Ileocecal vascularized lymph node transfer for the treatment of extremity lymphedema: A case report

Vascularized lymph node (VLN) transfer has been of high interest in the past decade for the treatment of lymphedema, since it has been shown to be effective in reducing limb volumes, decreasing infectious episodes and improving quality of life. Multiple donor sites have been described in the quest for the optimal one. Herein, we describe a novel lymph node flap option based on the ileocolic artery and vein. The ileocecal vascularized lymph node (IC‐VLN) flap was used in the management of a 33‐year‐old male patient with lower extremity lymphedema secondary to left inguinal trauma. The patient had previously underwent a pedicled omentum flap transposition with minimal improvement in limb size and persistent episodes of infection. At 15 month follow‐up, the IC‐VLN flap improved the lymphatic drainage in the affected limb with a mean limb circumference reduction rate of 26.3%. No donor site complications or further episodes of infection were noted. According to our findings, the IC‐VLN flap may be another option for VLN transfer in very selected cases. Nevertheless, larger series with a longer follow‐up are required to analyze the efficacy and long‐term results of this flap.     

薄层血管化腹股沟淋巴结皮瓣移植联合反向淋巴显影在继发性上肢淋巴水肿手术中的应用

目的 探讨薄层血管化腹股沟淋巴结皮瓣移植联合反向淋巴显影在继发性上肢淋巴水肿手术中的应用效果。方法 2019年7月至2020年9月,应用吲哚菁绿、美蓝双染法引导的反向淋巴显影术,制备薄层游离血管化腹股沟淋巴结皮瓣,切取后移植于患侧上肢,治疗乳腺癌术后继发性淋巴水肿患者5例。皮瓣约10 cm×5 cm大小,平均厚度约0.7 cm,切取供区淋巴结约2～3枚,术后随访7～15个月。结果 5例皮瓣存活良好,淋巴结均存活。术后随访显示,患肢臂围均于1.5个月后出现明显缩小,供区无并发症。结论 联合反向淋巴显影技术完成的薄层血管化淋巴结游离皮瓣移植治疗继发性上肢淋巴水肿疗效优良,明显改善患肢臃肿外形。     

Post‐traumatic lymphedema treatment with superficial circumflex iliac artery perforator lymphatic free flap: A case report

Post‐traumatic lymphedema is poorly understood. It is rarely considered in limb reconstruction decision‐making approach. We report a case of a 41‐year‐old female who presented with right upper extremity lymphedema after degloving injury and split thickness skin graft, successfully treated with a superficial circumflex iliac artery perforator (SCIP) free flap restoring the lymphatic drainage. Right upper extremity had an excess of 258.7 mL or an excess volume of 27.86% compared to the healthy contralateral limb. A SCIP free flap including lymphatic vessels (SCIP‐L) was performed to replace the skin graft in order to restore the lymphatic flow. Flap size was 19 × 8 cm and pedicle length was 4 cm. No lymph nodes were included and no lymphatic or lymphovenous anastomoses were performed. The surgery was uneventful, and there were no postoperative complications. Fourteen days after free tissue transfer, lymphedema showed clear improvement. At a 4‐month follow‐up, 55.6% reduction of excess volume was obtained. Indocyanine green lymphography performed at that time showed a restitution of lymph flow through the flap. Lymphedema improvements persisted at a 6‐month follow‐up. A successful treatment of post‐traumatic lymphedema can be performed by using the SCIP‐L free flap for soft tissue reconstruction of critical lymphatic drainage areas.     

携带淋巴结的组织瓣移植治疗下肢淋巴水肿

目的 探讨携带淋巴结的组织瓣移植治疗下肢淋巴水肿的疗效。方法 2019年6月至2021年6月,采用携带淋巴结的组织瓣移植治疗Ⅱ～Ⅲ期下肢淋巴水肿5例,皮瓣大小（10～30） cm×（4～9） cm,受区选择患肢小腿区,受区血管为胫前动脉及伴行静脉,术后定期随访。结果 1例皮瓣术后部分坏死,予以换药对症治疗后,创面瘢痕愈合,其余4例移植皮瓣顺利成活。术后随访0.5～2年,患肢周径于术后1个月及6个月平均减少0.84 cm及2.29 cm,术后未出现淋巴管炎,供区未出现淋巴漏及淋巴水肿。结论 应用淋巴结皮瓣移植治疗肢体淋巴水肿近期疗效较好,供区无并发症,是早中期下肢淋巴水肿可选择的治疗方法之一。     

Modified lymph vessel flap transplantation for the treatment of refractory lymphedema: A case report

