MICROSURGICAL LYMPHATIC VASCULAR GRAFTING AND SECONDARY LIPOSUCTION: RESULTS OF COMBINATION TREATMENT IN SECONDARY LYMPHEDEMA

Surgical treatment of lymphedema with liposuction typically requires subsequent compression therapy. Here we describe an approach where secondary arm lymphedemas are initially treated by autologous lymphatic grafting to bypass the axilla and restore lymphatic flow. In the presence of excess adipose tissue, liposuction is then performed in a second procedure. To assess outcomes, the authors evaluated 28 consecutive adult patients who had undergone secondary liposuction following lymphatic grafting. Arm volumes were measured prior to lymphatic grafting and after the secondary liposuction. The necessity for additional treatment by compression garment and manual lymphatic drainage was assessed prior to lymphatic grafting and after the secondary liposuction following the direct postoperative regimen. The mean arm volumes were reduced significantly (p<0.001) from a mean of 3417±171 (SEM) cm3 prior to lymphatic grafting to 3020±125 cm3 after reconstruction of the lymphatic vascular system and finally to 2516±104 cm3 after the secondary liposuction (SLS). All 28 adult patients underwent continuous compression and manual lymph-drainage (MLD) prior to the reconstructive surgery. All 28 patients were evaluated regarding necessity of any additional therapy more than 6 months after SLS with a median follow up period of 37 months (range, 7-160 months). 18 of 28 patients did not require any supportive therapy beyond 6 months after SLS to maintain the results. Three patients continued to utilize manual lymphatic drainage, 4 used a combination of MLD and compression therapy and 3 used elastic compression therapy (one patient only while at work). These results indicate that microsurgical restoration of lymphatic outflow followed by SLS eliminates the need for additional treatment in more than two thirds of patients.

Microsurgical lymphatic vascular grafting and secondary liposuction: Results of combination treatment in secondary lymphedema

Surgical treatment of lymphedema with liposuction typically requires subsequent compression therapy. Here we describe an approach where secondary arm lymphedemas are initially treated by autologous lymphatic grafting to bypass the axilla and restore lymphatic flow. In the presence of excess adipose tissue, liposuction is then performed in a second procedure. To assess outcomes, the authors evaluated 28 consecutive adult patients who had undergone secondary liposuction following lymphatic grafting. Arm volumes were measured prior to lymphatic grafting and after the secondary liposuction. The necessity for additional treatment by compression garment and manual lymphatic drainage was assessed prior to lymphatic grafting and after the secondary liposuction following the direct postoperative regimen. The mean arm volumes were reduced significantly (p<0.001) from a mean of 3417± 171 (SEM) cm3 prior to lymphatic grafting to 3020±125 cm3 after reconstruction of the lymphatic vascular system and finally to 2516±104 cm3 after the secondary liposuction (SLS). All 28 adult patients underwent continuous compression and manual lymph-drainage (MLD) prior to the reconstructive surgery. All 28 patients were evaluated regarding necessity of any additional therapy more than 6 months after SLS with a median follow up period of 37 months (range, 7-160 months). 18 of 28 patients did not require any supportive therapy beyond 6 months after SLS to maintain the results. Three patients continued to utilize manual lymphatic drainage, 4 used a combination of MLD and compression therapy and 3 used elastic compression therapy (one patient only while at work). These results indicate that microsurgical restoration of lymphatic outflow followed by SLS eliminates the need for additional treatment in more than two thirds of patients.

Lymphsequenzszintigraphie für die nichtinvasive Langzeitbeobachtung des funktionellen Therapieerfolges nach Transplantation autologer Lymphgefäße

