Vascularized Lymph Node Transfer for Lymphedema

Abstract

Advances in our understanding of the lymphatic system and the pathogenesis of lymphedema have resulted in the development of effective surgical treatments. Vascularized lymph node transfer (VLNT) involves the microvascular transplantation of functional lymph nodes into an extremity to restore physiological lymphatic function. It is most commonly performed by transferring combined deep inferior epigastric artery perforator and superficial inguinal lymph node flaps for postmastectomy breast reconstruction. For patients who do not require or are unable to undergo free abdominal breast reconstruction or have lymphedema affecting the lower extremity, several other VLNT options are available. These include flaps harvested from within the axillary, inguinal, or cervical lymph node basins, and lymph node flaps from within the abdominal cavity. This article reviews the lymph node flap options and techniques available for VLNT for lymphedema.

Efficacy and early results after combining laparoscopic harvest of double gastroepiploic lymph node flap and active physiotherapy for lower extremity lymphedema

“…The use of minimally invasive surgery techniques for flap harvest reduces donor site morbidity and allows a faster recovery. Not least, it has been well described in the literature that ligation and use of the right gastroepiploic artery does not increase the risk of gastric ischemia or other abdominal complications (Ciudad, Maruccia, Socas, Lee, et al, 2017;Schaverien et al, 2018;Suma, 2013;Suma et al, 2007). For all the aforementioned reasons, Inspired by this, we tried to draw up and standardize an integrated approach for patients affected by lower limb lymphedema who are suitable for a physiological surgical procedure.…”

“…Lymphedemas resistant to conservative therapy, pain and chronic infection are the preferred indications for surgical treatment. Lymph node flap transfer has gradually gained popularity for the treatment of both upper and lower limb lymphedema (Althubaiti, Crosby, & Chang, 2013;Azuma, Yamamoto, & Koshima, 2013;Becker, 2016;Chang, Masià, & Smith, 2018;Cheng, Koshima, Chang, & Masia, 2017;Giudice et al, 2017;Gould, Mehrara, Neligan, Cheng, & Patel, 2018;Kung et al, 2017;Lin et al, 2009;Masià, Pons, & Rodríguez-Bauzà, 2016;Patel, Lin, & Cheng, 2015;Schaverien, Badash, Patel, Selber, & Cheng, 2018;Silva & Chang, 2016). Several donor sites for lymph node flaps have been described, including the abdominal area Ciudad, Kiranantawat, Sapountzis, et al, 2015;Ciudad, Manrique, Date, Agko, et al, 2017;Ciudad, Manrique, Date, Sacak, et al, 2017;Di Taranto, Chen, Elia, et al, 2019;Di Taranto, Elia, Amorosi, et al, 2018;Leuzzi et al, 2018;Maruccia et al, 2019).…”

Surgical debulking, lymphatico venous anastomosis, vascularised lymph node transfer in lower limb lymphoedema

“…However, in late cases, the limb is fibrotic and sclerosed, and VLNT is a physiological means to improve lymphoedema. The presence of significant backflow with few or no functioning lymphatic vessels on imaging using ICG, lymphography, lymphoscintigraphy or MRL suggests that VLNT may be indicated [23] . VLNT can be combined with LVA in certain cases if some good lymphatic channels are available, to give a better outcome [ Figure 1A-E].…”

Lymphedema: Conventional to Cutting Edge Treatment

“…Various donor sites have been described for harvesting of vascularized lymph node flaps, including the inguinal, thoracic, submental, supraclavicular, mesenteric, and omental lymph node basins. [43][44][45][46][47][48] Each of these flaps have their own advantages and disadvantages. The donor site is typically chosen based on surgeon preference, scar location, risks of donor site lymphedema, and the amount of lymphatic tissue required.…”