Lymph vessel flap transplantation (LFT), lymphaticovenous anastomosis (LVA), or lymph node flap transfer are sometimes used to treat lymphedema that is resistant to conservative treatment. LFT harvested from the contralateral limb has been reported for the treatment of lymphedema. Here we report the use of modified LFT from the abdominal wall for the treatment of refractory lymphedema. Our patient was a 57‐year‐old patient with secondary lower limb lymphedema was previously treated with conservative therapy and lymphaticovenous anastomosis. We first examined the lymphatic function of the lower abdominal region in the patient using indocyanine green (ICG) lymphography. After confirming the good lymphatic function in the right abdominal region, we harvested the pedicled abdominal adiposal flap containing multiple abdominal lymph vessels and transferred it to the left groin region. The flap (20 × 10 cm²) was based on the superficial circumflex iliac artery perforator. We anastomosed one lymph vessel in the flap to that in the recipient site. We also performed multiple fibrotripsy using a 3‐mm‐diameter stainless steel stick inserted into small incisions. The postoperative course was uneventful. The circumference measurement was decreased by 2.2–13.5 cm at 1 year after the operation. The lower abdominal region has many lymph vessel networks and is thought to be a less risky donor site in patients with lymphedema than the lower limbs. Thus, LFT may be an option for the treatment of chronic lymphedema. © 2015 Wiley Periodicals, Inc. Microsurgery 36:695–699, 2016.     

血管化淋巴结皮瓣移植治疗下肢淋巴水肿的研究进展

下肢淋巴水肿的治疗是临床研究中的难点和重点。严重的下肢淋巴水肿对患者的生存质量影响极大。近年来,血管化淋巴结皮瓣移植作为一种新兴的手术方式,对重度下肢淋巴水肿具有较好的治疗效果。本文对血管化淋巴结皮瓣移植的作用机制、手术方式、辅助手段、常见并发症等方面的研究进展进行综述。     

Chimeric thoracodorsal lymph node flap with a perforator-based fasciocutaneous skin island for treatment of lower extremity lymphedema: A case report

Free vascularized lymph node transfer (VLNT) is applied more and more in the treatment of lymphedema. A random-pattern skin island with VLNT is of use but can have its limitations in flap inset. We describe an option for free VLNT in the treatment of lower extremity lymphedema. We present the case of a chimeric thoracodorsal lymph node flap (TAP-VLNT) with a thoracodorsal artery perforator (TAP) flap (5 × 9 cm) to the lower leg in a 22-year old female patient with stage 2 lower leg lymphedema caused by severe traumatic skin decollement and postoperative scarring after a car accident. TAP flap enabled tailored and tension-free wound closure at the recipient site after scar release and lymph node flap inset. The anastomosis was performed to the anterior tibial artery. The postoperative course was uneventful with no complications or secondary donor-site lymphedema. Follow-up at 6 months showed reasonable cosmetic and functional outcomes. The circumference reduction rate was up to 11% and the patient reported improved quality of life. The purpose of this report is to describe a case of a more flexible lymph node flap inset and tension-free wound closure by harvesting a thin thoracodorsal artery perforator (TAP) skin island together with a thoracodorsal VLNT as a chimeric flap (TAP-VLNT) for treatment of lower extremity lymphedema. Larger series with longer follow-up data are needed to justify its widespread use and demonstrate long-term results.     

The latissimus dorsi‐groin‐lymph node compound flap: A comprehensive technique with three features including skin coverage,restoration of motor function,and prevention of upper limb lymphedema

Reconstruction of complex upper extremity defects requires a need for multiple tissue components. The supercharged latissimus dorsi (LD)‐groin compound flap is an option that can provide a large skin paddle with simultaneous functional muscle transfer. It is necessary to supercharge the flap with the superficial circumflex iliac pedicle to ensure the viability of its groin extension. In this report, we present a case of a supercharged LD‐groin flap in combination with vascularized inguinal lymph nodes, which was used for upper limb reconstruction in a young male patient, following excision of high‐grade liposarcoma. Resection resulted in a 28 cm × 15 cm skin defect extending from the upper arm to the proximal forearm, also involving the triceps muscle, a segment of the ulnar nerve and the axillary lymph nodes. Restoration of triceps function was achieved with transfer of the innervated LD muscle. Part of the ulnar nerve was resected and repaired with sural nerve grafts. Post‐operatively, the flap survived fully with no partial necrosis, and no complications at both the recipient and donor sites. At 1‐year follow up, the patient had a well‐healed wound with good elbow extension (against resistance), no tumor recurrence, and no signs of lymphedema. We believe this comprehensive approach may represent a valuable technique, for not only the oncological reconstruction of upper extremity, but also for the prevention of lymphedema. © 2015 Wiley Periodicals, Inc. Microsurgery 36:689–694, 2016.     

