Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3798_Библиотеки_им_академика_М_И_Перельмана.pdf
42 Lymphatic-Lymphatic Reconstructive Microsurgery
Indications for Lymphatic Reconstruction Using Lymphatic Grafts
359
Secondary lymphedemas due to a locally interrupted lymphatic system are the main
indication for lymphatic grafting.
10,11
Arm edemas after axillary node dissection are a predominant form of chronic
lymphedema in the countries outside the tropical region and are those mostly treated
in our series.
Leg edema after the interventions in the inguinal or pelvic region is also common
in developed countries generally as unilateral lymphedema. This iatrogenic condition can also be treated by transposing the lymphatic vessels from the healthy to the
affected side. One leg has to serve as the harvesting side.
In primary lymphedemas, a selected group with unilateral atresias of the inguinal
and/or pelvic region can be treated by lymphatic grafting as well.
In cases with a history of malignancies, the patient must be tested to be tumor-free.
Since the burden of surgery is comparable to that of venous interventions in the subcutaneous tissue, there is almost no known general restriction for this type of surgery.
Each patient should report adequate conservative treatment before the surgery of
at least 6 months’ duration. During that time period, spontaneous regression of the
edema is also reported.
Therefore, before the reconstructive surgery is performed, the patient has to get a
complete set of lymphatic decongestion therapy, including manual lymphatic drainage, elastic stockings, and compression bandage therapy for at least half a year.
Operative Technique
The grafts are harvested from the medial aspect of the thigh (Fig. 42.4). As many as
16 lymphatic vessels can be found within the ventromedial bundle. About one to
three vessels are used as grafts, but should be harvested with caution avoiding the
narrowing portions of the lymphatic system at the groin and at the knee region.
The lymph nodes at the knee region as well as the groin are not touched or
removed to spare the lymphatic system as much as possible.
The number of lymphatic collectors, used for grafting, is sufficient for reconstructive purposes, since anatomical studies also showed that only one preserved
lymphatic collector of the long lateral bundle of the upper arm is able to prevent a
patient after axillary node dissection from developing arm edema.
12
To facilitate the preparation, about 15 min before the incision, Patent blue® is
injected subdermally into the first to second web space. The joints are moved to
improve the transport of the dye.
The incision is started medial to the palpable vessels beneath the inguinal ligament. The incision is extended distally step-by-step following the direction of the
stained vessels.
360 R.G.H. Baumeister
Fig. 42.4 Harvesting lymphatic vessels from the patient’s thigh
Also, the ramifications of the main lymphatic collectors can be saved to use for
anastomosing purposes. Therefore, more lympho-lymphatic anastomoses can be
performed at the affected extremity as the equivalent of the number of the harvested
main collectors. For safety reasons, it is necessary that stained lymphatic vessels
also remain untouched.
Depending on the length of the thigh, the grafts can be harvested up to a length
of about 30 cm. The grafts are secured at the proximal end with 6–0 sutures and
transected proximally and distally. Distally on the transected side, the proximal
ends of incoming lymphatic vessels are ligated to avoid lymphatic leakages.
In arm edemas (Fig. 42.5), an oblique incision is performed at the inner aspect of
the upper arm. Under the microscope, the tissue is searched for lymphatic vessels.
Since the transport of dye is disturbed in lymphedema, no staining is performed.
At the neck, an oblique incision is made at the dorsal rim of the sternocleidomastoid muscle. Prior to this step, a dye injection is performed cranial to the ear to
enhance the chance of dyeing the lymphatic vessels at the neck. Behind the muscle
up to the lateral border of the internal jugular vein, thin-walled lymphatic vessels
can be found. Often, it is easier to prepare several lymph nodes.
In between the incisions at the upper arm and the neck, a tunnel is created by
blunt dissection, and a silicon tube is temporarily inserted, and with its help, the
grafts are pulled through. Finally, the tube is removed, and the grafts lie in the subcutaneous tissue without friction.
The anastomoses are performed under the “tension-free” anastomosing technique in an end-to-end or end-to-side fashion with 10–0 absorbable suture material.