Ziel: Die autologe Lymphgefäßtransplantation führt bei bestehendem Lymphödem zu einer signifikanten Verbesserung der Lymphabflußverhältnisse. Die vorliegende Studie untersucht, ob die Lymphsequenzszintigraphie geeignet ist, die persistierende Funktion autologer Lymphgefäßtransplantate und damit den Erfolg dieser Operationsmethode zu dokumentieren. Methoden: In die Studie gingen die Daten von 20 Patienten (17 Frauen und 3 Männer) ein. Anlaß für die Operation war in 4 Fällen ein primäres, in 16 Fällen ein sekundäres Lymphödem. Szintigraphi-sche Analogaufnahmen mit semiquantitativer Beurteilung des Lymphtransportes erfolgten als Ausgangsuntersuchung vor Transplantation und anschließend über einen Zeitraum von sieben Jahren. Ergebnisse: Bei 17 von 20 Patienten (Transplantationssitus: obere Extremität n = 12, untere Extremität n = 8) war postoperativ eine persistierende Verbesserung des Lymphtransportes im Vergleich zur präoperativen Situation an einem signifikanten Abfall der Transportindices nachweisbar. Bei 5 Patienten gelang zusätzlich die direkte szintigraphische Darstellung der Lymphgefäßtransplantate. In diesen Fällen konnte postoperativ ein signifikant höherer Abfall der Transportindices im Vergleich zu Patienten ohne szintigraphisch darstellbares Transplantat beobachtet werden. Lediglich 3 der 20 Patienten zeigten keine Besserung im Vergleich zur Ausgangssituation. Schlußfolgerungen: Somit erwies sich die Lymphsequenzszintigraphie mit semiquantitativer Einschätzung der Lymphabflußverhältnisse vor und nach autologer Lymphgefäßtransplantation als einfache, nicht invasive Untersuchungsmethode zur objektiven Beurteilung des Therapieerfolges im Langzeitverlauf. Eine szintigraphisch direkte Darstellung des autologen Lymphgefäßtransplantats scheint einen prognostisch günstigen Faktor bezüglich der postoperativen Lymphdrainage darzustellen.

The clinical yield of SPECT/CT for the assessment of lymphatic transport disorders

Ziel dieser Studie war zu untersuchen, ob die zusätzliche Bildgebung mittels SPECT/CTTechnik den diagnostischen Wert der planaren Lymphszintigraphie bei Patienten mit Lymphtransportstörungen verbessern kann. Patienten, Methoden: Über einen festgelegten Zeitraum von zwei Jahren wurden 36 konsekutive Patienten (27 Frauen, 9 Männer, Alter 27–87 Jahre) in unsere Studie eingeschlossen. Zusätzlich zur planaren Lymphszintigraphie wurden weitere ergänzende SPECT/CT-Akquisitionen der betroffenen Extremitäten oder des Körperstamms durchgeführt. Insgesamt erfolgte eine prospektive Auswertung von 48 anatomischen Lymphabflussregionen mittels planarer Szintigraphie und tomographischer SPECT/CT. Ergebnisse: In 28/48 Fällen (58%) brachte die SPECT/CTBildgebung klinisch relevante Zusatzinformationen im Vergleich zur planaren Technik; darunter 27 bezüglich der exakten anatomischen Lokalisation der Transportstörungen sowie 8 Fälle, bei denen die Ausdehnung der lymphogenen Störung mittels SPECT/CT ausgedehnter beurteilt wurde als in der alleinigen planaren Szintigraphie. In 3 Fällen konnte durch die SPECT/CT differenzialdiagnostisch zwischen Lymphknoten versus Lymphozele differenziert werden. In keinem der Fälle konnten Lymphgefäße/-transplantate durch die morphologische CT-Komponente dargestellt werden. Schlussfolgerungen: Die zusätzlich zur planaren Lymphszintigraphie durchgeführte SPECT/CT präzisiert die anatomische Zuordnung lymphogen bedingter Transportstörungen und somit die Abschätzung der Ausdehnung der Pathologie. Des Weiteren löst sie Überlagerungseffekte anatomischer Strukturen durch die tomographische Akquisition auf und ermöglicht die Differenzialdiagnose von Lymphknoten versus Lymphozelen.

[Microsurgical Autologous Lymph Vessel Transplantation: Does Harvesting Lymphatic Vessel Grafts Induce Lymphatic Transport Disturbances in the Donor Limb?]

OBJECTIVE

The aim of this study was to determine whether the extirpation of lymphatic vessels induces lymphatic transport disturbances in the donor limb of patients following the harvest of lymph vessel grafts.

PATIENTS, MATERIAL AND METHODS

A total of 19 consecutive patients (15 females, 4 males; mean age 51.5 years, range 21.8-72.3) were examined by lymphoscintigraphy before and after surgery. The patients had previously been diagnosed with upper or lower limb lymphoedema in accordance with the criteria of the International Society of Lymphology, and autologous lymph vessel transplantation had been intended for treatment. Since only patients with normal scintigraphic tests at the harvesting site were considered for treatment, all consecutive patients (n=19) had normal scintigraphic tests of the donor limb prior to surgery. In order to quantify the visual scintigraphic findings, a well established numeric transport index (TI) was used, which combined 5 visual parameters of transport kinetics. To that end, the following visually assessed criteria were evaluated: temporal and spatial kinetics, radiopharmaceutical distribution pattern, time to appearance of inguinal lymph nodes, qualitative visualisation of lymph nodes and lymph vessels.

