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Handchir Mikrochir Plast Chir 2019; 51(06): 424-433
DOI: 10.1055/a-0874-2212
Consensus Statement
© Georg Thieme Verlag KG Stuttgart · New York

Rekonstruktive Mikrochirurgie des sekundären Lymphödems: Konsensus der Deutschsprachigen Arbeitsgemeinschaft für Mikrochirurgie der peripheren Nerven und Gefäße (DAM) zur Indikation, Diagnostik und Therapie mittels Lymphovenöser Anastomosen (LVA) und vaskularisierter Lymphknotentransplantation (VLKT)

Lympho-reconstructive microsurgery for secondary lymphedema: Consensus of the German-Speaking Society for Microsurgery of Peripheral Nerves and Vessels (DAM) on indication, diagnostic and therapy by lymphovenous anastomosis (LVA) and vascularized lymph node transfer (VLNT)
Christoph Hirche
1   Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Mikrochirurgie, Schwerbrandverletztenzentrum, Klinik für Plastische und Handchirurgie an der Universität Heidelberg
,
Holger Engel
1   Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Mikrochirurgie, Schwerbrandverletztenzentrum, Klinik für Plastische und Handchirurgie an der Universität Heidelberg
2   Klinik für Plastisch-rekonstruktive, Ästhetische und Handchirurgie, Klinikum Kassel
,
Katrin Seidenstuecker
3   Abteilung für Plastische Chirurgie II, Rekonstruktive Mikro- und Lymphchirurgie, Sana-Kliniken Düsseldorf, Standort Benrath
,
Christian Taeger
4   Abteilung für Plastische, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Regensburg
,
Hans-Günther Machens
5   Klinik für Plastische Chirurgie und Handchirurgie, Klinikum rechts der Isar der Technischen Universität München, Deutschland
,
Andreas Frick
6   Abteilung für Handchirurgie, Plastische Chirurgie und Ästhetische Chirurgie Campus Innenstadt und Großhadern der Ludwig-Maximilians Universität Münche
,
Yves Harder
7   Klinik für Plastische, Rekonstruktive und Ästhetische Chirurgie, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale, Lugano, Schweiz
› Author Affiliations
Further Information

Publication History

18 December 2018

02 March 2019

Publication Date:
08 May 2019 (online)

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Zusammenfassung

Das sekundäre Lymphödem ist eine komplexe Erkrankung, die durch chronische Inflammation und reduzierte Immunkompetenz, Ansammlung von Lymphflüssigkeit und Proteinablagerungen sowie sekundärer Fettablagerung und Fibrosierung bei der Stadienmigration charakterisiert ist. Während die Domäne der Behandlung immer noch eine lebenslange komplexe physikalische Entstauungstherapie (KPE) ist, wird der Fokus auf chirurgische Verfahren zur physiologischen Rekonstruktion gesetzt. Die lymphovenösen Anastomosen (LVA) und die freie, vaskularisierte Lymphknotentransplantation (VLKT) sind die am verbreitetsten angewendeten, rekonstruktiven Techniken, die die Wiederherstellung oder Verbesserung der physiologischen Lymphtransportkapzität adressieren. Der vorliegende Artikel fasst die Empfehlungen eines Expertenpanels zur Diagnostik, Indikation und Therapie von LVA und VLKT bei sekundären Lymphödemen während der 40. Jahrestagung der Deutschsprachigen Arbeitsgemeinschaft für Mikrochirurgie der peripheren Nerven und Gefäße (DAM) in Lugano, Schweiz, zusammen und diskutiert sie. Das Expertengremium befasste sich mit der Diagnostik für die lymphorekonstruktive Chirurgie, einschließlich der essentiellen Anwendung der Fluoreszenz-Lymphangiographie mit Indocyaningrün (ICG) und der intraoperativen Navigation für beide Techniken sowie dem „reverse mapping“, um die Rate des Hebestellen-Lymphödems nach VLKT zu reduzieren, sowie die Verwendung von Lymphödem-spezifischen Fragebögen zur Lebensqualität. Sowohl LVA als auch VLKT werden einschließlich Tipps und Tricks zur Identifizierung funktioneller Lymphkollektoren, Ausrüstung, Anastomosenarten und Dokumentation für LVA sowie Auswahl der Spender- und Empfängerstelle, Anzahl der inkludierten Lymphknoten und Herangehensweise an spezifische Spenderstellen, wie z. B. jejunal-mesenterial für den VLKT, beschrieben. Die synchrone und sequentielle Anwendung von LVA, VLKT und/oder ablativer Liposuktion wird vor dem Hintergrund der Wirksamkeit und Morbidität diskutiert. Schließlich werden Empfehlungen zur postoperativen Behandlung und Diagnostik erörtert. Die vorliegende Konsensusarbeit adressiert eine Erhöhung des Standardisierungsgrades der Behandlung für weitere multizentrische Studien im deutschsprachigen Raum in diesem aufstrebenden Gebiet der Lymphödemtherapie.

