Return of lymphatic function after flap transfer for acute lymphedema

OBJECTIVE: The goals of this work were to develop animal models of lymphedema and tissue flap transfer, and to observe physiologic changes in lymphatic function that occur in these models over time, both systemically with lymphoscintigraphy (LS) and locally using fluorescence microlymphangiography (FM). SUMMARY BACKGROUND DATA: Although lymphedema has been managed by a combination of medical and surgical approaches, no effective long-term cure exists. Surgical attempts aimed at reconnecting impaired lymphatic channels or bypassing obstructed areas have failed. METHODS: The tails of rats (A groups) and mice (B groups) were used because of their different features. Lymphedema was created by ligation of the lymphatics at the tail base and quantified by diameter measurements there. In the experimental group, rectus abdominis myocutaneous flap was transferred across the ligation. In addition to the ligation (A1 and B1) and ligation + flap (A2 and B2) groups, three control groups were included: sham flap with ligation (B4), sham flap alone (B5), and normal (A3 and B3) animals. Observations were made at weekly time points for lymphatic function and continuity. RESULTS: Lymphedema was successfully created in the mouse ligation groups (B1 and B4) and sustained for the entire length of observation (up to 14 weeks). Lymphatic continuity was restored in those animals with transferred flaps across the ligation site (A2 and B2), as seen both by LS and FM. Sham flaps did not visibly affect lymphatic function nor did they cause any visible swelling in the tail. CONCLUSIONS: Acute lymphedema developing after ligation of tail lymphatics in mice can be prevented by myocutaneous flap transfer. Restored lymphatic continuity and function were demonstrable using lymphoscintigraphy and fluorescence microlymphangiography.     

Free muscle flap transfer as a lymphatic bridge for upper extremity lymphedema

There are limited reports in the literature describing the use of muscle or skin pedicle flaps as a lymphatic bridge to treat obstructive lymphedema. This report demonstrates the successful use of a free muscle flap for a circumferential scar of a forearm as treatment for obstructive lymphedema. Lymphatic drainage is demonstrated across the free flap by lymphoscintigraphy postoperatively. This is the first case report using a free muscle flap to reestablish lymphatic flow across an area of obstructive limb lymphedema.     

Collateral lymphatic circulation

The collateral lymphatic circulation is a very important clinical pathophysiological phenomenon. The presence of a collateral lymphatic circulation is a sign of an obstructed lymph outflow and depends on location of the obstruction and on developmental anatomy of the lymphatic system. Direct lymphography is the method of choice to study lymphatic pathways. The collateral lymphatic circulation was studied in patients with malignant metastatic lymph node involvement, in primary lymphomas, in filariasis, in protein losing enteropathy, and in patients with secondary postoperative and/or postirradiation therapy. The collateral lymphatic circulation demonstrated by direct lymphography shows various types of collaterals. We have divided them into the typical collaterals (cutaneous, subcutaneous, parietal, perivisceral) and atypical collaterals (lymphovenous communications, extravasation into cavities, internal lymphatic fistula). The various collaterals are described and demonstrated in this paper. Of special importance for surgeons and physiotherapists, are the cutaneous and subcutaneous collaterals crossing lymphoshed borders. The main goal for the surgeon is to recognize preoperatively not only lymphatic obstruction, but also existing lymphatic collateral pathways, and to try to preserve them. Received: 3 August 1999 / Accepted: 21 September 1999     

胸大肌肌瓣转移术预防乳腺癌术后淋巴漏的临床研究

目的探讨胸大肌肌瓣转移术对乳腺癌改良根治术后淋巴漏的预防效果。方法乳腺癌患者75例,将75例患者分成两组,实验组35例,行乳腺癌改良根治术+胸大肌肌瓣转移术;对照组40例,单纯行乳腺癌改良根治术。观察两组患者术后第1、2、3天引流量、拔管时间、皮下积液情况,并进行比较。结果实验组术后第1、2、3天引流量分别为(129.82±11.46)ml、(89.94±9.73)ml和(30.82±10.56)ml,对照组分别为(179.47±24.23)ml、(130.82±10.56)m和(87.82±8.44)n1;实验组术后拔管时间为(6.47±1.62)天,对照组为(9.41±1.91)天;实验组皮下积液发生率为2.85%,对照组为17.5%,两组3种指标比较,差异均有统计学意义(P0.05)。结论乳腺癌改良根治术后行胸大肌肌瓣转移可预防术后淋巴漏的发生。     

