required a smaller flap-used weight but higher flap-used/flap-harvested percentage for unilateral microsurgical breast reconstructions that could be performed with a high success rate and comparable complication and revision rates.
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http://dx.doi.org/10.1245/s10434-020-09076-3DOI Listing
January 2021

Morbidity of marginal mandibular nerve post vascularized submental lymph node flap transplantation.

J Surg Oncol 2020 Dec 31;122(8):1747-1754. Epub 2020 Aug 31.

Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan.

Background: This study investigated the morbidity of the marginal mandibular nerve (MMN) post vascularized submental lymph node (VSLN) harvest.

Methods: The VSLN with sacrifying or preserving the medial platysma was retrospectively classified as group I or II. Midline deviation and horizontal tilt were subjectively evaluated. Horizontal, vertical, and "area distribution" of the lower lip excursions of the surgical site were objectively compared with the nonsurgical site.

Results: Seventeen patients in group I and 12 patients in group II were included. At a median follow-up of 48.6 ± 16.8 months in group I and 14.8 ± 7.5 months in group II, no MMN palsy was found in both groups. Median midline deviation and horizontal tilt were 4.53 ± 0.52 and 5 ± 0 in group I and 4.67 ± 0.65 and 5 ± 0 in group II, respectively (P = .419 and 1.000). Median horizontal, vertical and area of distribution of lower lip excursions were 97.5 ± 12.3%, 98.8 ± 14.4% and 87.2 ± 14.7% in group I, and 99.3 ± 15.1%, 95.8 ± 8.2% and 84.2 ± 14.2% in group II, respectively (P = .679, .948 and .711).

Conclusion: The VSLN flap was a safe procedure with minimal MMN morbidity.
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http://dx.doi.org/10.1002/jso.26191DOI Listing
December 2020

Heparin-induced thrombocytopenia and thrombosis in a patient with Covid-19.

Thromb Res 2020 12 3;196:11-14. Epub 2020 Aug 3.

Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan; Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, United States of America. Electronic address:

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http://dx.doi.org/10.1016/j.thromres.2020.07.056DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7834633PMC
December 2020

Chylovenous bypass for mesenteric lymphangiomatosis: A case report.

J Surg Oncol 2020 Oct 15;122(5):1004-1005. Epub 2020 Jul 15.

Department of Plastic and Reconstructive Surgery, College of Medicine, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan.

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http://dx.doi.org/10.1002/jso.26126DOI Listing
October 2020

Lymphedema microsurgery improved outcomes of pediatric primary extremity lymphedema.

Microsurgery 2020 Oct 11;40(7):766-775. Epub 2020 Jul 11.

Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan.

Background: Primary lymphedema is an anomaly of the regional lymphatic system with long symptom duration or severe lymphatic obstruction. Few microsurgical treatments for primary lymphedema have been reported. This aim of this study was to investigate the outcomes of microsurgical treatments in pediatric primary lymphedema patients.

Methods: Between 2013 and 2017, pediatric primary lymphedema patients who underwent either lymphovenous anastomosis (LVA) or vascularized lymph node transfer (VLNT) were retrospectively reviewed. Cheng's Lymphedema Grading, Taiwan Lymphoscintigraphy Staging and indocyanine green lymphography were used to select the procedures. No compression garments were used postoperatively. Outcome measurements included circumferential difference, episodes of cellulitis, and Lymphedema-specific Quality of life questionnaire (LYMQoL).

Results: Nine patients with mean age of 9.2 years (range, 2-19 years) with 11 lower and two upper lymphedematous limbs underwent 11 VLNT and two LVA. All VLNT flaps survived. At a mean 38.4-months (range, 16-63 months) of follow-up, the mean circumferential difference in nine unilateral lymphedematous limbs was improved by 6.7 ± 9.9% (p = .066). Two patients with bilateral lower limb lymphedema had mean limb circumference improvements of 1.3 and 6.5 cm, respectively. In nine limbs with cellulitis preoperatively, episodes of cellulitis decreased by 2.67 times/year (p = .007). At a mean 22.3-months of follow-up (range, 13-24 months), the LYMQoL overall score in 6 patients older than 7 years was improved by 3.2 ± 1.1 points (p = .007).

Conclusions: Lymphedema microsurgery significantly improved the episodes of cellulitis and quality of life without utilizing compression garments in pediatric primary lymphedema patients.
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http://dx.doi.org/10.1002/micr.30622DOI Listing
October 2020

ASO Author Reflections: Simultaneous Ipsilateral Vascularized Lymph Node Transplantation and Contralateral Lymphovenous Anastomosis in Bilateral Different-Severities Extremity Lymphedema.

