Operative Therapiemöglichkeiten in der Lymphologie

Zusammenfassung

Das Lymphgefäßsystem ist essenziell für den Rücktransport interstitieller Flüssigkeit aus dem Gewebe zurück in den Blutkreislauf. Bei Störungen des komplexen Netzwerkes kommt es zur Ausbildung von Ödemen und der Ansammlung und Ablagerung von Proteinen und Lipiden in der betroffenen Region. Obwohl das Lymphsystem schon seit Jahrhunderten Gegenstand der Forschung ist, haben lymphologische Krankheitsbilder wie das Lymphödem als mögliche Folge onkologischer Therapien erst in den vergangenen Jahren an Aufmerksamkeit gewonnen. So liegt die Inzidenz des sekundären Lymphödems, das durch traumatische, infektiöse oder iatrogene Schädigung auftritt, zwischen 0,13 und 2 % und betrifft meist Frauen. Auch das davon abzugrenzende Lipödem ist in den letzten Jahren zunehmend in den Fokus der Öffentlichkeit gerückt. Beide Erkrankungen können mit einer schmerzhaften Umfangsvermehrung, einer beruflichen und alltäglichen Einschränkung und einer Reduktion der Lebensqualität einhergehen. Neben der klinischen Untersuchung und Anamnese gewinnen neue bildgebende Verfahren eine zunehmende Bedeutung zur Verbesserung der Diagnosestellung, Stadieneinteilung und Therapieplanung, wenngleich immer noch oftmals Monate bis Jahre bis zur korrekten Diagnosestellung vergehen. Während konservative Therapiemethoden wie die komplexe physikalische Entstauungstherapie weiterhin die Grundlage der Behandlung bilden, kommen zunehmend auch operative Verfahren bei der Therapie des Lymphödems zum Einsatz. Hierbei unterscheidet man die reduzierenden Verfahren, die hauptsächlich auf die Symptomreduktion abzielen, von den rekonstruktiven Verfahren zur Wiederherstellung des Lymphsystems mittels mikrochirurgischer Techniken. Nachfolgend werden verschiedene operative Therapiemöglichkeiten in der Lymphologie dargestellt.

Abstract

The lymphatic system is essential for the transport of interstitial fluid back into the vascular system. Disturbance of the complex network can lead to edema and the accumulation of proteins and lipids in the affected body region. Even though the lymphatic system has been a topic of intense research for centuries, lymphological diseases like lymphedema as a possible secondary effect of oncological treatment only recently gained attention. Secondary lymphedema can have traumatic, infectious or iatrogenic causes and mainly affects women with an incidence of 0.13–2 %. The lipedema is another disease with increasing public interest in recent years but should be differentiated from lymphedema. Both diseases can involve painful circumferential growth, limitations in the professional and private daily routine and lead to a reduced quality of life. Beside clinical examination new imaging techniques are of increasing importance for the diagnostic procedure, the staging and the planning of treatments. However, in many cases it takes months or even years until the correct diagnosis is found. While therapy is still based on conservative treatment options like the complex manual decongestion therapy, surgical treatment options are increasingly used for patients with lymphedema. Reducing surgical methods are mainly leading to a decrease of symptoms whereas reconstructive surgical techniques aim to reconstruct the lymphatic system using microsurgery. In the following, various surgical therapy options in lymphology are presented.