RESULTS

All patients underwent a preoperative scintigraphic baseline study and a postoperative scintigraphic follow-up after autologous lymphatic vessel grafting. The mean time period from the baseline study to the date of microsurgical lymph vessel transplantation was 3.5 months (median 2.5 months). The scintigraphic follow-up was performed 48.6 months (median 57.8 months) following transplantation. In all patients the postoperative TI was very close to the TI calculated in the preoperative baseline scintigraphy, and all TIs were within the normal range (TI<10). The absolute value of deviation of pre- vs. post-operative transport indices was calculated to be 0.2 on average (maximum 0.4).

CONCLUSIONS

The results show that microsurgical transfer of lymph vessel grafts is possible without compromising lymphatic drainage of the donor limb if safety precautions are taken into account.

Protective effects of activated protein C (APC) on free groin flaps after secondary venous stasis in the rat model

BACKGROUND

The goal of this study was to determine whether the focused delivery of APC by rinsing of free adipocutaneous groin flaps shows protective effects on flap survival following a fatal secondary venous stasis in a rat model.

METHODS

36 Sprague Dawley rats were randomized to three groups and free microvascular groin flaps were transplanted to the neck in each animal. 20 hours postoperatively the flap pedicle was re-explored and the distal stump of the flap artery was catheterised. Animals in group I (n = 12) remained untreated, whereas animals of group II were treated with 1 ml of Ringer's solution. Those in group III received 1 ml of APC (2 mg/kg). Afterwards the flap vein was clamped for 35 minutes. The skin of the flaps and the native contralateral groin was examined by intravital video microscopy using FITC-Dextran and CFDA-SE-labelled thrombocytes.

RESULTS

APC-pretreatment significantly increased the functional capillary density (FCD) of the flaps. Flap viability was 8% in group I (n = 1/12), 9% in group II (n = 1/11) and 60% in group III (n = 6/10), respectively. No partial flap loss was detected.

CONCLUSIONS

The focused delivery of APC resulted in significantly improved flap salvage.

Examination of the protective effects of heparin and recombinant tissue plasminogen activator (rtPA) in compromised adipocutaneous free flaps in the rat model using intravital video microscopy

BACKGROUND

The purpose of this study was to determine whether the focused delivery of heparin or recombinant tissue plasminogen activator (rtPA) by rinsing accords protective effects which increases the survival of free groin flaps following fatal secondary venous stasis.

METHODS

Free microvascular groin flaps (n = 40) were transplanted to the necks of adult Sprague-Dawley rats 20 hours before the experiment. The study groups (each n = 10 animals) were: No adjunctive treatment (Group I), Ringer's solution (Group II), heparin solution (100 IU/kg, group III) and rtPA (2 mg/kg, group IV), respectively. The flap vein was then clamped for 35 minutes. Intravital video microscopy was applied and flap viability was assessed 14 days later.

RESULTS

Mean flap necrosis was 90% in group I and II, whereas the rate of flap survival was 80% in group III and 60% in group IV, respectively.

CONCLUSIONS

Even though clinical and microvascular flap perfusion parameters in both the rtPA-group and heparin group were initially similar, it has been demonstrated here in our investigations that the flaps treated with heparin showed a higher viability rate. Therefore, we can conclude that the focused delivery of heparin and rtPA resulted in a significantly improved flap salvage.

Changes in quality of life of patients with lymphedema after lymphatic vessel transplantation

There are multiple treatment options for patients with chronic lymphedema, and one successful approach is lymph vessel transplantation. As quality of life assessments are frequently not utilized in standard treatment regimes, we investigated the change in quality of life for patients with chronic lymphedema (total = 212) who had undergone lymphatic vessel transplantation and conservative therapy for at least 6 months prior to operation. Quality of life was assessed by a modified standard questionnaire examining the physiological and psychological status of the patients. Results document a significant improvement in quality of life and underscore success of autologous lymphatic vessel transplantation as a therapy for lymphedema.

Revisionseingriffe nach Karpaldachspaltung

In the last eight years we performed 63 re-interventions because of recurrent carpal tunnel syndromes. Intact parts of the retinaculum were the reason for persistent symptoms in 38 patients. 21 patients suffered from scar tethering, two patients from circumferential fibrosis of the nerve. In one patient a ganglion and in another patient a direct injury to the median nerve was detected. In 21 patients short incisions were performed in the primary procedures. Since the introduction of endoscopic carpal tunnel release, an open decompression via a short incision is recommended as an alternative. Since then we encounter an increase of necessary operative revisions after short incisions. Optical tools may increase the survey especially in short incisions. In extended teno-synovialitis of the flexor tendons, a longer incision over the wrist enables adequate conditions for a safe teno-synovialectomy. The length of the incision has to be chosen according to the pathologic-anatomic situation, the disposable equipment and the experience of the surgeon.