Venous versus lymphatic duct autotransplantation in the treatment of experimental lymphedema

Experimental autologous lymphatic duct transplantation is technically feasible and therapeutically effective in the treatment of chronic lymphedema of the extremity. However, we demonstrate that the risk of inducing lymphedema in the donor limb is evident; therefore, the clinical application of lymphatic transplantation is compromised. To obviate this risk, a vein graft was substituted in experimental animals with good prophylactic results. Postoperative lymphangiography showing free passage of contrast media through the interposed vein, rapid disappearance of acute lymphedema in the recipient limb (28.6%), and no risk of inducing lymphedema of the donor limb all favor the possibility of using a vein graft transfer in clinically treating chronic lymphedema of the extremity.     

Treatment of secondary scrotal and lower extremity lymphedema using combined pedicled lymph node transfer and lymphaticovenous anastomosis: A case report

Combined secondary scrotal and lower extremity lymphedema is an infrequent complication of radical excision of urogenital cancers associated with pelvic lymphadenectomy. Scrotal lymphedema is usually psychologically distressing, and difficult to treat. We report a case of a 41-years old male who presented with scrotal and left lower extremity lymphedema after radical prostatectomy and pelvic lymphadenectomy successfully treated with pedicled superficial inguinal lymph node (SILN) transfer and lymphaticovenous anastomosis (LVA) restoring the lymphatic drainage. The flap consisted of subscarpal adipofascial tissue between the level of the inguinal ligament and the groin crease measuring 11 × 7 cm. The flap composed of afferent lymphatics from the lower abdomen, lymph nodes, and fatty tissue without skin, the right-sided flap was transposed to the root of scrotum while the left one to the proximal left thigh, then two-level LVA were performed in the left extremity. The surgery went uneventful with no postoperative complications. At a 9 month follow-up, there was a significant reduction of the scrotal volume with a reduction of excess volume of the lower extremity from 49.6 to 9.4% compared with the healthy side. No cellulitis was reported during the follow-up period with improvement in the patient's clinical symptoms and quality of life. We believe that pedicled superficial inguinal lymph node flap together with LVA is a reliable and safe treatment option for either scrotal or lower extremity lymphedema following pelvic cancer treatment.     

Vascularized axillary lymph node transfer: A novel model in the rat

Vascularized lymph node transfer (VLNT) is a promising microvascular free flap technique for the surgical treatment of lymphedema. To date, few experimental animal models for VLNT have been described and the viability of lymph nodes after the transfer tested. We aimed to evaluate the feasibility of axillary VLNT in the rat. Lymph node containing flaps were harvested from the axillary region in 10 Lewis rats based on the axillary vessels. Flaps were transferred to the ipsilateral groin and end‐to‐side microanastomosis was performed to the femoral vessels using 10‐0 sutures. Indocyanine green (ICG) angiography was used to confirm flap perfusion. On postoperative day 7, flaps were elevated to assess their structure and vessel patency. Hematoxylin and eosin staining was used to confirm the presence and survival of lymph nodes. All animals tolerated the procedure well. Immediate post‐procedure ICG angiography confirmed flap perfusion. No signs of ischemia or necrosis were observed in donor extremities. At postoperative day 7, all flaps remained viable with patent vascular pedicles. Gross examination and histology confirmed the presence of 3.6 ± 0.5 lymph nodes in each flap without any signs of necrosis. This study showed that the transfer of axillary lymph nodes based on the axillary vessels is feasible. The flap can be used without the need for donor animals and it contains a consistent number of lymph nodes. This reliable VLNT can be further utilized in studies involving lymphedema, transplantation, and induction of immunologic tolerance. © 2015 Wiley Periodicals, Inc. Microsurgery 35:662–667, 2015.     

手动负压抽吸联合血管化淋巴结移植治疗继发性下肢淋巴水肿的疗效分析

目的 探讨手动负压抽吸联合血管化淋巴结移植治疗继发性下肢淋巴水肿的临床疗效。方法 回顾性分析2018年11月至2021年11月接受联合治疗的12例妇科恶性肿瘤术后继发性下肢淋巴水肿患者的临床资料。患肢大腿采用手动负压抽吸减容,同时取锁骨上血管化淋巴结移植至患侧小腿。比较治疗前后患肢周径变化;记录治疗前后丹毒发作情况及生活质量的改变。结果 患肢大腿抽取脂肪组织500～1 200 mL,平均（917±196） mL。术后患肢周径明显减小（P<0.05）。治疗后随访期间所有患者均无丹毒发作,主观症状均较术前明显好转。结论 手动负压抽吸联合血管化淋巴结移植治疗下肢淋巴水肿疗效确切,值得推广。     

