Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3783_Библиотеки_им_академика_М_И_Перельмана

The early years following the rst clinical description of vas­cularized lymph node transplant (VLNT) by Becker were met with excitement but also justiable skepticism and con­cerns regarding its safety [1]. On one hand, there was a visionary procedure using familiar microsurgical techniques that could potentially treat a disabling and relentlessly pro­gressive disease. On the other hand, the concept of harvest­ing lymph nodes with a risk of causing iatrogenic lymphedema seemed altogether misguided. I recall argu­ments for VLNT along the lines of “donor site lymphedema has not been reported,” until, of course, reports of iatrogenic lymphedema began to surface [2]. The risk/benet equation for a procedure with signicant uncertainty and signicant risk clearly tipped the scale out of favor. Until there would be greater safety and a satisfactory degree of efcacy, the VLNT procedure failed to gain traction for about 20years since its introduction.

applied it to vascularized lymph node harvest for both the groin and axillary donor sites [6]. We initially used blue dye but a major limitation became clear: the critical lymph nodes draining blue dye could not be identied until you were directly in contact with the lymph node, risking injury to the efferent and afferent lymphatics and circulation which could compromise the node. We had modied the technique to use ltered technetium injected into the extremity (hand or foot) and indocyanine green (ICG) dye injected into the trunk. Technetium provided two advantages: (1) critical lymph nodes could be localized prior to the incision and throughout the dissection providing a GPS-like system for maximum safety; and (2) the uptake into any lymph node could be quantied with a 10-second count. This quantication allowed for formal evaluation of the percent of uptake into the harvested lymph nodes compared to the limb sentinel nodes that were left behind. Injection of ICG into the upper limb has since been described, providing a more convenient and cost-effective alternative [7]. The authors still prefer technetium because the uptake can be quantied, unlike ICG, which is either “on” or “off,” and allows for earlier identication. Since the author has routinely used VLNT with reverse lymphatic mapping, donor site lymphedema has not been observed in over 200 patients with follow-up rang­ing from 1 to 10years. While the data demonstrates a solid safety prole, all patients are informed very clearly of the risk of donor site lymphedema. There is also a risk that there is shared drainage between the sentinel nodes draining the limb and those draining the trunk, in which case one cannot safely complete the lymph node ap harvest. This potential scenario (approximately 5% in our series) should be dis­cussed with the patient prior to surgery and a backup plan should be included in the consent. Most commonly, we will list a second potential donor site. The omentum and supra­clavicular lymph nodes are alternative options in this sce­nario that have virtually eliminated the risk of donor site lymphedema, but are not always feasible depending on the requirements of the defect.