Добавил:

Sekretar kiopkiopkiop18@yandex.ru t.me/Prokururor I Вовсе не секретарь, но почту проверяю Опубликованный материал нарушает ваши авторские права? Сообщите нам.

Вуз:

Ростовский Государственный Медицинский Университет

Предмет:

Медицина общая

Файл:

Книга_3996_Библиотеки_им_академика_М_И_Перельмана

.pdf

Скачиваний:

Добавлен:

12.10.2026

Размер:

5 Мб

Скачать

☆

<<< < Предыдущая 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 1617 / 1717

To enhance long-term outcome, the measurement of endolym-

phatic pressure, lymphatic flow rate, and venous pressure is recom-

mended before the performance of microsurgical anastomosis [3].

Thus, optimal conditions could be created for the best approach.

Moreover, whenever possible, lymphatic vessels with contracting

ability should be chosen for the anastomosis [13]. In addition to that,

patency of the selected vessels should be proven prior surgery [14].

It has also been shown that the absence of blood inside of the venous

branch utilized for the anastomosis decreases the risk of thrombosis

[15,16]. Most successful results could be accomplished in patients

with local, segmental obstructions in the proximal lymph

vessels [17].

First results in patients suffering from secondary lymphedema

were promising indicating adequate decompression of the limb

[18,19]. However, long-term results were less effective in the prox-

imal compared with the distal part of the extremity [18]. The

authors concluded the higher degree of destruction of the proximal

lymphatic system was responsible for this phenomenon suggesting

surgery at an earlier time when lymphatic disruption is less

advanced. Consequently, it is generally recommended to treat

lymphedema with lymphaticovenular anastomosis as early as pos-

sible [15,16], before the development of tissue fibrosis or lymphatic

damage due to increasing tissue pressure or infection. Neverthe-

less, the impact of duration and severity of lymphedema is classi-

fied differentially with some surgeons claiming to have found no

influence of the length of the condition of the patient on the out-

come after surgery [11,20].

Regarding the technique of anastomosis (e.g., end to end, end

to side, and side to end), most authors indicated their choice was

based on anatomical conditions at the site of operation after iso-

lating lymphatics and veins [3,15,16].Incontrasttotheother

options, side-to-end anastomosis preserves t he original flow of

the lymphatic fluids and offers the possibility for further opera-

tions at the same vessels if an obstruction of the first anastomosis

occurs [21]. Nevertheless, this procedure is more complex, which

is why a novel method was introduced to facilitate side-to-end

anastomosis. With expanding the lymphatic vessel, shortly before

performing the anastomosis, the creation of a lateral window in

the lymphatic wall is facilitated, thus improving the success rate

157Current options for lymphatic reconstruction

https://t.me/medicina_free

in the performed study [22]. Obstacles still present small lym-

phatic vessels with a diameter below 0.35mm where side-to-

end anastomosis is not recommended even after expansion due

to a relatively high failure rate. Follow-up studies indicated ben-

eficial results after lymphaticovenular anastomosis with immedi-

ate and long-term significant improvements [11,12,14–16,20,21,23].

In conclusion, lymphaticovenular anastomosis represents a

promising approach for decreasing secondary lymphedema. Nev-

ertheless, postoperative compressive therapy still has to be

performed. Additionally, it has to be noted that the aforemen-

tioned studies utilized different methods and follow-up periods.

For the determination of patency, methods varied from circumfer-

ence measurement to v olumetry, lower extremity lymphedema

(LEL) index, or lymphoscintigraphy. Thus, a direct comparison

between the studies appears to be challenging. Yet, objective

and subjective results are indicating a place in the treatment of

secondary lymphedema especially when conservative therapy is

failing.

Vascularized lymph node transfer

Vascularized lymph node transfer represents a relatively novel

method where a transfer into regions with dissected lymph nodes

(e.g., cancer treatment) or into distal regions of limbs with lymph-

edema is performed to reestablish lymphatic drainage function [24].

Starting in animal studies, vascularized lymph node transfer

showed a complete preservation of the original histological struc-

tures [25] in contrast to what has been seen in a vascularized lymph

node transfers [26,27].