Delayed grafting for banked skin graft in lymph node flap transfer

Over the last decade, lymph node flap (LNF) transfer has turned out to be an effective method in the management of lymphoedema of extremities. Most of the time, the pockets created for LNF cannot be closed primarily and need to be resurfaced with split thickness skin grafts. Partial graft loss was frequently noted in these cases. The need to prevent graft loss on these iatrogenic wounds made us explore the possibility of attempting delayed skin grafting. We have herein reported our experience with delayed grafting with autologous banked split skin grafts in cases of LNF transfer for lymphoedema of the extremities. Ten patients with International Society of Lymphology stage II–III lymphoedema of upper or lower extremity were included in this study over an 8‐month period. All patients were thoroughly evaluated and subjected to lymph node flap transfer. The split skin graft was harvested and banked at the donor site, avoiding immediate resurfacing over the flap. The same was carried out in an aseptic manner as a bedside procedure after confirming flap viability and allowing flap swelling to subside. Patients were followed up to evaluate long‐term outcomes. Flap survival was 100%. Successful delayed skin grafting was done between the 4th and 6th post‐operative day as a bedside procedure under local anaesthesia. The split thickness skin grafts (STSG) takes more than 97%. One patient needed additional medications during the bedside procedure. All patients had minimal post‐operative pain and skin graft requirement. The patients were also reported to be satisfied with the final aesthetic results. There were no complications related to either the skin grafts or donor sites during the entire period of follow‐up. Delayed split skin grafting is a reliable method of resurfacing lymph node flaps and has been shown to reduce the possibility of flap complications as well as the operative time and costs.     

Update on Post‐mastectomy Lymphedema Management

Lymphedema is a chronic, progressive condition caused by an imbalance of lymphatic flow. Upper extremity lymphedema has been reported in 16–40% of breast cancer patients following axillary lymph node dissection. Furthermore, lymphedema following sentinel lymph node biopsy alone has been reported in 3.5% of patients. While the disease process is not new, there has been significant progress in the surgical care of lymphedema that can offer alternatives and improvements in management. The purpose of this review is to provide a comprehensive update and overview of the current advances and surgical treatment options for upper extremity lymphedema.     

Anatomical and Surgical Concepts in Lymphatic Regeneration

Chronic post-surgical lymphedema is common condition that afflicts nearly 2 million Americans. In the USA, it is most commonly encountered in the upper extremities of patients who have undergone axillary lymph node dissection for breast cancer. Lymphedema has a significant negative effect on cosmesis, limb function, and overall quality of life. Despite the impact of this condition, very little is known about how to effectively prevent or treat lymphedema. While therapeutic options for chronic extremity lymphedema remain limited, several surgical approaches have been suggested. These include techniques aimed at reducing limb volume, as well as techniques that aim to reconstitute disrupted lymphatic channels. Operations proposed to re-establish lymphatic continuity include lymphatico-venous anastomoses, lymphatico-lymphatico anastomoses, and tissue transfer.     

Review of Current Surgical Treatments for Lymphedema

Background

The current mainstay of lymphedema therapy has been conservative nonsurgical treatment. However, surgical options for lymphedema have been reported for over a century. Early surgical procedures were often invasive and disfiguring, and they often had only limited long-term success. In contrast, contemporary surgical techniques are much less invasive and have been shown to be effective in reducing excess limb volume, the risk of cellulitis, and the need for compression garment use and lymphedema therapy. Microsurgical procedures such as lymphaticovenous anastomosis and vascularized lymph node transfer lymphaticolymphatic bypass can treat the excess fluid component of lymphedema swelling that presents as pitting edema. Suction-assisted protein lipectomy is a minimally invasive procedure that addresses the solid component of lymphedema swelling that typically occurs later in the disease process and presents as chronic nonpitting lymphedema. These surgical techniques are becoming increasingly popular and their success continues to be documented in the medical literature. We review the efficacy and limitations of these contemporary surgical procedures for lymphedema.

Methods

A Medline literature review was performed of lymphedema surgery, vascularized lymph node transfer, lymphaticovenous anastomosis, lymphatic liposuction, and lymphaticolymphatic bypass with particular emphasis on developments within the past 10 years. A literature review of technique, indications, and outcomes of the surgical treatments for lymphedema was undertaken.

Results

Surgical treatments have evolved to become less invasive and more effective.

