Comprehensive Review Of Vascularized Lymph Node Transfers For Lymphedema: Outcomes And Complications

Mario F. Scaglioni, M.D.,1,3 Michael Arvanitakis, M.D.,3 Yen-Chou Chen, M.D.,1 Pietro Giovanoli, M.D.,3 Johnson Chia-Shen Yang, M.D.,1 And Edward I. Chang, M.D. Microsurgery 38:222–229, 2018

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Comprehensive Review Of Vascularized Lymph Node Transfers For Lymphedema: Outcomes And Complications

Mario F. Scaglioni, M.D.,1,3 Michael Arvanitakis, M.D.,3 Yen-Chou Chen, M.D.,1 Pietro Giovanoli, M.D.,3 Johnson Chia-Shen Yang, M.D.,1 And Edward I. Chang, M.D. Microsurgery 2018

Introduction: Lymphedema remains a challenging clinical problem. A new field of lymphatic surgery using micro and super microsurgery techniques is a rapidly advancing field aimed to treat recalcitrant cases. The objective of this study was to evaluate outcomes and complications of vascularized lymph node transfer (VLNT). Several early preliminary studies have reported promising outcomes, but they are limited by small numbers, short follow-up, and are inconsistent in addressing the origin and recipient site of the transferred lymph nodes as well as the donor site morbidity.

Methods: A review of literature was conducted using PubMed-MEDLINE, EMBASE for key words vascularized lymph node transfer (also autologous, lymph node transplant). Only human studies were included. Results: A total 24 studies encompassing 271 vascularized lymph node transfers were included. The inguinal nodes were the most commonly used donor site followed by the lateral thoracic lymph nodes. The lateral thoracic lymph nodes were the least effective and had the highest complication rates (27.5%) compared to other lymph node donor sites (inguinal: 10.3% and supraclavicular: 5.6%). Upper extremity lymphedema responded better compared to lower extremity (74.2 vs. 53.2%), but there was no difference in placing the lymph nodes more proximally versus distally on the extremity (proximal: 76.9% vs. distal: 80.4%).

Conclusion: Vascularized lymph node transfer for lymphedema treatment is a promising operative technique showing beneficial results in early but also in advanced stage lymphedema. This physiologic surgical procedure should be included in a modern reconstructive concept for lymphedema treatment.

Main findings

  • Lymphatic vascular anastomosis (LVA) seems to have higher efficacy in early stage of lymphedema before existing lymph vessels become sclerotic, vascularized lymph node transfer (VLNT) is an option for advanced stages of lymphedema where the native lymphatic channels are no longer available for an LVA. The concept of VLNT consists of transferring lymph nodes into the affected limb to restore lymphatic drainage function.
  • Transferred lymph nodes act as a sponge to absorb the lymphatic fluid while another other theory suggests that the transferred lymph nodes stimulate neolymphangiogenesis where new lymphatic channels form to improve the drainage from the extremity.
  • The inguinal nodes were used in the vast majority of studies with 72% of all cases followed by the lateral thoracic lymph nodes in 14.8%. Supraclavicular, omental, and submental nodes were taken in 6.5, 3.7 and 3%, respectively.
  • For upper extremity lymphedema, a VLNT can be transferred to the axilla, elbow or the wrist. For treatment of upper extremity lymphedema, the inguinal nodes were most frequently placed proximally into the axilla than at the wrist.
  • For lower extremity lymphedema, there is also some debate whether the VLNT should be transferred proximally or distally. The groin, popliteal fossa, and ankle have been described as potential recipient sites.
  • The lateral thoracic lymph nodes were predominantly used for lower extremity lymphedema with seven pedicle flaps placed proximally into the axilla for upper extremity lymphedema.
  • Unfortunately, the number and degree of improvement following VNLT was not thoroughly or consistently documented in the majority of studies. Based on the number of patients who reported a benefit to the lymph node transfer, submental nodes were the most effective with 100% of patients (n58) reporting an improvement. The supraclavicular had the next highest rate of benefit 88.2% (n515), followed by the inguinal lymph nodes (70.4%, n5138). Six of the 10 omental (60%) flaps demonstrated benefit, and only 5% of lateral thoracic lymph nodes reported an improvement in patient lymphedema (n52).
  • Patients undergoing treatment for upper extremity lymphedema had an overall better response rate compared to those undergoing surgery for the lower extremity (74.2 vs. 53.2%).
  • No robust guidelines exist to optimize lymph node harvest avoiding the sentinel nodes and minimizing donor site morbidity.