Authors:
Ming-Huei Cheng

Ann Surg Oncol 2020 Dec 10;27(13):5277-5278. Epub 2020 Jul 10.

Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan.

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http://dx.doi.org/10.1245/s10434-020-08810-1DOI Listing
December 2020

Continuous gentle aspiration device for safe operative field clearance in microsurgery.

Microsurgery 2020 09 12;40(6):721-722. Epub 2020 Jun 12.

Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan.

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http://dx.doi.org/10.1002/micr.30617DOI Listing
September 2020

Volumetric Differences in the Suprafascial and Subfascial Compartments of Patients with Secondary Unilateral Lower Limb Lymphedema.

Plast Reconstr Surg 2020 06;145(6):1528-1537

From the Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital; Institute for Radiological Research, Chang Gung University; the Section of Plastic Surgery, Department of Surgery, and the Morphomic Analysis Group, University of Michigan; and the Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University College of Medicine.

Background: The subfascial compartment (deep to the deep fascia) in extremity lymphedema has not been evaluated. This study investigated the volumetric differences between the suprafascial and subfascial compartments of patients with unilateral lower extremity lymphedema.

Methods: Thirty-two female patients with unilateral lower extremity lymphedema were enrolled, with eight patients in each of Cheng lymphedema grades I to IV. The volumes of the suprafascial and subfascial compartments were calculated after manually drawing the region of interest on computed tomographic images. The volumetric differences and their ratios in the suprafascial and subfascial compartments between each patient's bilateral limbs were compared.

Results: The volume of the lymphedematous limbs (9647 ml) was significantly greater than the volume of unaffected limbs (6906 ml), with a median volumetric difference of 2097 ml (30.6 percent) (p < 0.01). The median suprafascial compartment volumetric difference was 1887 ml (56.6 percent) and the subfascial compartment volumetric difference was 208 ml (4.7 percent) (p < 0.01). The median volumetric difference ratio of the thigh and lower leg was 24.6 percent and 40.6 percent, respectively. The median volumetric differences in Cheng lymphedema grades I to IV were 1012, 1787, 2434, and 4107 ml, respectively, which were statistically significant among the four Cheng lymphedema grades using the Kruskal-Wallis test (p < 0.01).

Conclusions: The volumetric differences in the lymphedematous limb were statistically significantly greater than in the unaffected limb, including both suprafascial and subfascial compartments. The volumetric differences are consistent with the Cheng lymphedema grading system as a reliable indicator of unilateral extremity lymphedema.

Clinical Question/level Of Evidence: Diagnostic, IV.
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http://dx.doi.org/10.1097/PRS.0000000000006844DOI Listing
June 2020

Making standardization in microsurgical education palatable.

J Surg Oncol 2020 Jun 8;121(8):1179-1180. Epub 2020 Apr 8.

Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan.

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http://dx.doi.org/10.1002/jso.25923DOI Listing
June 2020

Characterization of limb lymphedema using the statistical analysis of ultrasound backscattering.

Quant Imaging Med Surg 2020 Jan;10(1):48-56

Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan.

Background: Lymphedema is a disease in which tissue swelling is caused by interstitial fluid retention in subcutaneous tissue. It is caused by a compromised lymphatic system. Lymphoscintigraphy is the current and primary modality used to assess lymphatic system dysfunction. Ultrasound elastography is a complementary tool used for evaluating the tissue stiffness of the lymphedematous limb. Tissue stiffness implies the existence of changes in tissue microstructures. However, ultrasound features related to tissue microstructures are neglected in clinical assessments of lymphedematous limbs. In this study, we aimed to evaluate the lymphedematous diagnostic values of ultrasound Nakagami and entropy imaging, which are, respectively, model- and nonmodel-based backscattered statistical analysis methods for scatterer characterization.

Methods: A total of 60 patients were recruited, and lymphoscintigraphy was used to score the patient's clinical severity of each of their limb lymphedema (0: normal; 1: partial lymphatic obstruction; and 2: total lymphatic obstruction). We performed ultrasound examinations to acquire ultrasound backscattered signals for B-mode, Nakagami, and entropy imaging. The envelope amplitude, Nakagami, and entropy values, as a function of the patients' lymphatic obstruction grades, were expressed in terms of their median and interquartile range (IQR). The values were then used in both an independent test and a receiver operating characteristic (ROC) curve analysis.