First attempts in clinical studies in 1982 showed a stable reduction

of lymphedema after transferring inguinal lymph nodes to the

contralateral inguinal region [28]. Similar results have been reported

for the upper extremity with a transfer either into the axillary region

[29] or into the wrist area [30].

In general, all studies performed on vascularized lymph node

transfer showed favorable outcomes for the patients after surgery

including reduction of lymphedematous limb volumes, infections,

and improved quality of life [31–34]. Lymph node flap harvest is

performed from different areas of the donor including groin,

158 8. Lymphatic reconstruction

https://t.me/medicina_free

submental, supraclavicular, lateral thoracic, gastroepiploic, jejunal,

appendicular, and ileocecal with no general ideal recommendation

until now. For better outcomes, lymph nodes may be transferred

with a skin paddle containing lymph capillaries, thus facilitating

recanalization of the lymphatic system [24].

It has to be noted that only few long-term results are available for

vascularized lymph node transfers until now. Moreover, the inter-

action between transferred lymph node and the lymphatic system

in the recipient area still needs to be elucidated. In addition, the risk

of causing lymphedema in the region of the donor lymph node

might be heightened [35–37]. Despite the promising technique,

additional excisional procedures are recommended after vascular-

ized lymph node transfers in patients suffering from secondary

lymphedema.

Lympholymphatic graft

In contrast to lymphaticovenular anastomosis and vascularized

lymph node transfer, only few studies have been conducted evalu-

ating lymphatic grafts in lymphedema treatment. First attempts of

harvesting autologous lymphatic grafts to bypass damaged lym-

phatic vessels resulted in not only volume reduction of 80% but also

high risk of donor site morbidity [38]. The bypass should be carried

out prior permanent damage of the remainder lymphatic vessels

due to back pressure or infection [39].

Alternatively, vein grafts have been used in patients with chronic

lymphedema to obtain a lymphatic-venous-lymphatic bypass [15,16]

with the result of improvement of both limb function and edema.

Most recent studies aimed to develop tissue-engineered grafts to

reestablish lymphatic circulation [40], and first studies under cultur-

ing conditions offered promising results for future clinical applica-

tion and as a potential new treatment option for secondary

lymphedema [41].

Conclusion

Nevertheless, until now, and despite the promising results

regarding the surgical approaches of lymphatic reconstruction, it

has to be noted that lymphatic reconstruction is still a palliative

159Conclusion

https://t.me/medicina_free

procedure. The creation of a bypass system for lymphatic system

offers no elimination of the etiologic factor; thus, obstructions or

destructions of the lymphatic vessel and infections leading to

decreased transport capacity of lymphatic fluid are still present.

In addition to that, in most cases, conservative therapy is still

required even though surgical reconstruction was performed. Fur-

ther improvement of the surgical techniques and a consensus in

standardized protocols and reporting of outcome is finally needed

to enhance and consolidate lymphatic reconstruction in secondary

lymphedema.

References

[1] Kung TA, Champaneria MC, et al. Current concepts in the surgical Manage-

ment of Lymphedema. Plast Reconstr Surg 2017;139(4).

[2] Ozturk CN, Ozturk C, et al. Free vascularized lymph node transfer for treat-

ment of lymphedema: a systematic evidence based review. J Plast Reconstr

Aesthet Surg 2016;69(9):1234–47.

[3] Campisi C, Boccardo F. Frontiers in lymphatic microsurgery. Microsurgery

1998;18(8):462–71.

[4] Becker C, Vasile JV, et al. Microlymphatic surgery for the treatment of iatro-

genic lymphedema. Clin Plast Surg 2012;39(4):385–98.

[5] Boccardo F, Fulcheri E, et al. Lymphatic microsurgery to treat lymphedema:

techniques and indications for better results. Ann Plast Surg 2013;71(2):191–5.

[6] Nielubowicz J, Olszewski W. Surgical lymphaticovenous shunts in patients

with secondary lymphoedema. Br J Surg 1968;55(6):440–2.

[7] Olszewski WL. Episodic dermatolymphangioadenitis (DLA) in patients with

lymphedema of the lower extremities before and after administration of ben-

zathine penicillin: a preliminary study. Lymphology 1996;29(3):126–31.

[8] Olszewski WL. Contractility patterns of human leg lymphatics in various

stages of obstructive lymphedema. Ann N Y Acad Sci 2008;010.