Schlüsselwörter

operative Lymphologie - LVA - VLNT - Liposuktion

Key words

surgical lymphology - LVA - VLNT - liposuction

Publikationsverlauf

Artikel online veröffentlicht:
29. Juli 2021

• Literatur

• 1 Petrek JA, Senie RT, Peters M. et al. Lymphedema in a cohort of breast carcinoma survivors 20 years after diagnosis. Cancer 2001; 92: 1368-1377
• 2 Warren AG, Brorson H, Borud LJ. et al. Lymphedema: a comprehensive review. Annals of plastic surgery 2007; 59: 464-472
• 3 Asim M, Cham A, Banerjee S. et al. Difficulties with defining lymphoedema after axillary dissection for breast cancer. N Z Med J 2012; 125: 29-39
• 4 Masia J. Surgical Treatment for Lymphedema: State of the Art. J Reconstr Microsurg 2016; 32: 1
• 5 Brorson H. Liposuction in Lymphedema Treatment. J Reconstr Microsurg 2016; 32: 56-65
• 6 Torre YS, Wadeea R, Rosas V. et al. Lipedema: friend and foe. Horm Mol Biol Clin Investig 2018; 33 (03)
• 7 Amann-Vesti BR, Franzeck UK, Bollinger A. Microlymphatic aneurysms in patients with lipedema. Lymphology 2001; 34: 170-175
• 8 Hirche C, Engel H, Seidenstuecker K. et al. [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)]. Handchir Mikrochir Plast Chir 2019; 51: 424-433
• 9 Zetzmann K, Ludolph I, Horch RE. et al. [Imaging for treatment planning in lipo-and lymphedema]. Handchir Mikrochir Plast Chir 2018; 50: 386-392
• 10 Chang DW, Masia J, Garza R. et al. Lymphedema: Surgical and Medical Therapy. Plast Reconstr Surg 2016; 138 (Suppl. 03) 209S-218S
• 11 Morgan PA, Murray S, Moffatt CJ. et al. The challenges of managing complex lymphoedema/chronic oedema in the UK and Canada. Int Wound J 2012; 9: 54-69
• 12 Campisi CC, Ryan M, Boccardo F. et al. A Single-Site Technique of Multiple Lymphatic-Venous Anastomoses for the Treatment of Peripheral Lymphedema: Long-Term Clinical Outcome. J Reconstr Microsurg 2016; 32: 42-49
• 13 Mehrara BJ, Zampell JC, Suami H. et al. Surgical management of lymphedema: past, present, and future. Lymphat Res Biol 2011; 9: 159-167
• 14 Campisi C, Bellini C, Campisi C. et al. Microsurgery for lymphedema: clinical research and long-term results. Microsurgery 2010; 30: 256-260
• 15 Boccardo F, Valenzano M, Costantini S. et al. LYMPHA Technique to Prevent Secondary Lower Limb Lymphedema. Ann Surg Oncol 2016; 23: 3558-3563
• 16 Baumeister RG, Mayo W, Notohamiprodjo M. et al. Microsurgical Lymphatic Vessel Transplantation. J Reconstr Microsurg 2016; 32: 34-41
• 17 Hartiala P, Saarikko AM. Lymphangiogenesis and Lymphangiogenic Growth Factors. J Reconstr Microsurg 2016; 32: 10-15
• 18 Becker C. Autologous Lymph Node Transfers. J Reconstr Microsurg 2016; 32: 28-33
• 19 Chu YY, Allen Jr RJ, Wu TJ. et al. Greater Omental Lymph Node Flap for Upper Limb Lymphedema with Lymph Nodes-depleted Patient. Plast Reconstr Surg Glob Open 2017; 5: e1288
• 20 Nguyen AT, Suami H. Laparoscopic Free Omental Lymphatic Flap for the Treatment of Lymphedema. Plast Reconstr Surg 2015; 136: 114-118
• 21 Forte AJ, Cinotto G, Boczar D. et al. Omental Lymph Node Transfer for Lymphedema Patients: A Systematic Review. Cureus 2019; 11: e6227
• 22 Ciudad P, Manrique OJ, Adabi K. et al. Combined double vascularized lymph node transfers and modified radical reduction with preservation of perforators for advanced stages of lymphedema. J Surg Oncol 2019; 119: 439-448
• 23 Saaristo AM, Niemi TS, Viitanen TP. et al. Microvascular breast reconstruction and lymph node transfer for postmastectomy lymphedema patients. Ann Surg 2012; 255: 468-473
• 24 Engel H, Lin CY, Huang JJ. et al. Outcomes of Lymphedema Microsurgery for Breast Cancer-related Lymphedema With or Without Microvascular Breast Reconstruction. Ann Surg 2018; 268: 1076-1083
• 25 Baumgartner A, Hueppe M, Schmeller W. Long-term benefit of liposuction in patients with lipoedema: a follow-up study after an average of 4 and 8 years. Br J Dermatol 2016; 174: 1061-1067
• 26 Brorson H, Svensson H, Norrgren K. et al. Liposuction reduces arm lymphedema without significantly altering the already impaired lymph transport. Lymphology 1998; 31: 156-172
• 27 Robering JW, Al-Abboodi M, Titzmann A. et al. Tissue Engineering of Lymphatic Vasculature in the Arteriovenous Loop Model of the Rat. Tissue Eng Part A 2021; 27: 129-141
• 28 Tammela T, Saaristo A, Holopainen T. et al. Therapeutic differentiation and maturation of lymphatic vessels after lymph node dissection and transplantation. Nat Med 2007; 13: 1458-1466
• 29 Chang DW, Dayan J, Greene AK. et al. Surgical Treatment of Lymphedema: A Systematic Review and Meta-Analysis of Controlled Trials. Results of a Consensus Conference. Plast Reconstr Surg 2021; 147: 975-993