Results: For each increase in a patient's score from 0 to 2, the envelope amplitude values were 405.44 (IQR: 238.72-488.17), 411.52 (IQR: 298.53-644.25), and 476.37 (IQR: 348.86-648.16), respectively. The Nakagami parameters were 0.16 (IQR: 0.14-0.22), 0.26 (IQR: 0.23-0.34), and 0.24 (IQR: 0.16-0.36), respectively, and the entropy values were 4.55 (IQR: 4.41-4.66), 4.86 (IQR: 4.78-4.99), and 4.87 (IQR: 4.81-4.97), respectively. The P values between the normal control and lymphedema groups obtained from B-mode and Nakagami analysis were larger than 0.05; whereas that of entropy imaging was smaller than 0.05. The areas under the ROC curve for B-mode, Nakagami, and entropy imaging were 0.64 (sensitivity: 70%; specificity: 47.5%), 0.75 (sensitivity: 70%; specificity: 75%), and 0.94 (sensitivity: 95%; specificity: 87.5%), respectively.

Conclusions: The current findings demonstrated the diagnostic values of ultrasound Nakagami and entropy imaging techniques. In particular, the use of non-model-based entropy imaging enables for improved performance when characterizing limb lymphedema.
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http://dx.doi.org/10.21037/qims.2019.10.12DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6960425PMC
January 2020

Staging and clinical correlations of lymphoscintigraphy for unilateral gynecological cancer-related lymphedema.

J Surg Oncol 2020 Mar 25;121(3):422-434. Epub 2019 Dec 25.

Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan.

Background: This study was to investigate the lymphoscintigraphy findings for the diagnosis and severity in unilateral gynecological cancer-related lymphedema (GCRL) and to correlate lymphoscintigraphy stages with the clinical findings.

Methods: Patients with unilateral GCRL who underwent lymphoscintigraphy were staged using the presence of ileo-inguinal lymph nodes, distal-lymphatic ducts, and dermal backflow findings. Taiwan Lymphoscintigraphy Staging (TLS) was divided into three patterns and seven stages: normal drainage (L-0); partial obstruction (P-1, P-2, and P-3); and total obstruction (T4, T-5, and T-6). Correlations between clinical lymphedema severity and TLS were evaluated using analysis of variance and multivariable linear regression analyses.

Results: A total of 141 patients with unilateral GCRL were divided as follows: 6 (4.3%) in normal drainage, 56 (39.7%) in partial-obstruction, and 79 (56%) in total obstruction. Cellulitis episodes, circumferential difference, and computed tomography (CT) volumetric difference were shown to be statistically different between TLS stages (P < .001 for all). Total obstruction stages were the most significant factors associated with the severity of circumferential difference (β = 19.72, 25.54, 32.42, respectively; P < .05) and CT volumetric difference (β = 36.04, 45.12, 52.78, respectively; P < .01).

Conclusions: Total lymphatic obstruction was present in 56% of unilateral GCGL. Lymphoscintigraphy stages were statistically correlated with episodes of cellulitis, circumferential difference and CT volumetric difference in unilateral GCRL.
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http://dx.doi.org/10.1002/jso.25817DOI Listing
March 2020

The versatile free medial sural artery perforator flap: An institutional experience for reconstruction of the head and neck, upper and lower extremities.

Microsurgery 2020 May 10;40(4):427-433. Epub 2019 Dec 10.

Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan.

Background: The medial sural artery perforator (MSAP) flap is an increasingly versatile and reliable flap for soft tissue reconstruction. This study investigates complication rates and long-term outcomes of the MSAP flap.

Methods: A retrospective review was performed on consecutive patients undergoing MSAP flap reconstruction at Chang Gung Memorial Hospital from 2006 through 2017. Patient demographics were assessed. Flap failure and wound complications were the outcome measures.

Results: In the cohort of 246 patients that underwent a total of 248 MSAP flap reconstructions were identified. The average age was 47.5 years (range 15-76). Of the 248 flaps, 170 were used for reconstruction of the head and neck, 48 for upper extremity reconstruction, and 30 for lower extremity reconstruction. The average MSAP flap size was 5.2 × 11.8 cm. 31 (12.5%) of the flaps developed arterial occlusion, venous insufficiency, or a hematoma postoperatively requiring re-exploration. Nineteen were successfully salvaged, yielding an overall failure rate of 4.8%. Minor complications included the need for flap debridement in 18 cases (7.3%) and need for donor site debridement in eight cases (3.2%).

Conclusions: The MSAP flap can be used in a versatile fashion to reconstruct defects of the head and neck, upper extremity, and lower extremity with minimal complication rates.
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http://dx.doi.org/10.1002/micr.30543DOI Listing
May 2020

Comparisons of Manual Tape Measurement and Morphomics Measurement of Patients with Upper Extremity Lymphedema.