In the neck region lympho-lymphonodular anastomoses can also be performed.
In unilateral lymphedema of the lower extremities (Fig. 42.6), the grafts remain
attached to the inguinal lymph nodes on the harvesting side. Ascending lymphatics
are dissected via an incision below the inguinal ligament on the affected side. The
grafts are placed in a technique similar to that in arm edemas. After microsurgical
lympho-lymphatic anastomosing, the lymph flows via the grafts to the healthy side.
42 Lymphatic-Lymphatic Reconstructive Microsurgery
Fig. 42.5 Bridging a
lymphatic gap at the axilla
with autogenous lymphatic
vessels by lympho-lymphatic
anastomoses at the upper arm
and the neck
361
Fig. 42.6 Lymphatic grafting in unilateral
lymphedema of lower extremities; the
grafts remain attached to the inguinal
lymph nodes
362 R.G.H. Baumeister
In penile and scrotal edemas with at least one edema-free leg, short lymphatic
collectors, remaining attached to the inguinal lymph nodes can be anastomosed
with draining lymphatic vessels at the route of the penis and the scrotum.
Post-operative Procedures
The limbs are elevated, and bed rest is recommended for 3 days. For about 5 days,
antibiotics are given, and infusions of low molecular dextran or HAES are administered. Elastic bandaging is applied, and elastic stockings should be worn for
6 months. In addition, a prophylaxis against erysipelas is recommended for the
same time period. Thereafter, we try to discontinue the additional therapy.
Results
In patients, follow-up studies included volume measurement of the affected extremity as well as of the harvesting area, lymphoscintigraphic studies, quality of life
interrogations; more invasive procedures like indirect lymphographies using water
soluble contrast medium and MRI lymphographies using gadolinium are undertaken among selected patients.
As complications, one patient developed a lymph cyst at the groin that was
treated with puncture drainage. One patient developed a swelling of the lower leg
due to the venous thrombosis and two patients showed postoperative erysipelas in
the first series of our patients prior to the routine post-operative administration of
antibiotics.
Starting in June 1980 and continuing until January 2009, a total of 329 patients
were treated: 187 suffered from arm edemas, 132 from leg edemas, and 10 from
scrotal and penile lymphedema.
In arm edemas as well as in leg edemas, more than 60% of the patients showed a
reduction in volume difference to the healthy side of more than 50% after a mean
follow-up period of more than 2 years.
In 100 arm edemas after a follow-up of more than 1 year a significant reduction
in volume from 3,234 ± 78 cm³ to 2,597 ± 66 cm³ compared with a volume of the
healthy contralateral arm of 2,181 ± 46 (p < 0.001) was demonstrated.
Follow-up in arm edemas up to at least 10 years also showed a significant reduction after this long period of time (mean volumes: 2,918 ± 141–2,243 ± 147 cm³
compared with 1,890 ± 88 cm³ in the healthy arm).
The patency of the graft was confirmed in an indirect way via lymphoscintigraphy.13 In arm edemas, the route of the grafts was able to track down along the visible
tracts of the tracer activity, whereas no such activity has been found prior to the
transplantation. In edemas of the lower extremities, the radioactive tracer activity
was able to be tracked toward the contralateral groin where the transposed cross-over
11,13
42 Lymphatic-Lymphatic Reconstructive Microsurgery
363
grafts remained attached to the nodes following the injection of radiotracer only to
the affected limb.
The proof of long-term patency was also possible after more than 10 years with
indirect lymphography in the upper and lower extremities, and more than 7 years
with MRI lymphoscintigraphies in the lower extremities.
Lymphoscintigraphy also enabled us to calculate the overall function of the lymphatic system of an extremity.
14,15
The lymphatic transport index was also feasible to estimate the function of the
graft.13 Hereby, the investigators of the department of nuclear medicine summarized
the findings as a score between 0 and 45:0 for the best and 45 for the worst outflow.
The difference between normal and pathological status is calculated based on the
transport index of 10.