Abstract

Secondary lymphedema is a complex and devastating disease including chronic inflammation and reduced immunofunction, lymphatic fluid and protein accumulation due to misdirected lymphatic transport, and secondary fat deposition followed by fibrosis. While the domain of treatment still is lifelong complex decongestive therapy, it is more and more widespread to treat the disease with a surgical focus on physiologic, reconstructive strategies or debulking surgery. Lymphovenous Anastomosis (LVA) and Vascularized lymph node transplantation (VLNT) are the mostly frequently applied, reconstructive techniques which address restoration or improvement of physiologic lymph clearance. The article summarizes and discusses the recommendations of an expert panel on the diagnostic, indication and therapy of LVA and VLNT in secondary lymphedema during the 40th Meeting of the Germanspeaking Society of Microsurgery in Lugano, Switzerland, 2018. The expert panel addressed the basic diagnostics prior to lymphoreconstructive surgery, including the inevitable application of Indocyanine Green (ICG) based fluorescence lymphangiography and navigation for both techniques including reverse mapping to reduce the rate of donor-site lymphedema for VLNT as well as the use of lymphedema-specific quality of life questionnaires. Both LVA and VLNT are elaborately described, including tips and tricks on identifying functional lymphatic collectors, equipment, types of anastomosis and documentation for LVA and choice of donor and recipient site, number of includable lymph nodes and management of specific donor sites, e. g. jejunal mesenteric for VLNT. The synchronous and sequential application of LVA, VLNT and/or ablative liposuction is discussed against the background of the effectivity and morbidity of both reconstructive, physiologic techniques. Finally, recommendations on post-operative treatment and diagnostics are discussed. The present consensus paper intends to improve the level of standardization for further multicenter studies in the germanspeaking countries in this aspiring field of lymphedema treatment.

Schlüsselwörter

Lymphödem - sekundär - lymphovenöse Anastomosen (LVA) - vaskularisierter Lymphknotentransfer - Konsensus - rekonstruktiv - Mikrochirurgie

Key words

lymphedema - secondary - lymphovenous anastomosis (LVA) - vascularized lymph node transfer (VLNT) - consensus - reconstructive - microsurgery
 