Plast Reconstr Surg Glob Open 2019 Oct 29;7(10):e2431. Epub 2019 Oct 29.

Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich.

Background: Lymphedema is a debilitating condition characterized by swelling from lymph fluid exceeding transport capacity. A gold standard for arm measurement is not established, and measurement methods vary. This study evaluates the comparability of the tape measure and Analytic Morphomics in deriving limb circumference measurements in patients with upper extremity lymphedema.

Methods: Fifteen participants with diagnosed upper limb lymphedema were included between July 2013 and June 2017 at Chang Gung Memorial Hospital in Taipei, Taiwan. Affected and unaffected arm circumferences were measured using a flexible tape or morphomic measurement at 10 cm above and below the elbow. Computed tomography scans were standardized, processed, smoothed with a piecewise polynomial algorithm for Analytic Morphomics of arm circumference. Comparative plots, mean percent difference, and adjusted coefficient of determination () were utilized to compare the consistency of both measurement procedures.

Results: The tape measure and Analytic Morphomics demonstrated consistent measures of arm circumference. On the affected arm, the mean (95% CI) difference in arm circumference between methods was 1.60 cm (0.99-2.20) above, and 0.57 cm (0.23-0.91) below the elbow. Mean percent differences in circumference was 6.65% (SD 3.52%) above and 1.38% (SD 2.11%) below the elbow. The adjusted for both methods was 94% above and 96% below the elbow.

Conclusions: Analytic Morphomics showed strong consistency with the manual tape measure of arm circumference measurement in those with upper extremity lymphedema. Analytic Morphomics present an opportunity for a precise, granular measurement of limb composition for assessment of disease state and patient planning.
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http://dx.doi.org/10.1097/GOX.0000000000002431DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6846299PMC
October 2019

Laser Doppler Flowmetry to Differentiate Arterial From Venous Occlusion in Free Tissue Transfer.

Plast Surg (Oakv) 2019 Nov 19;27(4):297-304. Epub 2019 Sep 19.

Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Kweishan, Tao-Yuan.

Purpose: The differentiation of arterial versus venous occlusion in free tissue transfers has rarely been described. This study investigated changes in blood flow caused by arterial and venous occlusion and the potential for laser Doppler flowmetry to distinguish between these 2 conditions for better clinical assessment and management of free tissue transfer.

Methods: Six patients with a mean age of 43.5 years underwent microsurgical free tissue transfer. The venous and arterial blood flow of the vessels and skin flap were monitored using laser Doppler flowmetry with high-frequency pulsed Doppler transducers for vessels and skin before, during, and after clamping the vessels for 10 minutes.

Results: The average decreases in blood flow in the artery and vein caused by clamping were 94.4% and 93.8%, respectively. On average, arterial occlusion demonstrated a sudden drop of 67.7% and venous occlusion caused a decrease of 26.6% on laser Doppler flowmetry in free tissue skin.

Conclusion: Using a vessel-holding probe, laser Doppler flowmetry could be used to differentiate between arterial and venous occlusion in free tissue transfer, thereby aiding decision-making for better clinical management.
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http://dx.doi.org/10.1177/2292550319876666DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6851729PMC
November 2019

Institutionalization of reconstructive lymphedema surgery in Austria-Single center experience.

J Surg Oncol 2020 Jan 25;121(1):91-99. Epub 2019 Oct 25.

Department of Plastic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.

Background: Lymphedema surgery was not widely known in Austria before the introduction of lymphovenous anastomosis (LVA) and vascularized lymph node transfer (VLNT) in 2014. This study shares the experience and process of establishing and institutionalizing lymphedema surgery service in Austria.

Methods: The purpose of introducing reconstructive lymphedema surgery in Austria was to improve lymphedema patients' quality of life and provide them surgical therapy as an adjuvant treatment to complete decongestive therapy. To initialize reconstructive lymphedema surgery in Austria, LVA and VLNT had to be presented and introduced, in the manner of branding and advertizing a new product. Surgeries were performed with quality control by standardized documentation, pre- and postoperatively.

Results: Aligned with branding and marketing, presentations were given externally and internally to share knowledge and experience of lymphedema surgery. Lymphedema surgery service was introduced as a new brand in the medical service in Austria. After several communications with the Austrian Health Insurance Fund and with the final application, LVA and VLNT were listed as novel surgical therapies in its 2020 reimbursement catalog. Since 2014, more than 300 lymphedema patients were consulted, and 102 reconstructive lymphedema surgeries were performed. Circumference reduction of extremities after surgery was between 20% and 43%, postoperatively.

