Immediate Lymphatic Reconstruction: Technical Points and Literature Review

Coriddi, Michelle; Mehrara, Babak J.; Skoracki, Roman J.; Singhal, Dhruv; Dayan, Joseph H.

doi:10.1097/gox.0000000000003431

Cited by 42 publications

(51 citation statements)

References 25 publications

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“…[4][5][6] Therefore, many surgeons began describing this procedure as an immediate lymphatic reconstruction (ILR), rather than preventive or prophylactic. [7][8][9] Boccardo and colleagues' results have been replicated by several retrospective and prospective studies. A 2018 meta-analysis of 4 papers found that patients who underwent upper-or lower-extremity ILR had a relative risk of 0.33 for developing lymphedema when compared to controls (P<0.0001).…”

Section: Classic and Modified Techniques Of Immediate Lymphatic Reconstructionmentioning

confidence: 78%

“…[4][5][6] Therefore, immediate lymphatic reconstruction (ILR) has been adopted by some as an alternative name. [7][8][9] While preliminary results are favorable, concerns exist surrounding scheduling issues, unfavorable proximal lymphovenous pressure gradients, oncologic safety, and anastomotic injury from postoperative radiation. 10 Delayed, distally-based LVA (DD-LVA) is an emerging alternative method that allows surgeons to avoid these issues.…”

Section: Introductionmentioning

confidence: 99%

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Surgical Prevention of Breast Cancer-Related Lymphedema: Delayed Distal Lymphaticovenicular Anastomosis– An Alternative to the Classic LYMPHA Technique

2021

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Breast cancer-related lymphedema (BCRL) is a devastating potential complication of axillary lymphadenectomy and radiotherapy. Several effective surgical treatment measures now exist, including lymphaticovenicular anastomosis (LVA), vascularized lymph node transplant (VLNT), and vascularized lymph vessel transplant (VLVT) for fluid-predominant disease, and liposuction and radical excision for solid-predominant disease. Super-microsurgical LVA is of particular interest, owing to its minimally invasive nature and highly favorable outcomes in the hands of experienced supermicrosurgeons. As LVA techniques are refined and improved, interest is rising in utilizing it to prevent the manifestation of disease in the first place. Lymphatic microsurgical preventive healing approach (LYMPHA), also known as immediate lymphatic reconstruction (ILR), is the most widely used approach. It involves performing axillary LVA immediately following axillary lymphadenectomy. While preliminary results are favorable, the high-pressure proximal axillary venous branches used in ILR and the site’s vulnerability to damage from radiotherapy endanger the long-term patency of these anastomoses. Moreover, a theoretical oncologic concern exists regarding creating a direct conduit for the remaining malignant cells in the axilla into the circulation. Finally, coordinating ILR with axillary lymphadenectomy creates significant logistical challenges. Delayed, distally-based LVA (DD-LVA) has emerged as an alternative method that avoids these issues. This article presents an overview of the development of preemptive lymphatic reconstruction, and the senior author’s approach to the novel technique of DD-LVA.

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Section: Classic and Modified Techniques Of Immediate Lymphatic Reconstructionmentioning

confidence: 78%

Section: Introductionmentioning

confidence: 99%

Surgical Prevention of Breast Cancer-Related Lymphedema: Delayed Distal Lymphaticovenicular Anastomosis– An Alternative to the Classic LYMPHA Technique

2021

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“…In addition, technique may be inconsistent among examiners. 9 In comparison, indocyanine green lymphangiography may be completed by the surgeon in the clinic and is a useful tool with which we can evaluate lymphatic patency. Patients who develop early, persistently increased LDEX scores or clinical lymphedema despite ILR may be appropriate candidates for further workup including ICG evaluation before initiating additional therapy.…”

