{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,21]],"date-time":"2026-09-21T16:57:22Z","timestamp":1790009842112,"version":"4.0.1"},"reference-count":36,"publisher":"Wiley","issue":"4","license":[{"start":{"date-parts":[[2019,1,6]],"date-time":"2019-01-06T00:00:00Z","timestamp":1546732800000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Journal of Surgical Oncology"],"published-print":{"date-parts":[[2019,3]]},"abstract":"<jats:sec><jats:title>Background<\/jats:title><jats:p>End\u2010stage lower extremity lymphedema (LEL) poses a particularly formidable challenge to surgeons as multiple pathological processes are at work. Because single modality treatment is often unsuccessful, we devised a comprehensive multimodal surgical treatment. The aim of this study is to share the technical considerations and examine the clinical outcomes of this combined approach.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>Between 2013 and 2017, patients with International Society of Lymphology stage III, who underwent the combination treatment of Charles,\u2019 Homan\u2019s procedure with toe management and vascularized lymph node transfer (CHAHOVA), were included in this retrospective study. Outcomes evaluated were limb size, number of infectious episodes, compression garment usage, and rate of complications.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>A total of 68 patients were included. With a mean follow\u2010up of 29 months, the overall circumference reduction rate for the upper thigh and the rest of the extremity was 67.4% (48.2\u201088.2%) and 98.1% (88\u2010100%), respectively. During the follow\u2010ups, 2 (2.9%) patients experienced episodes of cellulitis and the average number of yearly infections decreased from 4.2 to 1.2 episodes per person. All patients were able to discontinue compression therapy without recurrence of lymphedema. Nine (13.2%) patients reported minor complications.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusion<\/jats:title><jats:p>The combine CHAHOVA in a single\u2010stage procedure is an effective and safe approach in the end\u2010stage LEL.<\/jats:p><\/jats:sec>","DOI":"10.1002\/jso.25356","type":"journal-article","created":{"date-parts":[[2019,1,7]],"date-time":"2019-01-07T03:06:52Z","timestamp":1546830412000},"page":"430-438","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":32,"title":["Comprehensive multimodal surgical treatment of end\u2010stage lower extremity lymphedema with toe management: The combined Charles,\u2019 Homan\u2019s, and vascularized lymph node transfer (CHAHOVA) procedures"],"prefix":"10.1002","volume":"119","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-4646-2676","authenticated-orcid":false,"given":"Pedro","family":"Ciudad","sequence":"first","affiliation":[{"name":"Department of Plastic and Burn Surgery Arzobispo Loayza National Hospital Lima Peru"},{"name":"Department of Plastic and Reconstructive Surgery National Cancer Institute of Peru (INEN) Lima Peru"},{"name":"Department of Plastic and Reconstructive Surgery China Medical University Hospital Taichung Taiwan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0242-0941","authenticated-orcid":false,"given":"Mouchammed","family":"Agko","sequence":"additional","affiliation":[{"name":"Section of Plastic Surgery Medical College of Georgia, Augusta University Augusta Georgia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tony C. T.","family":"Huang","sequence":"additional","affiliation":[{"name":"Department of Plastic and Reconstructive Surgery Mayo Clinic Rochester Minnesota"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Oscar J","family":"Manrique","sequence":"additional","affiliation":[{"name":"Department of Plastic and Reconstructive Surgery Mayo Clinic Rochester Minnesota"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Wei\u2010Ling","family":"Chang","sequence":"additional","affiliation":[{"name":"Department of Plastic and Reconstructive Surgery China Medical University Hospital Taichung Taiwan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0809-5572","authenticated-orcid":false,"given":"Fabio","family":"Nicoli","sequence":"additional","affiliation":[{"name":"Department of Plastic and Reconstructive Surgery China Medical University Hospital Taichung Taiwan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michele","family":"Maruccia","sequence":"additional","affiliation":[{"name":"Department of Plastic and Reconstructive Surgery China Medical University Hospital Taichung Taiwan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Federico","family":"Lo Torto","sequence":"additional","affiliation":[{"name":"Department of Plastic and Reconstructive Surgery National Cancer Institute of Peru (INEN) Lima Peru"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hung\u2010Chi","family":"Chen","sequence":"additional","affiliation":[{"name":"Department of Plastic and Reconstructive Surgery China Medical University Hospital Taichung