Publications

Although surgical and medical treatment options are available for the treatment of chronic lymphedema, there is no cure. Recent advances in microsurgery have provided an opportunity to perform immediate lymphatic reconstruction after lymphadenectomy for disease prevention. In this review, we provide the historical background leading to a paradigm shift in performing this procedure. We will also discuss the current evidence for immediate lymphatic reconstruction, potential oncologic procedures amenable to this approach, and detail ongoing challenges.

BACKGROUND: Over 72% of Americans use online health information to assist in health care decision-making. Previous studies of lymphedema literature have focused only on reading level of patient-oriented materials online. Findings indicate they are too advanced for most patients to comprehend. This, more comprehensive study, expands the previous analysis to include critical elements of health materials beyond readability using assessment tools to report on the complexity and density of data as well as text design, vocabulary, and organization.

METHODS: The top 10 highest ranked websites on lymphedema were identified using the most popular search engine (Google). Website content was analyzed for readability, complexity, and suitability using Simple Measure of Gobbledygook, PMOSE/iKIRSCH, and Suitability Assessment of Materials (SAM), respectively. PMOSE/iKIRSCH and SAM were performed by two independent raters. Fleiss' kappa score was calculated to ensure inter-rater reliability.

RESULTS: Online lymphedema literature had a reading grade level of 14.0 (SMOG). Overall complexity score was 6.7 (PMOSE/iKIRSCH) corresponding to "low" complexity and requiring a 8th-12th grade education. Fleiss' kappa score was 80% (P = 0.04, "substantial" agreement). Overall suitability score was 45% (SAM) correlating to the lowest level of "adequate" suitability. Fleiss' kappa score was 76% (P = 0.06, "substantial" agreement).

CONCLUSIONS: Online resources for lymphedema are above the recommended levels for readability and complexity. The suitability level is barely adequate for the intended audience. Overall, these materials are too sophisticated for the average American adult, whose literacy skills are well documented. Further efforts to revise these materials are needed to improve patient comprehension and understanding.

The Lymphatic Microsurgical Preventing Healing Approach (LYMPHA) procedure entails performing a lymphovenous bypass (LVB) at the time of axillary lymph node dissection to reduce lymphedema risk. The two most common fluorophores utilized in LVB are blue dye and indocyanine green. We developed a novel application of fluorescein isothiocyanate for intraoperative lymphatic mapping. Our goal is to demonstrate the safety and efficacy of fluorescein isothiocyanate for this application. We reviewed a prospectively collected database on breast cancer patients who underwent LYMPHA from March to September 2015. Fluorescein isothiocyanate was used to identify arm lymphatic channels after axillary lymph node dissection to perform an LVB between disrupted lymphatics and axillary vein tributaries. Data on preoperative and intraoperative variables were analyzed. Thirteen patients underwent LYMPHA with intraoperative fluorescein isothiocyanate lymphatic mapping from March to September 2015. Average patient age was 50 years with a mean body mass index of 28. On average, 3.4 lacerated lymphatic channels were identified at an average distance of 2.72 cm (range, 0.25-5 cm) caudal to the axillary vein. On average, 1.7 channels were bypassed per patient. Eleven anastomoses were performed to the accessory branch of the axillary vein and 1 to a lateral branch. In 1 patient, a bypass was not performed due to poor lymphatic caliber and inadequate length of the harvested vein tributary. No intraoperative adverse events were noted. Fluorescein isothiocyanate is a safe and effective method for intra-operative lymphatic mapping. Fluorescein isothiocyanate imaging allows for simultaneous dissection and lymphatic visualization, making it an ideal agent for lymphatic mapping and dissection in open surgical fields, such as in the LYMPHA procedure.