[9] Olszewski WL, Engeset A, et al. Lymph flow and protein in the normal male leg

during lying, getting up, and walking. Lymphology 1977;10(3):178–83.

[10] Jacobson II JH, Suarez EL. Microvascular surgery. Dis Chest 1962;41:220–4.

[11] Koshima I, Inagawa K, et al. Supermicrosurgical lymphaticovenular anastomo-

sis for the treatment of lymphedema in the upper extremities. J Reconstr Micro-

surg 2000;16(6):437–42.

[12] Winters H, Tielemans HJP, et al. The efficacy of lymphaticovenular

anastomosis in breast cancer-related lymphedema. Breast Cancer Res Treat

2017;165(2):321–7.

[13] Campisi C, Bellini C, et al. Microsurgery for lymphedema: clinical research and

long-term results. Microsurgery 2010;30(4):256– 60.

160 8. Lymphatic reconstruction

https://t.me/medicina_free

[14] Demirtas Y, Ozturk N, et al. Supermicrosurgical lymphaticovenular anastomo-

sis and lymphaticovenous implantation for treatment of unilateral lower

extremity lymphedema. Microsurgery 2009;29(8):609 – 18.

[15] CampisiC,BoccardoF,etal.Long-termresu lts after lymphatic-venous anastomo-

ses for the treatment of obstructive lymphedema. Microsurgery 2001;21(4):135–9.

[16] Campisi C, Boccardo F, et al. The use of vein grafts in the treatment of periph-

eral lymphedemas: long-term results. Microsurgery 2001;21(4):143–7.

[17] Olszewski WL. The treatment of lymphedema of the extremities with microsur-

gical lympho-venous anastomoses. Int Angiol 1988;7(4):312–21.

[18] O’Brien BM, Mellow CG, et al. Long-term results after microlymphaticovenous

anastomoses for the treatment of obstructive lymphedema. Plast Reconstr Surg

1990;85(4):562–72.

[19] O’Brien BM, Shafiroff BB. Microlymphaticovenous and resectional surgery in

obstructive lymphedema. World J Surg 1979;3(1):3–15.

[20] Koshima I, Nanba Y, et al. Long-term follow-up after lymphaticovenular anas-

tomosis for lymphedema in the leg. J Reconstr Microsurg 2003;19(4):209–15.

[21] Maegawa J, Yabuki Y, et al. Outcomes of lymphaticovenous side-to-end anas-

tomosis in peripheral lymphedema. J Vasc Surg 2012;55(3):753–60.

[22] Yamamoto T, Yoshimatsu H, et al. Side-to-end lymphaticovenular anastomosis

through temporary lymphatic expansion. PLoS One 2013;8(3):25.

[23] Cornelissen AJM, Kool M, et al. Lymphatico-venous anastomosis as treatment

for breast cancer-related lymphedema: a prospective study on quality of life.

Breast Cancer Res Treat 2017;163(2):281–6.

[24] Ito R, Suami H. Overview of lymph node transfer for lymphedema treatment.

Plast Reconstr Surg 2014;134(3):548–56.

[25] Shesol BF, Nakashima R, et al. Successful lymph node transplantation in rats,

with restoration of lymphatic function. Plast Reconstr Surg 1979;63(6):817–23.

[26] Jaffe HL, Richter MN. The regeneration of autoplastic lymph node transplants.

J Exp Med 1928;47(6):977–80.

[27] Tobbia D, Semple J, et al. Experimental assessment of autologous lymph node

transplantation as treatment of postsurgical lymphedema. Plast Reconstr Surg

2009;124(3):777–86.

[28] Clodius L, Smith PJ, et al. The lymphatics of the groin flap. Ann Plast Surg

1982;9(6):447–58.

[29] Becker C, Assouad J, et al. Postmastectomy lymphedema: long-term results fol-

lowing microsurgical lymph node transplantation. Ann Surg 2006;243(3):313–5.

[30] Lin CH, Ali R, et al. Vascularized groin lymph node transfer using the wrist as a

recipient site for management of postmastectomy upper extremity lymph-

edema. Plast Reconstr Surg 2009;123(4):1265–75.

