Krzesniak Natalia Ewa, Zaleska Marzanna, Mohos Balazs, Czedik-Eysenberg Manon, Krammel Michaela, Tzou Chieh-Han John
Department of Plastic and Reconstructive Surgery, Centre of Postgraduate Medical Education, Prof. W. Orlowski Memorial Hospital, Warsaw, Poland.
Department of Applied Physiology, Medical Research Institute, Polish Academy of Sciences, Warsaw, Poland.
Microsurgery. 2025 Jan;45(1):e70015. doi: 10.1002/micr.70015.
The Charles procedure (CP) is a potentially devastating treatment; however, in cases of an end stage of untreated or improperly treated lymphedema, it is the ultimate surgical therapy. As a life-saving solution, it quickly relieves patients with giant, hypertrophic extremities, mostly in ambulation and hygiene maintenance. Nevertheless, long-term results may disappoint both doctors and patients, who struggle with social stigma, the need for lifelong compression, massive lymphoedema in the distal parts of the feet, badly fitting shoes, excessive skin fibrosis, severe keratinization of skin-grafted surfaces, periodic lymphorrhea from the resected areas, or acute and chronic inflammation. For these reasons, patients may seek further surgical help, even many years after treatment. This article describes findings in fluorescent lymphography with indocyanine green (ICG-L) in four patients (49, 56, 56 years old females and 35 years old males) after CP and outcomes of treatment with lymphaticovenous anastomosis (LVA). In all patients, nonresected areas of the dorsum of the feet showed massive lymphedema stage II to III with dermal backflow (DB). In two patients, resected and skin-grafted areas showed deep subfascial lymphatics with lazy flow and no DB. In the remaining two cases, resected areas showed massive DB. Patients were reluctant to undergo further extensive surgical treatment with lymph node transfers due to the trauma experienced after CP. Since they still struggle with residual lower extremity lymphedema in unresected areas of the lower limbs, we performed minimally invasive, physiologic LVA surgeries in their feet, and in one patient in proximal thighs. In all cases, the postoperative course was uneventful. The treatment brought relief, reducing the circumference of the feet by ~2 cm, and allowed the return to previously used shoes in a follow-up of 18-36 months. This is the first report of ICG-L findings in CP patients, who benefit from minimal invasive LVA surgery. This information might help improve the life quality of patients after CP.
查尔斯手术（CP）是一种具有潜在破坏性的治疗方法；然而，对于未经治疗或治疗不当的晚期淋巴水肿病例，它是最终的手术治疗手段。作为一种挽救生命的解决方案，它能迅速缓解患有巨大、肥厚肢体的患者的症状，主要体现在行走和日常卫生维护方面。尽管如此，长期效果可能会让医生和患者都感到失望，他们要面对社会歧视、终身需要加压治疗、足部远端大量淋巴水肿、鞋子不合脚、皮肤过度纤维化、植皮表面严重角化、切除部位周期性淋巴溢液，或急性和慢性炎症。出于这些原因，患者甚至在治疗多年后可能仍会寻求进一步的手术帮助。本文描述了4例患者（49岁、56岁、56岁女性和35岁男性）在接受CP治疗后进行吲哚菁绿荧光淋巴造影（ICG-L）的结果以及淋巴静脉吻合术（LVA）的治疗效果。在所有患者中，足部背侧未切除区域显示为伴有真皮回流（DB）的II至III期大量淋巴水肿。在2例患者中，切除和植皮区域显示深筋膜下淋巴管血流缓慢且无DB。在其余2例中，切除区域显示大量DB。由于CP治疗后经历的创伤，患者不愿接受进一步的广泛淋巴结转移手术。由于他们仍在为下肢未切除区域残留的下肢淋巴水肿而苦恼，我们在他们的足部以及1例患者的大腿近端进行了微创生理性LVA手术。在所有病例中，术后过程均顺利。该治疗带来了缓解效果，使足部周长减少了约2厘米，并在18至36个月的随访中使患者能够重新穿上之前的鞋子。这是关于CP患者ICG-L检查结果的首份报告，这些患者从微创LVA手术中受益。这些信息可能有助于改善CP患者术后的生活质量。
