Comments on “Ileocecal vascularized lymph node transfer for the treatment of extremity lymphedema: A case report”

Abstract

The extent to which the lymphatic system can compensate for major interventions in the area of its main collectors is quite limited. This is the case despite almost completely preserved venous outflow pathways in the context of oncological lymphadenectomy. Furthermore, serious damage in the form of an iatrogenic lymph flow blockage can be observed in the dependent extremities whilst harvesting lymph node transplants from the axillary/ thoracic and inguinal regions. In the visceral compartment, the effects are quite different. Despite the most extensive oncological visceral interventions, we do not know the clinical occurrence of the chronic lymphedema of viscera. Therefore, the harvesting of a transplant for vascularized lymph node transfer from the visceral system appears more promising.The flap harvesting from the ileocolic vessel region was proposed by Ciudad et al. (in press). It is important to consider that the cranial terminal branch of ileocolic artery, the appendicular artery, runs dorsally in the margin of the mesenteriolum. Should this vessel fail, ischemia of the appendix is to be feared. Therefore, it is more likely that an appendectomy entails an additional risk, at least in the case of a larger organ. If an appendectomy has already been carried out previously, this argument is redundant.However, in our opinion, the ileal mesentery seems to be the most suitable for graft harvesting. Our experience with a series of patients with post-oncological lymphedema of both upper and lower extremities has shown promising results. The mesentery is not only richly arterially and venously supplied but it also includes a myriad of lymph nodes. No other region of the body shows so many lymph nodes in such a narrow space, which in turn results from the physiological function of the small intestine. Furthermore, the terminal ileum is supplied by numerous, segmental vessels, which in turn form a widely branched vascular network. By preserving the marginal arches, a lymph node flap pedicled on segmental vessels can be harvested (Figure 1). There is never the risk of ischemia of the intestine and a consecutive lymph blockage has not been observed. The mesenteric lymph node flap has a large caliber pedicle. If necessary, several transplants can also be harvested simultaneously or successively, leaving at least one supply tract in between.The only disadvantage of grafts from the ileal mesentery is their relatively elaborate preparation, as it is currently not possible to achieve this with minimally invasive techniques. Therefore, to access the mesentery of the terminal ileum, we frequently use old scars already existing from previous interventions. If there are no scars, a Pfannenstiel incision is preferred to other incision types, due to aesthetic reasons. A previously performed laparascopic exploration may be advantageous in certain cases, e.g., in obesity in order to quickly identify and mobilize the appropriate intestinal section. Restrictions of the method are self-evident. Extensive adhesions can make access to the ...

Intra‐abdominal lymph node flaps in lymphedema therapy: An anatomical guide to donor site selection

“…When harvesting icLNF, surgeons need to explore the mesoappendix, as the appendicular artery is a terminal branch of the ileocolic vessels. The appendicular artery runs dorsally at the margin of the mesenteriolum, should there be any ischemia resultant of the icLNF harvesting, the appendix is at risk 27,43 …”

“…The appendicular artery runs dorsally at the margin of the mesenteriolum, should there be any ischemia resultant of the icLNF harvesting, the appendix is at risk. 27,43…”

“…In our clinical experience, often we may intraoperatively need to change the harvesting region due to inconstant or nonpalpable LNs. Yet, preoperative estimates of intra‐abdominal LNFs are lacking 27–29 …”

“…Yet, preoperative estimates of intra-abdominal LNFs are lacking. [27][28][29] The purpose of this anatomical study is to investigate the LN count in proximity to the vessels and the volume of the clinically most relevant intra-abdominal donor sites and compare them at once in each patient.…”

Reply to comment on: Ileocecal vascularized lymph node transfer for the treatment of extremity lymphedema: A case report

“…We greatly appreciate Ring, Stern, and Udrescu's (2018) comments on our manuscript. So far, there are several intra-abdominal lymph node flaps that have been described in the literature for vascularized lymph node transfer (VLNT) Ciudad, Manrique, Date, et al, 2016;.…”