Microsurgical lymphatic vascular grafting and secondary liposuction: Results of combination treatment in secondary lymphedema.

Surgical treatment of lymphedema with liposuction typically requires subsequent compression therapy. Here we describe an approach where secondary arm lymphedemas are initially treated by autologous lymphatic grafting to bypass the axilla and restore lymphatic flow. In the presence of excess adipose tissue, liposuction is then performed in a second procedure. To assess outcomes, the authors evaluated 28 consecutive adult patients who had undergone secondary liposuction following lymphatic grafting. Arm volumes were measured prior to lymphatic grafting and after the secondary liposuction. The necessity for additional treatment by compression garment and manual lymphatic drainage was assessed prior to lymphatic grafting and after the secondary liposuction following the direct postoperative regimen. The mean arm volumes were reduced significantly (p<0.001) from a mean of 3417± 171 (SEM) cm3 prior to lymphatic grafting to 3020±125 cm3 after reconstruction of the lymphatic vascular system and finally to 2516±104 cm3 after the secondary liposuction (SLS). All 28 adult patients underwent continuous compression and manual lymph-drainage (MLD) prior to the reconstructive surgery. All 28 patients were evaluated regarding necessity of any additional therapy more than 6 months after SLS with a median follow up period of 37 months (range, 7-160 months). 18 of 28 patients did not require any supportive therapy beyond 6 months after SLS to maintain the results. Three patients continued to utilize manual lymphatic drainage, 4 used a combination of MLD and compression therapy and 3 used elastic compression therapy (one patient only while at work). These results indicate that microsurgical restoration of lymphatic outflow followed by SLS eliminates the need for additional treatment in more than two thirds of patients.

[Microsurgical Autologous Lymph Vessel Transplantation: Does Harvesting Lymphatic Vessel Grafts Induce Lymphatic Transport Disturbances in the Donor Limb?]. / Mikrochirurgische autologe Lymphgefäß-Transplantation: Verursacht die Entnahme von Lymphgefäß-Transplantaten Lymphtransportstörungen an der Spenderextremität?

OBJECTIVE: The aim of this study was to determine whether the extirpation of lymphatic vessels induces lymphatic transport disturbances in the donor limb of patients following the harvest of lymph vessel grafts. PATIENTS, MATERIAL AND METHODS: A total of 19 consecutive patients (15 females, 4 males; mean age 51.5 years, range 21.8-72.3) were examined by lymphoscintigraphy before and after surgery. The patients had previously been diagnosed with upper or lower limb lymphoedema in accordance with the criteria of the International Society of Lymphology, and autologous lymph vessel transplantation had been intended for treatment. Since only patients with normal scintigraphic tests at the harvesting site were considered for treatment, all consecutive patients (n=19) had normal scintigraphic tests of the donor limb prior to surgery. In order to quantify the visual scintigraphic findings, a well established numeric transport index (TI) was used, which combined 5 visual parameters of transport kinetics. To that end, the following visually assessed criteria were evaluated: temporal and spatial kinetics, radiopharmaceutical distribution pattern, time to appearance of inguinal lymph nodes, qualitative visualisation of lymph nodes and lymph vessels. RESULTS: All patients underwent a preoperative scintigraphic baseline study and a postoperative scintigraphic follow-up after autologous lymphatic vessel grafting. The mean time period from the baseline study to the date of microsurgical lymph vessel transplantation was 3.5 months (median 2.5 months). The scintigraphic follow-up was performed 48.6 months (median 57.8 months) following transplantation. In all patients the postoperative TI was very close to the TI calculated in the preoperative baseline scintigraphy, and all TIs were within the normal range (TI<10). The absolute value of deviation of pre- vs. post-operative transport indices was calculated to be 0.2 on average (maximum 0.4). CONCLUSIONS: The results show that microsurgical transfer of lymph vessel grafts is possible without compromising lymphatic drainage of the donor limb if safety precautions are taken into account.

Chylothorax and chylous ascites. Clinical utility of planar scintigraphy and tomographic imaging with SPECT/CT.

UNLABELLED: The aim was to analyze conventional planar scintigraphy and SPECT/CT in patients clinically suspicious for chylothorax or chylous ascites. Lymphoscintigraphy was performed for two reasons: first, to help diagnose chylothorax or -abdomen, by demonstrating diffuse uptake in fluid accumulations, and then secondly, to detect the site of leakage to test the prediction that additional use of SPECT/CT-technique improves upon the diagnostic value of planar lymphoscintigraphy in the baseline detection of thoraco-abdominal lymphatic disorders. PATIENTS, MATERIAL, METHODS: From 7/2008-7/2014 a total of 24 consecutive patients (8 woman, 16 men; age, range 31-79 years) presenting with clinical symptoms suspicious for chylothorax and/or chylous ascites were examined by planar lymphoscintigraphy (n = 26) and additional tomographic SPECT/CT- (n = 22) or SPECT-technique (n = 2). RESULTS: Chylothorax could be scintigraphically confirmed in n = 9, chylous ascites in n = 5 scintigraphies, and excluded in n = 10 patients. In all planar scintigraphy findings of pathological lymph drainage regions (n = 14), SPECT/CT delivered additional relevant information, notably the anatomic localization of the lymphatic leakage. For the baseline detection of thoraco-abdominal lymphatic transport disorders, lymphoscintigraphy showed sensitivity of 88%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 80%. CONCLUSIONS: Our findings show that due to the particular advantages presented by tomographic separation of overlapping sources, SPECT/CT specifies better the anatomical sites, improving the localization of lymphatic leakage in aid of planning surgical re-interventions.