Conclusions

With proper diagnosis and the appropriate selection of procedure, surgical techniques can be used to treat lymphedema safely and effectively in many patients when combined with integrated lymphedema therapy.     

Microsurgical treatment of lower extremity lymphedema: A multidisciplinary approach to improve morbidity in advanced penile cancer patients

IntroductionLower extremity lymphedema is a major source of morbidity in up to 70% of penile cancer patients. Lymphedema is often thought to be incurable, though surgical treatments have started to emerge. This study is the first to apply lymphovenous bypass specifically to penile cancer patients status post lymphadenectomy.MethodsWe performed microsurgical lymphovenous bypass in 3 patients who underwent inguinal lymphadenectomy for advanced penile cancer, and later lymph node transplant in 1 patient.ResultsThe lymphovenous bypass was performed by a trained microsurgeon: Two patients were treated as outpatients for lymphedema, and 1 patient underwent prophylactic lymphovenous bypass simultaneously with initial lymphadenectomy. We saw significant improvement in patient's clinical lymphedema as well as lymphatic drainage on infared imaging for 2 of 3 patients at 12 months, however 1 of these patients did require later lymph node transfer at 24 months.ConclusionThis early proof of concept study shows that these procedures should be considered and studied further in the treatment and prevention of debilitating lymphedema in the penile cancer population.     

皮瓣转移结合负压抽吸治疗乳腺癌术后上肢淋巴水肿

目的 探讨一种治疗乳腺癌根治术后上肢淋巴水肿的手术方法。方法 2001～2002年我们采用侧胸壁皮瓣或背阔肌肌皮瓣转移结合上肢负压抽吸治疗10例单侧乳腺癌根治术后上肢淋巴水肿患者。结果 术后所有患者上肢周径均有不同程度减小，核素淋巴管造影显示淋巴回流有显著改善。术后随访3～18个月，疗效稳定。结论 皮瓣转移结合负压抽吸可以有效地治疗乳腺癌根治术后淋巴水肿。     

Treatment of upper limb lymphedema with combination of liposuction, myocutaneous flap transfer, and lymph-fascia grafting: a preliminary study

Treatment of obstructive extremity lymphedema remains a challenge in reconstructive surgery, since none of the varieties of procedures have been demonstrated a reliable resolution for the lymphedema. In this report, we present the preliminary results of treatment of severe upper extremity lymphedema with combined liposuction, latissimus myocutaneous flap transfer, and lymph-fascia grafting in 11 patients. All patients had histories of radical mastectomy, irradiation therapy for breast cancer, and frequent onsets of erysipelas. Postoperative measurements in an average of 26 months follow up showed that significant decrease of circumferences of the arms on all levels at surgery side were achieved. The onsets of erysipelas were also reduced. There was no chronic lymphedema found in the donor leg after harvest of the lymph-fascia graft. The results suggest the strategy of liposuction, latissimus myocutaneous flap transfer, and lymph-fascia grafting may provide a useful method for treatment of the chronic upper extremity lymphedema with severe axillary scar contracture.     

逆向腋淋巴显影技术在乳腺癌患者中的临床运用及上肢回流淋巴结的分布与转移特点分析

目的研究逆向腋淋巴显影技术(ARM)在乳腺癌患者中的临床运用,分析乳腺癌患者上肢回流淋巴结的分布与转移特点。方法前瞻性选择2017年6月至2020年2月期间接受外科手术治疗的乳腺癌女性患者130例,所有患者均行ARM,且均为初次手术者。采用SPSS23.0进行统计学分析。术中上臂直径以(±s)表示,采用t检验;上肢回流淋巴结的转移单因素分析采用χ²检验分析,多因素分析采用Logistic回归分析,P<0.05差异有统计学意义。结果122例患者中501枚上肢回流淋巴结追踪成功,成功率为93.8%,A区和B区分别追踪327枚和106枚,共占83.1%,明显高于其他区域(P<0.05);而上肢回流淋巴结的行走方向以腋静脉、第二肋间臂神经、胸背神经血管束、背阔肌前缘以及前锯肌为界限,主要集中在腋静脉周围;单因素分析显示,患者腋窝淋巴情况、BMI指数、肿瘤分布位置、上臂直径与ARM技术上肢回流淋巴结转移有关(P<0.05),Logistic回归分析进一步表明,腋窝淋巴情况和肿瘤分布位置是ARM术上肢回流淋巴结转移的独立危险因素。结论ARM在乳腺癌手术中可成功定位淋巴结,通过了解淋巴分布位置和行走趋势,可提升淋巴系统保留的完整度,对降低术后淋巴水肿率,提高手术成功率有一定的意义。