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Further reading
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153Further reading
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CHAPTER
8
Lymphatic reconstruction
Annika Mohr, Daniel Palmes, Felix Becker
Clinic of General, Visceral and Transplantation Surgery, University
Hospital M€unster, M€unster, Germany
Introduction
Lymphatic reconstruction as a surgical approach is mostly
utilized for patients with destructed or obstructed lymphatic vessels
who are suffering from secondary lymphedema [1]. The accumula-
tion of abnormal fluid in the interstitium results in an enlargement
of the affected area [2]. Due to continued lymphatic stasis, inflam-
matory activation bay immune cells, cytokines, and microorganisms
might lead to inflammation, gradual fibrosis, and thus a decrease in
the number of functional lymphatic channels [1]. Underlying
reasons for the disruption of the lymphatic drainage system are
mostly posttraumatic, postinfectious, or postinflammational due
to surgery, radiotherapy, or cancer [3]. However, clinical manifesta-
tion may be delayed after the initial incidence by months or
even years.
Nevertheless if once occurred, adjusted treatment is initiated for
providing symptomatic improvement and deceleration of the
progressive disease with conservative therapy representing the
today’s gold standard [4]. Although for most patients beneficial,
major disadvantages are the required compliance of the patient,
as well as the lifelong commitment necessary for a prosperous
therapy.
Thus, surgical treatment options represent an additional option
when conservative therapy is unable to control the symptoms of
155Lymphatic Structure and Function in Health and Disease
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lymphedema [1]. Specifically, patients with insufficient reduction
by medical and physical therapy (less than 50%) and those dissatis-
fied by the results of conservative methods and willing to proceed
with surgical options might benefit from surgical reconstruction
approaches of the lymphatic system [5].
History of surgical approac hes for lymphatic reconstruction
Surgical approaches for lymphatic reconstruction are per-
formed since the 1960s. Niebulowisz et al. performed a lymph-
draining anastomosis between a lymph node and a neighboring
vein in patients with secondary lymphedema of the lower limb
[6]. Subsequent research about the mechanisms of the develop-
ment of secondary lymphedema mostly due to improvement of
imaging systems led to adjustments of surgical methods. Thus,
spontaneous lymphatic pulse, stagnation of tissue fluid, and the
presence of bacterial flora could be visualized [7–9]. In addition
to that, the improveme nt of microsurgical equipment (e.g., micro-
scope and atraumatic sutures) helped to facilitate lymphatic
reconstruction [10,11].
Current options for lymphatic reconstruction
Lymphaticovenular anastomosis
First anastomoses between lymph vessels and veins were per-
formed in the 1960s due to the introduction of d issection micro-
scopes into surgery [10]. The procedure should imitate the
natural communication between lymphatics and veins, thus redir-
ecting the accumulated lymph fluid into the venous system. Since
the first approaches, several studies have been cond ucted leading
to a variation of surgical techniques (e.g., end to end, end to side,
and side to end) and heterogeneous evidence of t reatment effec-
tiveness. Major problems when utilizing this technique are high
venous blood pressure and consequently the risk of thrombus for-
mation due to blood coagulation [12].
156 8. Lymphatic reconstruction
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