Prenatally-detected giant lymphatic malformation

We present a case of a giant lymphatic malformation of the chest and abdominal wall that was diagnosed in the third trimester of pregnancy. It was treated by one stage excision with good functional and cosmetic outcomes.     

Frontiers in lymphatic microsurgery

The Authors report an overview on the modern surgical treatment of peripheral lymphoedema. The aim of lymphatic microsurgical operations is to drain the lymph either toward the venous circulation (lympho-venous shunts) or the lymphatic collectors above the obstacle to the lymph flow, with the interposition of lymphatic or venous grafts (lymphatic-venous-lymphatic plasty). Selection of candidate patients for lymphatic microsurgery is based on an adequate diagnostic investigation, which includes above all lymphoscintigraphy, conventional oil contrast lymphangiography, Doppler venous flowmetry and manometry, and, if necessary (angiodysplasias), an accurate study also of the artery circulation. The clinical outcome of lymphatic microsurgery, assessed by water volumetry and lymphangioscintigraphy, performed at variable distance of time from operations till over 5 years after surgery, shows a significant reduction of edema volume and improvement of lymph flow in all patients and that the more precocious the microsurgical treatment the better the results. © 1998 Wiley-Liss, Inc. MICROSURGERY 18:462–471 1998     

Management of lymphatic malformations

Lymphatic malformation results from an error in the embryonic development of the lymphatic system. Clinically, lymphatic malformation is characterized by the size of the malformed channels: microcystic, macrocystic, or combined (microcystic/macrocystic).This article describes the clinical features, diagnosis, and management of lymphatic malformations.     

Prediction of lymphatic invasion by peritumoral lymphatic vessel density in prostate biopsy cores

BACKGROUND: Lymphatic invasion in radical prostatectomy specimens has been suggested to be an unfavorable prognostic factor in clinically localized prostate cancer. Lymphangiogenesis detected by antibodies specific for lymphatic endothelial cells has been associated with lymphatic invasion and lymph node metastasis in prostate cancer. This study was designed to examine whether lymphangiogenesis in prostate biopsy could predict lymphatic spread in radical prostatectomy specimens. METHODS: Paraffin-embedded positive biopsy cores obtained from 99 patients who underwent radical prostatectomy at our institution were immunostained with D2-40 monoclonal antibody, which specifically recognizes lymphatic endothelium. The association between lymphatic parameters in prostate biopsy and pathological parameters in radical prostatectomy specimens was analyzed. RESULTS: Peritumoral and intratumoral lymphatic (ITL) vessels were observed in 90 (90.9%) and 23 cases (23.2%). Average and maximal peritumoral lymphatic vessel density (PTLD) and the presence of ITL in positive biopsy cores were significantly associated with positive biopsy core rates (P = 0.0015 for average PTLD, P < 0.0001 for maximal PTLD, and P = 0.0038 for ITL) and lymphatic vessel invasion (P < 0.0001 for average PTLD, P < 0.0001 for maximal PTLD, and P = 0.0322 for ITL). Among preoperative parameters, the biopsy Gleason score (P = 0.0092, HR = 6.108) and average PTLD (P = 0.0034, HR = 1.860) were significant predictors of lymphatic invasion in radical prostatectomy specimens in multivariate analysis. CONCLUSIONS: PTLD in prostate biopsy specimens assessed by immunohistochemistry using D2-40 antibody could be a useful parameter for predicting lymphatic spread of clinically localized prostate cancer.