Taiwan"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2019,1,6]]},"reference":[{"key":"e_1_2_8_1_2_1","doi-asserted-by":"publisher","DOI":"10.1177\/1358863X10364553"},{"key":"e_1_2_8_1_3_1","doi-asserted-by":"publisher","DOI":"10.1186\/s12885-017-3444-9"},{"key":"e_1_2_8_1_4_1","doi-asserted-by":"publisher","DOI":"10.1097\/SLA.0000000000000763"},{"key":"e_1_2_8_1_5_1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1475-097X.2010.00969.x"},{"key":"e_1_2_8_1_6_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.mvr.2006.05.009"},{"key":"e_1_2_8_1_7_1","doi-asserted-by":"publisher","DOI":"10.1097\/PRS.0000000000003218"},{"key":"e_1_2_8_1_8_1","doi-asserted-by":"publisher","DOI":"10.1002\/jso.24969"},{"key":"e_1_2_8_1_9_1","doi-asserted-by":"publisher","DOI":"10.1007\/s10103-015-1736-3"},{"issue":"1","key":"e_1_2_8_1_10_1","first-page":"1","article-title":"Consensus document of the international society of lymphology","volume":"46","author":"International Society of Lymphology. The diagnosis and treatment of peripheral lymphedema: 2013","year":"2013","journal-title":"Lymphology"},{"key":"e_1_2_8_1_11_1","doi-asserted-by":"publisher","DOI":"10.1002\/micr.22235"},{"key":"e_1_2_8_1_12_1","first-page":"23","article-title":"Immune cells in peripheral lymph and skin of patients with obstructive lymphedema","volume":"23","author":"Olszewski WL","year":"1990","journal-title":"Lymphology"},{"key":"e_1_2_8_1_13_1","doi-asserted-by":"publisher","DOI":"10.1001\/archsurg.1979.01370250084018"},{"key":"e_1_2_8_1_14_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jamcollsurg.2012.03.020"},{"key":"e_1_2_8_1_15_1","doi-asserted-by":"publisher","DOI":"10.1002\/jso.24730"},{"key":"e_1_2_8_1_16_1","doi-asserted-by":"publisher","DOI":"10.1002\/micr.30168"},{"key":"e_1_2_8_1_17_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.bjps.2017.08.011"},{"key":"e_1_2_8_1_18_1","doi-asserted-by":"publisher","DOI":"10.1097\/PRS.0b013e3182450b2d"},{"key":"e_1_2_8_1_19_1","doi-asserted-by":"publisher","DOI":"10.1089\/lrb.2013.1132"},{"key":"e_1_2_8_1_20_1","doi-asserted-by":"publisher","DOI":"10.4269\/ajtmh.1997.57.7"},{"key":"e_1_2_8_1_21_1","doi-asserted-by":"publisher","DOI":"10.1097\/PRS.0b013e3182a4d626"},{"key":"e_1_2_8_1_22_1","doi-asserted-by":"publisher","DOI":"10.1097\/SAP.0000000000000513"},{"key":"e_1_2_8_1_23_1","first-page":"504","article-title":"Elephantiasis scroti","volume":"3","author":"Charles RHH","year":"1912","journal-title":"A Syst Treat"},{"key":"e_1_2_8_1_24_1","doi-asserted-by":"publisher","DOI":"10.3109\/02844319709085480"},{"key":"e_1_2_8_1_25_1","doi-asserted-by":"publisher","DOI":"10.1097\/00006534-199810000-00022"},{"key":"e_1_2_8_1_26_1","doi-asserted-by":"publisher","DOI":"10.1056\/NEJM193612102152401"},{"key":"e_1_2_8_1_27_1","first-page":"389","article-title":"Supplemental surgical treatment to end stage (stage IV\u2010V) of chronic lymphedema","volume":"27","author":"Lee BB","year":"2008","journal-title":"Int Angiol"},{"key":"e_1_2_8_1_28_1","doi-asserted-by":"publisher","DOI":"10.1097\/SAP.0b013e3181d6e45e"},{"key":"e_1_2_8_1_29_1","doi-asserted-by":"publisher","DOI":"10.1016\/0002-9610(80)90276-7"},{"key":"e_1_2_8_1_30_1","doi-asserted-by":"publisher","DOI":"10.1097\/SAP.0b013e31818c4ab6"},{"key":"e_1_2_8_1_31_1","doi-asserted-by":"publisher","DOI":"10.1097\/00006534-197710000-00015"},{"key":"e_1_2_8_1_32_1","doi-asserted-by":"publisher","DOI":"10.1097\/SAP.0b013e3181b30416"},{"key":"e_1_2_8_1_33_1","doi-asserted-by":"publisher","DOI":"10.1097\/SAP.0b013e318180cd24"},{"issue":"5","key":"e_1_2_8_1_34_1","first-page":"127","article-title":"Evaluation of different surgical procedures in filarial lymphoedema of lower extremity","volume":"89","author":"Dandapat MC","year":"1991","journal-title":"J Indian Med Assoc"},{"key":"e_1_2_8_1_35_1","doi-asserted-by":"publisher","DOI":"10.1097\/PRS.0000000000000295"},{"key":"e_1_2_8_1_36_1","first-page":"167","article-title":"Lymphedema: surgical approach and specific topics. china medical university hospital book series 2","journal-title":"Elsevier Taiwan"},{"key":"e_1_2_8_1_37_1","doi-asserted-by":"publisher","DOI":"10.1097\/SLA.0b013e31826ed043"}],"container-title":["Journal of Surgical Oncology"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/api.wiley.com\/onlinelibrary\/tdm\/v1\/articles\/10.1002%2Fjso.25356","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/pdf\/10.1002\/jso.25356","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2023,9,14]],"date-time":"2023-09-14T10:13:28Z","timestamp":1694686408000},"score":1,"resource":{"primary":{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/10.1002\/jso.25356"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2019,1,6]]},"references-count":36,"journal-issue":{"issue":"4","published-print":{"date-parts":[[2019,3]]}},"alternative-id":["10.1002\/jso.25356"],"URL":"https:\/\/doi.org\/10.1002\/jso.25356","archive":["Portico"],"relation":{},"ISSN":["0022-4790","1096-9098"],"issn-type":[{"value":"0022-4790","type":"print"},{"value":"1096-9098","type":"electronic"}],"subject":[],"published":{"date-parts":[[2019,1,6]]},"assertion":[{"value":"2018-07-19","order":0,"name":"received","label":"Received","group":{"name":"publication_history","label":"Publication History"}},{"value":"2018-12-16","order":1,"name":"accepted","label":"Accepted","group":{"name":"publication_history","label":"Publication History"}},{"value":"2019-01-06","order":2,"name":"published","label":"Published","group":{"name":"publication_history","label":"Publication History"}}]}}