A follow-up study within 7 years showed a score of 10 in the group with a clearly
visible activity of the transplants, which means it reached the value of a normal
lymphatic outflow. Since the decrease in limb volume runs parallel to the improvement shown on lymphoscintigraphy, it suggests a potential chance for a cure and
freedom from further additional treatment.
15
In long-standing lymphedemas with excess accumulation of adipose and fibrous
tissue, additional removal of surplus tissue with lymphatic sparing suction might be
added to get closer to the condition/shape of the healthy extremity without continuous treatment.
References
1. Cordeiro AK, Bracat FF, Al Assal F. Transplantation of lymphatic ducts, preliminary and
experimental report. In: Abstract VII Congress of Lymphology Florence; 1979.
2. Baumeister RGH, Seifert J, Wiebecke B. Transplantation of lymph vessels on rats as well as a
first therapeutic application on the experimental lymphedema of the dog. Eur Surg Res.
1980;12(suppl 2):7.
3. Baumeister RGH, Seifert J, Wiebecke B, Hahn D. Experimental basis and first application of
clinical lymphvessel transplantation of secondary lymphedema. World J Surg. 1981;5:401-407.
4. Földi M. Physiologie des Lymphgefäßsystems. Angiologica. 1971;8:212.
5. Földi M, Földi E. Physiology and pathophysiology of the lymphatic system. In: Földi M, Földi
E, eds. Földi’s Textbook of Lymphology. 2nd ed. Munich: Mosby/Elsevier; 2006.
6. Frick A, Hoffmann JN, Baumeister RGH, Putz R. Liposuction technique and lymphatic lesions
in lower legs – anatomic study to reduce risks. Plast Reconstr. Surg. 1999;103:1868-1873
7. Brorson H, Svensson H. Complete reduction of lymphedema of the arm by liposuction after
breast cancer. Scand J Plast Reconstr Surg Hand Surg. 1997;31:137-143.
8. Danese C, Bower R, Howard J. Experimental anastomosis of lymphatics. Arch Surg.
1962;84:24.
9. Yuwono HS, Klopper PJ. Comparison of lymphatic and venous interpositional autografts in
experimental microsurgery of the canine lymphatics. Plast Reconstr Surg. 1990;86:752-757.
10. Baumeister RG, Siuda S. Treatment of lymphedemas by microsurgical lymphatic grafting:
what is proved? Plast Reconstr Surg. 1990;85:64-74.
11. Baumeister RGH, Frick A. Die mikrochirurgische Lymphgefäßtransplantation. Handchir
Mikrochir Plast Chir. 2003;35:202-209.
12. Kubik S. Zur klinischen Anatomie des Lymphsystems. Verh Anat Ges. 1975;69:109-116.
364 R.G.H. Baumeister
13. Kleinhans E, Baumeister RGH, Hahn D, Siuda S, Buell U, Moser E. Evaluation of transport
kinetics in lymphoscintigraphy: follow-up study in patients with transplanted lymphatic vessels. Eur J Nucl Med. 1985;10:349-352.
14. Notohamiprodjo M, Baumeister RG, Jakobs TF, et al. MR-lymphangiography at 3.0 T—
a feasibility study. Eur Radiol. 2009;19(11):2771-2778. Epub Jun 6, 2009.
15. Weiss M, Baumeister RGH, Hahn D. Post-therapeutic lymphedema: scintigraphy before and
after autologous lymph vessel transplantation 8 years of long term follow-up. Clin Nucl Med.
2002;27(11):788-792.
Chapter 43
Lymph Node-Venous Microvascular
Reconstructive Surgery: Filariasis
Lymphedema
Gurusamy Manokaran
Lymphatic filariasis is one of the most chronic, incapacitating diseases; once it was
believed that there was no treatment. Ancient sculptures and scriptures depict lymphatic filariasis of the lower limb and still can be seen in many temples in India.