Section: Future Directionsmentioning

confidence: 99%

Relationship of Adjuvant Radiation and the Lymphedema Index

et al. 2022

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Background Immediate lymphaticovenular bypass (immediate lymphatic reconstruction [ILR]) at the time of axillary lymph node dissection has emerged as a preventative paradigm to decrease the incidence of breast cancer–related lymphedema in high-risk patients. These patients are often treated with adjuvant therapies, including radiation. Bioimpedance spectroscopy is a validated tool for trending breast cancer–related lymphedema and identifying subclinical disease. Lymphedema Index (LDEX) values are commonly obtained in ILR patients; however, postoperative trends and relationships with adjuvant treatments are yet to be reported in the literature. Methods After International Review Board approval, 100 consecutive patients underwent axillary lymph node dissection with axillary reverse lymphatic mapping and ILR at a tertiary cancer center. These patients were then followed prospectively in a multidisciplinary lymphedema clinic at 3-month intervals with clinical examination, circumferential limb girth measurements and bioimpedance spectroscopy (LDEX). Results Seventy-two patients met inclusion for analysis at 3 months, 60 at 6 months, 51 at 9 months, 45 at 12 months, 41 at 15 months, and 22 at 18 months. A majority of the patients included underwent adjuvant radiation. Average LDEX score for patients who developed lymphedema was 3.02 at 3 months, at 29.1 months, 17.8 at 9 months, 15.05 at 12 months, 18.75 at 15 months, and 7.7 at 18 months. Patients who went on to develop lymphedema had a higher LDEX score at 6 months (29.1 vs 3.20, P = 0.1329), which reached a significant difference beginning at 9 months (17.8 vs 3.19, P = 0.0004). All patients who went on to develop lymphedema received adjuvant radiation. Conclusions These data provide valuable insight guiding follow-up after ILR. Six-month LDEX is much higher in patients who developed lymphedema, all of which underwent adjuvant radiation therapy, which correlates with the time of completion of their treatment. Average LDEX value after this remains significantly higher in this population. Patients who demonstrate this increase in LDEX and received adjuvant radiation are at highest risk to develop lymphedema despite ILR. All patients who developed lymphedema despite ILR had adjuvant radiation, and this is likely a contributing factor. Injury from adjuvant radiation and its impact after ILR is not insignificant and warrants further studies.

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“…Attention is paid to identifying and preserving lymphatic channels draining the arm with as much length as possible. It is also critical to preserve axillary vein branches with a suitable length (6-7 cm) found within level one and level two of the axilla, specifically targeting the thoracoepigastric vein, lateral thoracic vein, medial pectoral vein, and branches emanating from the thoracodorsal vein, if possible, from an oncologic perspective (104). If neither of these veins have been preserved, an unnamed vein could be used if it is found within proximity to the lymphatic vessel or alternatively a vein graft could be used.…”

Section: Lymphatic Reconstruction Proceduresmentioning

confidence: 99%

Current Surgical Innovations in the Treatment of Breast Cancer

Crystal¹,

Mella-Catinchi²,

Xu³

et al. 2022

Breast Cancer

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Surgery is an essential component in the management of treatable breast cancer. With the use of standardized staging and data collection, evidence-based management of breast cancer has evolved to limit treatments to what is necessary but sufficient to allow tissue preservation and control of treatment-specific morbidity. As more tumors are discovered by pretreatment imaging and are not identifiable on physical exam, intraoperative tumor localization techniques have become increasingly sophisticated and reliable. Techniques for localization of "sentinel" nodes has become increasingly accurate and technically less complicated. Surgical treatment may occur Note to the reader: This chapter is part of the book Breast Cancer (ISBN: 978-0-6453320-3-2), scheduled for publication in July 2022. The book is being published by Exon Publications,

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Immediate Lymphatic Reconstruction: Technical Points and Literature Review

Cited by 42 publications

References 25 publications

Surgical Prevention of Breast Cancer-Related Lymphedema: Delayed Distal Lymphaticovenicular Anastomosis– An Alternative to the Classic LYMPHA Technique

Surgical Prevention of Breast Cancer-Related Lymphedema: Delayed Distal Lymphaticovenicular Anastomosis– An Alternative to the Classic LYMPHA Technique

Relationship of Adjuvant Radiation and the Lymphedema Index

Current Surgical Innovations in the Treatment of Breast Cancer

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