Conclusion: Acceptance of surgery in lymphedema patients varies among continents, hospitals, and surgeons. Evaluation of the requirement of the surgical setup and insurance conditions for lymphedema surgery is essential to establish lymphedema surgery, providing targeted marketing and branding to spread knowledge of the novel technique and grant patients access to therapeutic treatment of their chronic disease.
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http://dx.doi.org/10.1002/jso.25740DOI Listing
January 2020

Efficacy validation of a lymphatic drainage device for lymphedema drainage in a rat model.

J Surg Oncol 2019 Dec 25;120(7):1162-1168. Epub 2019 Sep 25.

Institute of Mechatronic Engineering, National Taipei University of Technology, Taipei, Taiwan.

Background: Vascularized lymph node transfer (VLNT) is an effective surgery for extremity lymphedema. This study evaluated a lymphatic drainage device (LDD) for the drainage of accumulated fluid into the venous system.

Methods: Micropore filtering membranes with pore sizes of 5, 0.65, and 0.22 μm polyvinylidene difluoride, and 0.8 μm Nylon Net Filter were evaluated to determine the in vitro efficiency of drainage flow of an LDD. The two superior membranes were further used for the evaluation of the inflow and outflow of the LDD in vivo using 5% albumin.

Results: At 5 minutes, the volumes drained with 5, 0.65, and 0.22 μm polyvinylidene difluoride and 0.8 μm nylon membranes were 15.2, 2.77, 2.37, and 0.59 mL, respectively (P < .01). At 10 minutes, the collected volumes of 5 and 0.65 μm polyvinylidene difluoride were 1788 and 1051 μL (P = .3). The indocyanine green fluorescence was detected at 50 seconds for the 5 μm polyvinylidene difluoride membrane but not for the 0.65 μm membrane.

Conclusions: The study successfully demonstrated the proof-of-concept of the LDD prototype that mimicked VLNT with drainage of 5% albumin into the venous system in a rat model.
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http://dx.doi.org/10.1002/jso.25707DOI Listing
December 2019

Non-contrast-enhanced magnetic resonance angiography of facial arteries for pre-operative evaluation of vascularized submental lymph node flaps.

BMC Med Imaging 2019 08 16;19(1):68. Epub 2019 Aug 16.

Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan; No. 5 Fuxing St., Guishan Dist, Taoyuan City, Taiwan.

Background: The aim of this study was to compare non-contrast-enhanced 3D phase contrast magnetic resonance angiography (3D PC-MRA) and conventional intravenous administration of contrast media, i.e., contrast-enhanced MRA (CE-MRA), to evaluate the courses of facial arteries for the preparation of vascularized submental lymph node flap (VSLN flap) transfer.

Methods: The head and neck regions of 20 patients with limb lymphedema were imaged using a 3 T MRI scanner. To improve the evaluation of facial artery courses, MRA was fused with anatomical structures generated by high-resolution T1-weighted imaging. The diagnostic and image qualities of facial arteries for VSLN flap planning were independently rated by two radiologists. Interobserver agreement was evaluated using Cohen's kappa. Differences between 3D PC-MRA and CE-MRA in terms of the diagnostic quality of facial arteries were evaluated using McNemar's test.

Results: Cohen's kappa indicated fair to good interobserver agreement for the diagnostic and image qualities of the bilateral facial arteries. No significant difference in terms of the diagnostic quality of the left and right facial arteries between 3D PC-MRA and CE-MRA, respectively, was identified.

Conclusions: Non-contrast 3D PC-MRA is a reliable method for the evaluation of facial artery courses prior to VSLN flap transfer and could serve as an alternative to CE-MRA for patients with renal insufficiency or severe adverse reactions to contrast media.
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http://dx.doi.org/10.1186/s12880-019-0368-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6698015PMC
August 2019

Comparison of Outcomes between Side-to-End and End-to-End Lymphovenous Anastomoses for Early-Grade Extremity Lymphedema.

Plast Reconstr Surg 2019 08;144(2):486-496

From the Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University, College of Medicine.

Background: Lymphovenous anastomosis is technically challenging and can be successfully performed with an advanced operating microscope, supermicrosurgical instruments, and indocyanine green lymphography. This study compared the outcomes between side-to-end and end-to-end lymphovenous anastomosis configurations for unilateral extremity lymphedema.