[31] Cheng MH, Huang JJ, et al. A novel approach to the treatment of lower extrem-

ity lymphedema by transferring a vascularized submental lymph node flap to

the ankle. Gynecol Oncol 2012;126(1):93–8.

[32] Ciudad P, Maruccia M, et al. The laparoscopic right gastroepiploic lymph node

flap transfer for upper and lower limb lymphedema: technique and outcomes.

Microsurgery 2017;37(3):197–205.

161References

https://t.me/medicina_free

[33] De Brucker B, Zeltzer A, et al. Breast Cancer-related lymphedema: quality of

life after lymph node transfer. Plast Reconstr Surg 2016;137(6):1673–80.

[34] Gratzon A, Schultz J, et al. Clinical and psychosocial outcomes of vascularized

lymph node transfer for the treatment of upper extremity lymphedema after

breast Cancer therapy. Ann Surg Oncol 2017;24(6):1475–81.

[35] Pons G, Masia J, et al. A case of donor-site lymphoedema after lymph node-

superficial circumflex iliac artery perforator flap transfer. J Plast Reconstr

Aesthet Surg 2014;67(1):119–23.

[36] Sulo E, Hartial a P, et al. Risk of donor-sit e lymphatic vessel dysfunction

after microvascular lymph node transfer. J Plast Reconstr Aesthet Surg

2015;68(4):551–8.

[37] Viitanen TP, Maki MT, et al. Donor-site lymphatic function after microvascular

lymph node transfer. Plast Reconstr Surg 2012;130(6):1246–53.

[38] Baumeister RG, Siuda S. Treatment of lymphedemas by microsurgical lym-

phatic grafting: what is proved? Plast Reconstr Surg 1990;85(1):64–74.

[39] Ho LC, Lai MF, et al. Microlymphatic bypass in obstructive lymphoedema. Br

J Plast Surg 1988;41(5):475–84.

[40] Kanapathy M, Patel NM, et al. Tissue-engineered lymphatic graft for the treat-

ment of lymphedema. J Surg Res 2014;192(2):544–54.

[41] Kanapathy M, Kalaskar D, et al. Development of a tissue-engineered lymphatic

graft using nanocomposite polymer for the treatment of secondary lymph-

edema. Artif Organs 2016;40(3):30.

162 8. Lymphatic reconstruction

https://t.me/medicina_free

Index

Note: Page numbers followed by f indicate figures, and t indicate tables.

Aging

CNS lymphatics in, 98–101

influences of, 76–86

Alzheimer’s disease (AD), 99

Angiopoietins, 13

Anoctamin-1 (ANO1), 24–25

Arthritic diseases, 35–37

Atrioventricular (AV) nodal conduction,

129

Cancer, 39–41

Cardiac lymphatics

characteristics, 127–128

within different cardiac structures,

131–136

experimental ablation effects, 139–142

experimental manipulation, cardiac

therapy, 142–144

flow of lymph in heart, 129–131

Fontan procedure, 138–139

inflammation and, 136–137

valves in lymphatic vessels, 137–138

in ventricular septum, 129

Central nervous system (CNS) lymphatics

aging, 98–101

Alzheimer’s disease, 99

cerebral ischemic injury, 100

characteristics, 93–97

in diseases, 96–97

drug delivery, 102–103

for drug discovery, 101–102

glymphatic pathway, 95–96

meningeal pathway, 96–97

microinfarcts, 100

multiple sclerosis, 99–100

perivascular pathway, 94–95

Centrifugal model, 7–9

Centripetal model, 6–9

Cerebral ischemic injury, 100

Chemokine production, 101

Cholesterol, reverse transport, 133

Circulatory system, 1, 4

Congenital vascular malformations

(CVMs), 3, 109

Contractility, pressure/stretch, 62–66

Cyclooxygenase-2 (COX-2), 136

Cystic/cavernous lymphangioma, 111

Cytokines, 101

Diabetes, 38–39

EphB4, 13

Ephrins, 13

Extratrucular lymphatic malformation,

111f, 112

Extrinsic lymph pump, 58–62

Fontan-Kreutzer procedure, 138–139

FOXC2, 32–33

Glymphatic pathway, 95–96

Heart, flow of lymph in, 129–131.