According to Manusrithi’s 300 BC written in Hindu mythology it was mentioned,
and some native treatments also have been mentioned. It was considered to be
caused by Karma (result of sins from a previous life), but through science and technology we have been able to identify the organism and its transmission to human
beings from the mosquito. Initially, a lot of medical and surgical treatments were
done unsuccessfully and this disease was classified as “neglected tropical disease.” Because exicisional surgery has not given good results, during the era of
microvascular reconstructive surgery in 1963 Niclubowicz, Olszewski developed
this nodovenal anastomosis in artificial lymphedema produced in dogs; subsequently this procedure was tried in various parts of world in human beings
with lymphedema. This procedure is a surgery of choice for treatment of early
lymphedema in some centers and in cases of elephantiasis before performing
cyto-reductive/debulking procedures. This nodovenal anastomosis is more of a
physiological procedure
of the afferent lymphatics to connect to the efferent lymphatics (e.g., lymphatic
filariasis, posttraumatic lymphedema, postinflammatory lymphedema). This is not
useful in disease for which there is no lymphatics or lymph node (e.g., after mastectomy, after irradiation, and congenital lymphedemas).
Thus, in developed countries, where lymphedema is mainly due to mastectomy,
irradiation, and congenital etiology, this procedure is not very popular, although it
has been introduced in Europe.
1-10
and is very useful when there is a deformity or disease
G. Manokaran
Department of Plastic and Reconstructive Surgery and Lymphologist,
Apollo Hospitals, 21, Greams Road, Chennai, India
B.-B. Lee et al. (eds.), Lymphedema,
DOI 10.1007/978-0-85729-567-5_43, © Springer-Verlag London Limited 2011
365
366 G. Manokaran
Lymph
node
Afferent
Vessels
Vein
abc
Fig. 43.1 Diagrammatic representation of a nodovenous by-pass (micro-vascular anastomosis)
(a) vein and node showing (dotted lines) the area to be shaved (b) anastomosis of node-vein end to
side (c) completion of anastomosis
NodoVenal Shunt
Indications
1. Patients with competent saphenofemoral junction.
2. Patients without inguinal abscess or sepsis.
3. All grades of lymphedema.
4. There should be a healthy and functioning lymph node (lymphoscintigraphy or
ultrasound finding).
Surgical Techniques
There are two methods of anastomosis: end to end or end to side (Fig. 43.1).
End-to-End Anastomosis
Nodovenal shunting for lower limb lymphedema is carried out with the patient in a
supine position under general or regional anesthesia. A vertical incision of 3 cms is
made, in the upper part of the thigh just medial to the femoral pulsations, and the long
saphenous vein or a good caliber vein is exposed. Ligate the distal end with chromic
43 Lymph Node-Venous Microvascular Reconstructive Surgery: Filariasis Lymphedema
catgut and the upper end is cut open like a fish mouth. There should not be any retrograde
flow in the proximal segment, proving that there is no sapheno-femoral incompetence.
Identify a vertical group of inguinal lymph nodes, these nodes must be reasonably big
(at least 1 cm in diameter) and pink in color. No dissection is performed around the
lymph node so that both afferent and efferent lymphatics are preserved. Shave the
upper capsule of the lymph nodes and you can see the lymph ooze from the cut surface.
Avoid using diathermy; if it is urgently needed use bipolar diathermy, so that it causes
less damage to the surroundings. Anastomose the proximally cut long saphenous vein
to the cut surface of the capsule of the node using 6-0 or 7-0 nylon continuous suture.
Then the wound is closed in layers after perfect hemostasis. No drain is required.
End-to-Side Anastomosis
A nodovenal shunt can be placed end-to-side also. In this method a vertical stab incision of 0.5–1 cm is made, depending upon the vein caliber, with an 11-sized blade.
The stab incision is made after applying vascular clamps proximally and distally and
the cut surface of the node is anastomosed with the vertical stab incision into the vein
using 8-0 nylon, interrupted sutures. Clamps are released and observed for filling of
the vein. Continuous irrigation of the anastomosis site with heparinized saline should
be performed because clot formation is common with this technique. When there is
no healthy or reasonable sized lymph node in the inguinal region, multiple lymphatic
channels can be buried into the continuous vein at three or four places. The open end
of the lymphatics are left in the venous lumen to float (use an 18-gauge needle to stab);
lymphatic vessels are anchored with 8–0 nylon as a single suture. This technique is
known as lymphatic venous anastomosis.