Methods: Between April of 2013 and June of 2017, lymphovenous anastomosis was indicated for 58 patients who preoperatively had patent lymphatic ducts by indocyanine green lymphography, including 20 patients with upper limb lymphedema and 38 patients with lower limb lymphedema. Either an end-to-end or a side-to-end lymphovenous anastomosis was used to anastomose the subdermal venule to the lymphatic duct. The circumferential difference and episodes of cellulitis were used as outcome measurements.

Results: Twenty-three patients underwent an end-to-end lymphovenous anastomosis and 35 patients underwent side-to-end lymphovenous anastomosis. All patients had an immediate patency evaluated by indocyanine green lymphography and patent blue assessments. All patients returned to their daily routine without the use of any compression garments. At an average follow-up of 16.5 months (range, 13.4 to 19.6 months), the improvement of circumferential difference (3.2 percent; range, 1.8 to 4.6 percent) in the side-to-end group was statistically greater than that in the end-to-end group (2.2 percent; range, 1 to 3.4 percent; p = 0.04). The overall episodes of cellulitis were significantly reduced from 1.7 times/year (range, 1.3 to 2.1 times/year) to 0.7 times/year (range, 0.3 to 1.1 times/year; p < 0.001), but no difference was observed between the two groups.

Conclusions: Both side-to-end and end-to-end lymphovenous anastomosis configurations were effective surgical approaches for improving early-grade extremity lymphedema. Side-to-end lymphovenous anastomosis has the advantages of having greater efficacy for lymph drainage, requiring only one anastomosis and eliminating the need to use compression garments.

Clinical Question/level Of Evidence: Therapeutic, III.
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http://dx.doi.org/10.1097/PRS.0000000000005870DOI Listing
August 2019

Summary of hands-on supermicrosurgery course and live surgeries at 8th world symposium for lymphedema surgery.

J Surg Oncol 2020 Jan 16;121(1):8-19. Epub 2019 Jul 16.

Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan.

The hands-on supermicrosurgery course provided participants a valuable learning experience of in-depth practices of supermicrosurgical skills with experts. Seven live surgeries were successfully demonstrated at 8th World Symposium for Lymphedema Surgery. Variable donor sites for vascularized lymph node transfer were the submental, supraclavicular, groin, and omental; while the recipient sites included the wrist and axilla in upper limb; and popliteal and groin in the lower limb. The therapeutic and preventive lymphovenous anastomosis was also satisfactorily performed.
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http://dx.doi.org/10.1002/jso.25619DOI Listing
January 2020

Introduction of the 8th world symposium for lymphedema surgery.

J Surg Oncol 2020 01 9;121(1). Epub 2019 Jul 9.

International Center for Lymphedema, Hiroshima University Hospital, Hiroshima, Japan.

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http://dx.doi.org/10.1002/jso.25620DOI Listing
January 2020

Delayed primary retention suture for inset of vascularized submental lymph node flap for lower extremity lymphedema.

J Surg Oncol 2020 Jan 5;121(1):138-143. Epub 2019 Jul 5.

Department of Plastic and Reconstrucitve Surgery, Chang Gung Memorial Hospital, Taipei, Taiwan.

Background: Vascularized lymph node transfer (VLNT) has become one of the effective surgical treatments for extremity lymphedema. This study was to evaluate the re-exploration and total complication rates of VLNT for lower extremity lymphedema between two different flap inset techniques.

Methods: Sixty-nine patients who underwent 74 submental VLNT transfers between 2008 and 2018 were retrospectively studied. Fifty-six flaps were inset using a new delayed primary retention suture (DPRS) technique and other 18 flaps using conventional interrupted sutures as the non-DPRS group.

Results: The overall flap success rate was 100%. The DPRS group was released at a mean of 1.7  ± 0.7 times and took a mean of 10.3 ± 3.3 days for wound closure. There were no statistical differences in demographics, mean symptom duration, and mean Cheng's Lymphedema Grading between two groups. Mean frequency of cellulitis of 2.5 ± 1.5 times/year in non-DPRS group was significantly greater than 1.4 ± 1.6 times/year in DPRS group (P = .01). The re-exploration and total complication rates were 5.4% and 7.1% in DPRS group, and 27.8% and 33.3% in non-DPRS group, respectively (P = .02 and .02, respectively).

Conclusions: The DPRS technique is a safe, simple, and reliable method for insetting the submental VLNT, which statistically decreased the re-exploration and total complication rates.
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http://dx.doi.org/10.1002/jso.25520DOI Listing
January 2020

Intra-abdominal chylovenous bypass treats retroperitoneal lymphangiomatosis.

J Surg Oncol 2020 Jan 4;121(1):75-84. Epub 2019 Jul 4.

Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan.

Background: Retroperitoneal lymphangiomatosis (RL) is a rare form of primary lymphedema featuring aberrant retroperitoneal lymphatic proliferation. It causes recurrent cellulitis, repeated interventions, and poor life quality. This study aimed to investigate proper diagnositc criteria and surgical outcomes for RL with extremity lymphedema.

Methods: Between 2012 and 2018, 44 primary lower-extremity lymphedema cases received lymphoscintigraphy, magnetic resonance imaging, and single-photon electron computed tomography to detect RL. RL patients underwent vascularized lymph node transfers (VLNT) for extremity lymphedema and intra-abdominal side-to-end chylovenous bypasses (CVB) for chylous ascites. Complications, CVB patency, and quality of life were evaluated postoperatively.

Results: Six RL patients (mean age of 30.3 years) had chylous ascites with five had lower-extremity lymphedema. All CVBs remained patent, though one required re-anastomosis, giving a 100% patency rate. Four unilateral and one bilateral extremity lymphedema underwent six VLNTs with 100% flap survival. Patients reported improved quality of life (P = 0.023), decreased cellulitis incidence (P = 0.041), and improved mean lymphedema circumference (P = 0.043). All patients resumed a normal diet and activity.

Conclusions: Evaluating primary lower-extremity lymphedema patients with MRI and SPECT could reveal a 13.6% prevalence of RL and guide treatment of refractory extremity lymphedema. Intra-abdominal CVB with VLNT effectively treated RL with chylous ascites and extremity lymphedema.
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http://dx.doi.org/10.1002/jso.25514DOI Listing
January 2020

Clinical features, microbiological epidemiology and recommendations for management of cellulitis in extremity lymphedema.

J Surg Oncol 2020 Jan 2;121(1):25-36. Epub 2019 Jul 2.

Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan.

Background: This high volume, single center study investigated the prevalence, bacterial epidemiology, and responsiveness to antibiotic therapy of cellulitis in extremity lymphedema.

Methods: From 2003 to 2018, cellulitis events from a cohort of 420 patients with extremity lymphedema were reviewed. Demographics, lymphedema grading, symptoms, inflammatory markers, cultures and antibiotic therapy regimens were compiled from cellulitis episodes data. Univariate and multivariate analyses were performed for detailed analysis.

Results: A total of 131 separate episodes of cellulitis were recorded from 43 (81.1%) lower limb and 10 (19.9%) upper limb lymphedema patients. The prevalence and recurrence rates for cellulitis in lymphedema patients were 12.6% (53 of 420) and 56.6% (30 of 53), respectively. The most common findings were increased limb circumference (127 of 131; 96.9%) and abnormal C-reactive protein (CRP) level (86 of 113; 76.1%). Blood cultures were obtained in 79 (60.3%) incidents, with 9 (11.4%) returning positive. Streptococcus agalactiae was the most isolated bacterium (5 of 9; 55.5%).

Conclusions: The cellulitis prevalence and recurrence rate in extremity lymphedema were 12.6%, and 56.6%, respectively. Strongest indicators of cellulitis were increased affected limb circumference and elevated CRP level. Empiric antibiotic therapy began with coverage for Steptococcus species before broadening to anti-Methicillin-resistant Staphylococcus aureus and anti-Gram negatives if needed for effective treatment of extremity lymphedema cellulitis.
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http://dx.doi.org/10.1002/jso.25525DOI Listing
January 2020

Long-term outcome of lower extremity lymphedema treated with vascularized lymph node flap transfer with or without venous complications.

J Surg Oncol 2020 Jan 27;121(1):129-137. Epub 2019 Jun 27.

Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University and Medical College, Taoyuan, Taiwan.

Background: Vascularized submental lymph node (VSLN) transfer is an emerging approach for extremity lymphedema. This study investigated the long-term outcome and venous complications of VSLN for unilateral lower extremity lymphedema.

Methods: Between 2010 and 2018, patients who underwent VSLN for unilateral lower extremity lymphedema were retrospectively evaluated. Patient demographics, operative records, complications, circumferential improvement, and episodes of cellulitis were analyzed. Further comparisons were performed between different types, numbers, and techniques of venous anastomoses.

Results: A total of 75 VSLNs in 70 patients survived, giving a 100% success rate. Six flaps (8%) had venous complications (VC group) and 69 flaps (92%) did not (No-VC group). There were no statistical differences in types, numbers, and techniques of anastomoses between two groups (P = .65, 1, and .56, respectively). At a mean follow-up of 32.0 ± 23.0 months, mean circumferential improvement and episodes of cellulitis between two groups did not statistically differ significantly (P = .31 and .09, respectively).