  • Literatur

  • 1 Olszewski WL. The pathophysiology of lymphedema – 2012. Handchirurgie, Mikrochirurgie, plastische Chirurgie : Organ der Deutschsprachigen Arbeitsgemeinschaft fur Handchirurgie : Organ der Deutschsprachigen Arbeitsgemeinschaft fur Mikrochirurgie der Peripheren Nerven und Gefasse 2012; 44: 322-328
    PubMedSearch in Google Scholar
  • 2 [Anonym]. S2k Leitlinie Diagnostik und Therapie des Lymphödems AWMF Reg.-Nr. 058–001. AWMF, DOI:
    PubMed
  • 3 Moffatt CJ, Franks PJ, Doherty DC. et al. Lymphoedema: an underestimated health problem. QJM 2003; 96: 731-738
    CrossrefPubMedSearch in Google Scholar
  • 4 Borup Christensen S, Lundgren E. Sequelae of axillary dissection vs. axillary sampling with or without irradiation for breast cancer. A randomized trial. Acta Chir Scand 1989; 155: 515-519
    PubMedSearch in Google Scholar
  • 5 Hirche C, Mohr Z, Kneif S. et al. The role of nodal staging in breast cancer. Past, present and future. Minerva Chir 2010; 65: 537-546
    PubMedSearch in Google Scholar
  • 6 Langer I, Guller U, Berclaz G. et al. Morbidity of sentinel lymph node biopsy (SLN) alone versus SLN and completion axillary lymph node dissection after breast cancer surgery: a prospective Swiss multicenter study on 659 patients. Annals of surgery 2007; 245: 452-461
    CrossrefPubMedSearch in Google Scholar
  • 7 Ozcinar B, Guler SA, Kocaman N. et al. Breast cancer related lymphedema in patients with different loco-regional treatments. Breast 2012; 21: 361-365
    CrossrefPubMedSearch in Google Scholar
  • 8 De Groef A, Van Kampen M, Tieto E. et al. Arm lymphoedema and upper limb impairments in sentinel node-negative breast cancer patients: A one year follow-up study. Breast 2016; 29: 102-108
    CrossrefPubMedSearch in Google Scholar
  • 9 Mohr Z, Hirche C, Gretschel S. et al. [Risk factors for the development of lymphatic fistula after ilioinguinal lymph node dissection before isolated limb perfusion and its potential clinical relevance]. Zentralbl Chir 2011; 136: 386-390
    Thieme ConnectPubMedSearch in Google Scholar
  • 10 Todo Y, Yamazaki H, Takeshita S. et al. Close relationship between removal of circumflex iliac nodes to distal external iliac nodes and postoperative lower-extremity lymphedema in uterine corpus malignant tumors. Gynecol Oncol 2015; 139: 160-164
    CrossrefPubMedSearch in Google Scholar
  • 11 Yamazaki H, Todo Y, Takeshita S. et al. Relationship between removal of circumflex iliac nodes distal to the external iliac nodes and postoperative lower-extremity lymphedema in uterine cervical cancer. Gynecol Oncol 2015; 139: 295-299
    CrossrefPubMedSearch in Google Scholar
  • 12 Baumeister RG, Mayo W, Notohamiprodjo M. et al. Microsurgical Lymphatic Vessel Transplantation. Journal of reconstructive microsurgery 2016; 32: 34-41
    PubMedSearch in Google Scholar
  • 13 Chang DW. Lymphaticovenular bypass surgery for lymphedema management in breast cancer patients. Handchirurgie, Mikrochirurgie, plastische Chirurgie : Organ der Deutschsprachigen Arbeitsgemeinschaft fur Handchirurgie : Organ der Deutschsprachigen Arbeitsgemeinschaft fur Mikrochirurgie der Peripheren Nerven und Gefasse 2012; 44: 343-347
    PubMedSearch in Google Scholar
  • 14 Cheng MH, Chen SC, Henry SL. et al. Vascularized groin lymph node flap transfer for postmastectomy upper limb lymphedema: flap anatomy, recipient sites, and outcomes. Plastic and reconstructive surgery 2013; 131: 1286-1298
    CrossrefPubMedSearch in Google Scholar
  • 15 Garza RM, Chang DW. Lymphovenous bypass for the treatment of lymphedema. Journal of surgical oncology 2018; 118: 743-749
    CrossrefPubMedSearch in Google Scholar
  • 16 Nguyen AT, Chang EI, Suami H. et al. 29:An Algorithmic Approach to Simultaneous Vascularized Lymph Node Transfer with Microvascular Breast Reconstruction. Ann Surg Oncol 2015; 22: 2919-2924
    CrossrefPubMedSearch in Google Scholar
  • 17 Saaristo AM, Niemi TS, Viitanen TP. et al. 9:Microvascular breast reconstruction and lymph node transfer for postmastectomy lymphedema patients. Annals of surgery 2012; 255: 468-473
    CrossrefPubMedSearch in Google Scholar