[The microsurgical lymph vessel transplantation]

Using advanced microsurgical techniques, single lymph vessels can be safely anastomosed and segments of lymphatics can bridge localized lymphatic blockades which are mostly due to lymphadenectomies. Lymphatic grafts are harvested from the patient's thigh with a length up to about 30 cm. In the case of an axillary blockade they are anastomosed with ascending lymph vessels at the upper arm and lymph vessels at the supraclavicular region. Unilateral oedemas of lower extremities are treated by transferring the grafts via the symphysis and anastomosing them with ascending lymphatics at the affected side. Lymphoedemas of the penis and the scrotum as well as lymphoedemas due to a localized peripheral lymphatic blockade can be treated by lymphatic grafts. In 127 arm oedemas the original difference in volume between the affected and the healthy arm was reduced at two third from 3368 cm (3) to 2567 cm(3) (p < 0.001). After a follow-up period of 2.6 years the volume was reduced to 2625 cm(3) (p < 0.001). The group of patients with a follow-up of at least ten years showed a volume of 2273 cm(3) (p < 0.001). The volume of unilateral lower extremity-lymphoedemas was reduced from 13 098 cm(3) to 10 578 cm(3) (p < 0.001) and showed a volume of 11 074 cm(3) after 1.7 years (p < 0.001) and 10 692 cm(3) after four years (p < 0.001). The original mean volume of the healthy contralateral leg was 9371 cm(3). Bridging localized gaps in the lymphatic system by autologous lymphatic grafts showed long lasting stable results. Starting the treatment of lymphoedemas by conservative procedures, one should not wait too long to ascertain the possibility of a microsurgical reconstruction in order to avoid increasing secondary tissue changes.

[Planning and monitoring of autologous lymph vessel transplantation by means of nuclear medicine lymphoscintigraphy]

Autologous lymph vessel transplantation significantly improves the lymph drainage in patients with primary and secondary lymphedema. The aim of the present study was to prove whether scintigraphic long-term follow-up could demonstrate the function of autologous lymph vessels and the persisting success of this microsurgical technique respectively. In this study, visual and semiquantitative lymphoscintigraphy was used to prove the function of lymphatic vessel grafts in 20 patients comparing a preoperative baseline study with postoperative follow-up investigations once a year for a period of seven years. The reason for microsurgical lymph vessel transplantation was a primary (n = 4) or a secondary (n = 16) lymphedema. In 12 cases the transplantation site was at the upper extremity, in eight cases at the lower limb. In 17/20 patients lymphatic function significantly improved after autologous lymph vessel transplantation compared to the preoperative findings, as verified by visual improvement of lymph drainage and decrease of a numeric transport index. In 5/20 cases the vessel graft could be visualized directly. In these patients with scintigraphic visualization of the vessel graft, the transport index decreased to a significantly greater extent compared to the preoperative baseline study. 3/20 patients did not benefit from microsurgical treatment. Lymphoscintigraphy has shown to be an easy, reliable and readily available technique to assess lymphatic function on the long run. Scintigraphic visualization of the vessel graft showed a significantly better postoperative outcome than those without. The scintigraphic visualization of the vessel graft therefore seems to indicate a favourable prognosis regarding lymph drainage.

[Vascularisation of a free jejunal graft at the neck in an insufficient vascular situation]

Free jejunal grafts are the method of choice for one-stage reconstruction of the hypopharynx and the upper esophagus. Prerequisites for a successful free transplantation are a sufficient arterial vascularisation and a corresponding venous drainage. In a 59-year old patient, an esophagectomy was performed because of a proximal esophageal cancer. The passage was primarily reconstructed by a pedicled colon interposition. Necrosis of the cranial graft occurred. After resection of the necrotic bowel, a free jejunal graft was introduced thoraco-cervically. The nutrient vessels of the graft were anastomosed to the upper thyroid artery and the vena thyroid ima. In an operative revision one day postoperatively due to lacking re-capillarisation, the arterial inflow stopped. The superior thyroid artery was cut at its cranial origin at the external carotid artery and microsurgically implanted into the common carotid artery. Hereafter, a venous outflow was re-established. But the critical time of ischaemia was exceeded. In another operative revision, the cephalic vein was exposed at the cranial upper arm, distally cut and anastomosed to the re-implanted superior thyroid artery. After the harvest of a second autogenous jejunal graft, the arterio-venous shunt was cut and the segments were anastomosed to the mesenterial artery and vein. Transpositions of arteries and veins with temporary formation of an arterio-venous shunt may be prerequisites for a sufficient vascularisation and can enable a successful free microsurgical transplantation even in critical vascular situations.