367
Contraindications
1. No visible lymph node in lymphoscintigraphy or in ultrasound
2. Associated varicose veins or sapheno-femoral incompetence
3. No reduction of circumferential measurements of the leg at any given point, even
after 6 days of MLD (manual lymph drainage)
4. Acute ADL (adeno-dermo-lymphangitis)
5. Elderly patients
6. Associated medical diseases
Complications
1. Seroma
2. Lymphorrohea
3. Lymphocele
4. Wound dehiscence
368 G. Manokaran
Free Omental Transfer
11,12
This procedure is carried out in lymphatic filariasis, post-traumatic, and postsurgical
lymphedemas. In lymphatic filariasis with lower limb lymphedemas, through a
vertical, upper thigh mid-line incision, the GSV, superficial circumflex iliac artery,
and the inguinal lymph nodes or lymphatics are exposed and prepared for microvascular anastomosis. The abdomen is opened with a lower transverse incision and the
omentum is dissected with its artery, vein, and lymphatics, which can be anastomosed
with the respective artery, vein, and lymphatics. A small window during the closure
of the thigh incision is left open for assessment of the viability of the omentum,
which can be closed secondarily. The abdomen is closed in layers after perfect
hemostasis.
The tunneling of the omentum into the inguinal region (omentoplasty), was
initially popular with Russian surgeons in the management of various types of
lymphedemas, but was subsequently abandoned, because of the increased incidence
of lymphangitis of the leg, leading to peritonitis as the omentum was kept in continuity.
Surgery for lymphedema should not cause mortality, although a certain amount of
morbidity is acceptable.
References
1. Campisi C, Boccardo F. Microsurgical techniques for lymphedema treatment: derivative lym-
phatic-venous microsurgery. World J Surg. 2004;28(6):609-613.
2. Clodius L, Piller NB, Casley-Smith JR. The problems of lymphatic microsurgery for lym-
phedema. Lymphology. 1981;14(2):69-76.
3. Olszewski WL. The treatment of lymphedema of the extremities with microsurgical lympho-
venous anastomoses. Int Angiol. 1988;7(4):312-321.
4. Gloviczki P. Microsurgical lymphovenous anastomosis for treatment of lymphedema: a critical
review. J Vasc Surg. 1988;7(5):647-652.
5. Gloviczki P. The natural history of microsurgical lymphovenous anastomoses: an experimental
study. J Vasc Surg. 1986;4(2):148-156.
6. Zolotorevskii VIa. Late results of lymphovenous anastomoses in lymphedema of the lower
extremities. Khirurgiia (Mosk). 1990;5:96-101.
7. O’Brien BM. Long-term results after microlymphaticovenous anastomoses for the treatment
of obstructive lymphedema. Plast Reconstr Surg. 1990;85(4):562-572.
8. Yamamoto Y. Microsurgical lymphaticovenous implantation for the treatment of chronic lym-
phedema. Plast Reconstr Surg. 1998;101(1):157-161.
9. Manokaran G. Management of genital manifestations of lymphatic filariasis. Indian J Urol.
2005;21(1):39-43.
10. Huang GK. Results of microsurgical lymphovenous anastomoses in lymphedema—report of
110 cases. Langenbecks Arch Chir. 1989;374(4):194-199.
11. Binoy C, GovardhanaRao Y, Ananthakrishnan N, Kate V, Yuvaraj J, Pani SP. Omentoplasty in
the management of filarial lymphoedema. Trans R Soc Trop Med Hyg. 1998;92(3):317-319.
12. Goldsmith HS, de los Santos R, Beattie EJ. Relief of chronic lymphedema by omental trans-
position. Ann Surg. 1967;166:572.