Conclusions: VSLN is an effective treatment for lower extremity lymphedema. The types, numbers of veins, and techniques of venous anastomoses did not statistically affect the venous complication rates. Functional outcomes of the VSLNs were not compromised if venous complications were salvaged promptly.
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http://dx.doi.org/10.1002/jso.25602DOI Listing
January 2020

Lymphoscintigraphy for the diagnosis of extremity lymphedema: Current controversies regarding protocol, interpretation, and clinical application.

J Surg Oncol 2020 Jan 18;121(1):37-47. Epub 2019 Jun 18.

Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, College of Medicine, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan.

Appropriate diagnosis, staging and a further selection of the best treatment are fundamental for the management of patients with extremity lymphedema. Several clinical and imaging tools have been described for these purposes. Lymphoscintigraphy is still considered the gold standard imaging modality for diagnosing lymphedema. However, protocol variability and poor image resolution can make the interpretation challenging. Here, we reviewed technical aspects of lymphoscintigraphy, interpretation of the lymphoscintigraphy findings, staging, and its clinical application.
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http://dx.doi.org/10.1002/jso.25526DOI Listing
January 2020

Factors associated with professional healthcare advice seeking in breast cancer-related lymphedema.

J Surg Oncol 2020 Jan 18;121(1):67-74. Epub 2019 Jun 18.

Department of Plastic and Reconstructive Surgery, College of Medicine, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan.

Objectives: This study aimed to identify the cognitive factors associated with the professional healthcare advice (PHCA) seeking behavior in breast cancer-related lymphedema (BCRL).

Methods: From January 2018 to December 2018, patients with BCRL were prospectively enrolled for a cross-sectional survey of lymphedema-related perceived risks, lymphedema quality of life (LYMQoL), knowledge scale of lymphedema, and PHCA behavior at first clinical visit, 3 and 6 months postbaseline.

Results: A total of 180 patients including 100 (55.6%) patients underwent a vascularized lymph node transfer (VLNT) and 80 (44.4%) patients received compressive decongestive therapy (CDT) were enrolled. At 6 months of follow-up, mean episodes of cellulitis (from 2.2 to 0.2 times/year), mean circumferential difference (7.8 ± 3.9%), wearing compression garments (from 29% to 0 %) in the VLNT group were statistically reduced than those in the CDT group (p = .01, <.01, and <.01, respectively). The overall LYMQoL had statistical improvement in VLNT group (p < .01). The short symptom duration, greater education level, less episodes of cellulitis, and higher knowledge of lymphedema were associated with increased adherence to PHCA (p = .03, .03, .02, and .01, respectively).

Conclusion: BCRL patients who sought PHCA had great control of lymphedema and improve their quality of life.
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http://dx.doi.org/10.1002/jso.25523DOI Listing
January 2020

Lymphedema microsurgery reduces the rate of implant removal for patients who have pre-existing lymphedema and total knee arthroplasty for knee osteoarthritis.

J Surg Oncol 2020 Jan 13;121(1):57-66. Epub 2019 Jun 13.

Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan.

Introduction: Patients with pre-existing lymphedema who undergo total knee arthroplasty (TKA) for osteoarthritis (OA) are at high risk for periprosthetic joint infection. This complication usually requires removal of the implant. This study aimed to investigate whether surgical treatment of lymphedema reduces the rate of prosthesis removal in such patients.

Materials And Methods: We retrospectively reviewed our prospective database of patient information collected between January 2009 and December 2018. A total of 348 cases of lower extremity lymphedema were reviewed, and those who underwent total knee TKA for OA of the knee were included. Patient demographics, clinical data, lymphedema surgical history, and TKA surgical history including any episodes of removal were collected and analyzed.

Results: There were nine of 15 lymphedema patients with knee OA who subsequently underwent TKA. The mean patient age was 70.4 ± 7.1 years. A total of 18 TKAs were performed in nine patients. The knee prosthesis removal rate was 66.7% (12/18). The prosthesis removal rate was 40% (2/5) in patients who underwent lymphedema microsurgery vs 76.9% (10/13) for those who did not (P = .03).

Conclusions: Pre-existing lymphedema is associated with a high rate of knee prosthesis removal. Lymphedema microsurgery reduced the removal rate of knee prostheses. We recommend that lymphedema microsurgery be considered for patients who require TKA as a treatment for of the knee.
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http://dx.doi.org/10.1002/jso.25517DOI Listing
January 2020