  • 18 Campisi C, Boccardo F. Vein graft interposition in treating peripheral lymphoedemas. Handchirurgie, Mikrochirurgie, plastische Chirurgie : Organ der Deutschsprachigen Arbeitsgemeinschaft fur Handchirurgie: Organ der Deutschsprachigen Arbeitsgemeinschaft fur Mikrochirurgie der Peripheren Nerven und Gefasse 2003; 35: 221-224
    PubMedSearch in Google Scholar
  • 19 O’Brien BM, Mellow CG, Khazanchi RK. et al. Long-term results after microlymphaticovenous anastomoses for the treatment of obstructive lymphedema. Plastic and reconstructive surgery 1990; 85: 562-572
    CrossrefPubMedSearch in Google Scholar
  • 20 Basta MN, Gao LL, Wu LC. Operative treatment of peripheral lymphedema: a systematic meta-analysis of the efficacy and safety of lymphovenous microsurgery and tissue transplantation. Plastic and reconstructive surgery 2014; 133: 905-913
    CrossrefPubMedSearch in Google Scholar
  • 21 Chang DW, Kim S. Breast reconstruction and lymphedema. Plastic and reconstructive surgery 2010; 125: 19-23
    PubMedSearch in Google Scholar
  • 22 Cheng MH, Lin CY, Patel K. The Groin vs. Submental Vascularized Lymph Node Flaps: A Head-to-Head Comparison of Surgical Outcomes Following Treatment for Upper Limb Lymphedema. Plastic and reconstructive surgery 2015; 136: 135
    PubMedSearch in Google Scholar
  • 23 Demirtas Y, Ozturk N, Yapici O. et al. Comparison of primary and secondary lower-extremity lymphedema treated with supermicrosurgical lymphaticovenous anastomosis and lymphaticovenous implantation. Journal of reconstructive microsurgery 2010; 26: 137-143
    Thieme ConnectPubMedSearch in Google Scholar
  • 24 Gould DJ, Mehrara BJ, Neligan P. et al. Lymph node transplantation for the treatment of lymphedema. Journal of surgical oncology 2018; 118: 736-742
    CrossrefPubMedSearch in Google Scholar
  • 25 Mihara M, Hara H, Araki J. et al. Indocyanine green (ICG) lymphography is superior to lymphoscintigraphy for diagnostic imaging of early lymphedema of the upper limbs. PLoS One 2012; 7: e38182
    CrossrefPubMedSearch in Google Scholar
  • 26 Xiong L, Engel H, Gazyakan E. et al. Current techniques for lymphatic imaging: State of the art and future perspectives. Eur J Surg Oncol 2014; 40: 270-276
    CrossrefPubMedSearch in Google Scholar
  • 27 Yamamoto T, Narushima M, Yoshimatsu H. et al. Dynamic Indocyanine Green (ICG) lymphography for breast cancer-related arm lymphedema. Ann Plast Surg 2014; 73: 706-709
    CrossrefPubMedSearch in Google Scholar
  • 28 Yamamoto T, Yamamoto N, Doi K. et al. Indocyanine green-enhanced lymphography for upper extremity lymphedema: a novel severity staging system using dermal backflow patterns. Plastic and reconstructive surgery 2011; 128: 941-947
    CrossrefPubMedSearch in Google Scholar
  • 29 Patel KM, Manrique O, Sosin M. et al. Lymphatic mapping and lymphedema surgery in the breast cancer patient. Gland Surg 2015; 4: 244-256
    PubMedSearch in Google Scholar
  • 30 Yamamoto T, Narushima M, Doi K. et al. Characteristic indocyanine green lymphography findings in lower extremity lymphedema: the generation of a novel lymphedema severity staging system using dermal backflow patterns. Plastic and reconstructive surgery 2011; 127: 1979-1986
    CrossrefPubMedSearch in Google Scholar
  • 31 Devoogdt N, De Groef A, Hendrickx A. et al. Lymphoedema Functioning, Disability and Health Questionnaire for Lower Limb Lymphoedema (Lymph-ICF-LL): reliability and validity. Phys Ther 2014; 94: 705-721
    CrossrefPubMedSearch in Google Scholar
  • 32 Patel KM, Lin CY, Cheng MH. A Prospective Evaluation of Lymphedema-Specific Quality-of-Life Outcomes Following Vascularized Lymph Node Transfer. Ann Surg Oncol 2015; 22: 2424-2430
    CrossrefPubMedSearch in Google Scholar
  • 33 Yamamoto T, Koshima I. A prospective analysis of 100 consecutive lymphovenous bypass cases for treatment of extremity lymphedema. Plastic and reconstructive surgery 2014; 133: 887e-888e
    CrossrefPubMedSearch in Google Scholar
  • 34 Yang JC, Wu SC, Chiang MH. et al. Intraoperative identification and definition of “functional” lymphatic collecting vessels for supermicrosurgical lymphatico-venous anastomosis in treating lymphedema patients. Journal of surgical oncology 2018; 117: 994-1000
    CrossrefPubMedSearch in Google Scholar
  • 35 Maegawa J, Yabuki Y, Tomoeda H. et al. Outcomes of lymphaticovenous side-to-end anastomosis in peripheral lymphedema. J Vasc Surg 2012; 55: 753-760
    CrossrefPubMedSearch in Google Scholar
  • 36 Tourani SS, Taylor GI, Ashton MW. Long-Term Patency of Lymphovenous Anastomoses: A Systematic Review. Plastic and reconstructive surgery 2016; 138: 492-498
    CrossrefPubMedSearch in Google Scholar
  • 37 Jorgensen MG, Toyserkani NM, Sorensen JA. The effect of prophylactic lymphovenous anastomosis and shunts for preventing cancer-related lymphedema: a systematic review and meta-analysis. Microsurgery. 2017 DOI: 10.1002/micr.30180
    PubMedSearch in Google Scholar
  • 38 Ito R, Suami H. Overview of lymph node transfer for lymphedema treatment. Plastic and reconstructive surgery 2014; 134: 548-556
    CrossrefPubMedSearch in Google Scholar
  • 39 Cheng MH, Huang JJ, Wu CW. et al. The mechanism of vascularized lymph node transfer for lymphedema: natural lymphaticovenous drainage. Plastic and reconstructive surgery 2014; 133: 192e-198e
    CrossrefPubMedSearch in Google Scholar
  • 40 Ito R, Zelken J, Yang CY. et al. Proposed pathway and mechanism of vascularized lymph node flaps. Gynecol Oncol 2016; 141: 182-188
    PubMedSearch in Google Scholar
  • 41 Becker C, Assouad J, Riquet M. et al. Postmastectomy lymphedema: long-term results following microsurgical lymph node transplantation. Annals of surgery 2006; 243: 313-315
    CrossrefPubMedSearch in Google Scholar
  • 42 Cheng MH, Huang JJ, Nguyen DH. et al. A novel approach to the treatment of lower extremity lymphedema by transferring a vascularized submental lymph node flap to the ankle. Gynecol Oncol 2012; 126: 93-98
    CrossrefPubMedSearch in Google Scholar
  • 43 Engel H, Lin CY, Huang JJ. et al. Outcomes of Lymphedema Microsurgery for Breast Cancer-related Lymphedema With or Without Microvascular Breast Reconstruction. Annals of surgery 2018; 268: 1076-1083
    CrossrefPubMedSearch in Google Scholar
  • 44 Gustafsson J, Chu SY, Chan WH. et al. Correlation between Quantity of Transferred Lymph Nodes and Outcome in Vascularized Submental Lymph Node Flap Transfer for Lower Limb Lymphedema. Plastic and reconstructive surgery 2018; 142: 1056-1063
    CrossrefPubMedSearch in Google Scholar
  • 45 Yang CY, Ho OA, Cheng MH. et al. Critical Ischemia Time, Perfusion, and Drainage Function of Vascularized Lymph Nodes. Plastic and reconstructive surgery 2018; 142: 688-697
    CrossrefPubMedSearch in Google Scholar
  • 46 Dayan JH, Dayan E, Smith ML. Reverse lymphatic mapping: a new technique for maximizing safety in vascularized lymph node transfer. Plastic and reconstructive surgery 2015; 135: 277-285
    CrossrefPubMedSearch in Google Scholar
  • 47 Pasko JL, Garreau J, Carl A. et al. Axillary reverse lymphatic mapping reduces patient perceived incidence of lymphedema after axillary dissection in breast cancer. Am J Surg 2015; 209: 890-895
    CrossrefPubMedSearch in Google Scholar
  • 48 Demiri E, Dionyssiou D, Tsimponis A. et al. Donor-Site Lymphedema Following Lymph Node Transfer for Breast Cancer-Related Lymphedema: A Systematic Review of the Literature. Lymphatic research and biology 2018; 16: 2-8
    CrossrefPubMedSearch in Google Scholar
  • 49 Viitanen TP, Maki MT, Seppanen MP. et al. Donor-site lymphatic function after microvascular lymph node transfer. Plastic and reconstructive surgery 2012; 130: 1246-1253
    CrossrefPubMedSearch in Google Scholar
  • 50 Coriddi M, Skoracki R, Eiferman D. Vascularized jejunal mesenteric lymph node transfer for treatment of extremity lymphedema. Microsurgery 2017; 37: 177-178
    CrossrefPubMedSearch in Google Scholar
  • 51 Coriddi M, Wee C, Meyerson J. et al. Vascularized Jejunal Mesenteric Lymph Node Transfer: A Novel Surgical Treatment for Extremity Lymphedema. Journal of the American College of Surgeons 2017; 225: 650-657
    CrossrefPubMedSearch in Google Scholar
  • 52 Chang K, Xia S, Sun YG. et al. [Liposuction combined with lymphatico-venous anastomosis for treatment of secondary lymphedema of the lower limbs: a report of 49 cases]. Zhonghua Wai Ke Za Zhi 2017; 55: 274-278
    PubMedSearch in Google Scholar