Protective effects of activated protein C (APC) on free groin flaps after secondary venous stasis in the rat model.

BACKGROUND: The goal of this study was to determine whether the focused delivery of APC by rinsing of free adipocutaneous groin flaps shows protective effects on flap survival following a fatal secondary venous stasis in a rat model. METHODS: 36 Sprague Dawley rats were randomized to three groups and free microvascular groin flaps were transplanted to the neck in each animal. 20 hours postoperatively the flap pedicle was re-explored and the distal stump of the flap artery was catheterised. Animals in group I (n = 12) remained untreated, whereas animals of group II were treated with 1 ml of Ringer's solution. Those in group III received 1 ml of APC (2 mg/kg). Afterwards the flap vein was clamped for 35 minutes. The skin of the flaps and the native contralateral groin was examined by intravital video microscopy using FITC-Dextran and CFDA-SE-labelled thrombocytes. RESULTS: APC-pretreatment significantly increased the functional capillary density (FCD) of the flaps. Flap viability was 8% in group I (n = 1/12), 9% in group II (n = 1/11) and 60% in group III (n = 6/10), respectively. No partial flap loss was detected. CONCLUSIONS: The focused delivery of APC resulted in significantly improved flap salvage.

Examination of the protective effects of heparin and recombinant tissue plasminogen activator (rtPA) in compromised adipocutaneous free flaps in the rat model using intravital video microscopy.

BACKGROUND: The purpose of this study was to determine whether the focused delivery of heparin or recombinant tissue plasminogen activator (rtPA) by rinsing accords protective effects which increases the survival of free groin flaps following fatal secondary venous stasis. METHODS: Free microvascular groin flaps (n = 40) were transplanted to the necks of adult Sprague-Dawley rats 20 hours before the experiment. The study groups (each n = 10 animals) were: No adjunctive treatment (Group I), Ringer's solution (Group II), heparin solution (100 IU/kg, group III) and rtPA (2 mg/kg, group IV), respectively. The flap vein was then clamped for 35 minutes. Intravital video microscopy was applied and flap viability was assessed 14 days later. RESULTS: Mean flap necrosis was 90% in group I and II, whereas the rate of flap survival was 80% in group III and 60% in group IV, respectively. CONCLUSIONS: Even though clinical and microvascular flap perfusion parameters in both the rtPA-group and heparin group were initially similar, it has been demonstrated here in our investigations that the flaps treated with heparin showed a higher viability rate. Therefore, we can conclude that the focused delivery of heparin and rtPA resulted in a significantly improved flap salvage.

Magnetic resonance imaging versus lymphoscintigraphy for the assessment of focal lymphatic transport disorders of the lower limb: first experiences.

PURPOSE: To compare the diagnostic accuracy of magnetic resonance imaging (MR-lymphangiography) and lymphoscintigraphy for assessment of focal lesions of the peripheral lymphatic system. Patients with focal lymphatic transport disorders might benefit from surgi-cal interventions. PATIENTS, METHODS: We examined by lymphoscintigraphy and MR-lymphangiography a total of 85 lower limbs in 46 consecutive patients (33 women; mean age 41 years; range 9-79 years) presenting with uni- or bilateral lymphedema. MR-lymphangiographies were obtained at isotropic sub-millimeter resolution with a 3.0 Tesla magnet after injection of gadolinium contrast medium. MR-lymphangiography was reviewed by radiologists, whereas lymphoscintigraphy was reviewed by nuclear medicine physicians. The images were examined for localization and distribution of any focal lesions of the lymphatic vessel system. Diagnostic accuracy of the MR-approach was calculated relative to the lymphoscintigraphy gold standard. RESULTS: There was substantial correlation of results by the two modalities (κ = 0.62). MR-lymphangiography had sensitivity of 68%, specificity of 91%, positive predictive value of 82%, and negative predictive value of 83%. CONCLUSIONS: Imaging findings of both lymphoscintigraphy and MR-lymphangiography showed good diagnostic accuracy. MR-lymphangiography proved more information about anatomic location of focal lesions of the lymphatic vessels, but use of MR-lymphangiography is currently constrained due to the requirement for off-label subcutaneous injection of gadolinium chelates. Consequently, and due to its superior sensitivity lymphoscintigraphy remains the most common imaging method to assess functional lymphatic disorders of the lower limb.

PDR-1/hParkin negatively regulates the phagocytosis of apoptotic cell corpses in Caenorhabditis elegans.

Apoptotic cell death is an integral part of cell turnover in many tissues, and proper corpse clearance is vital to maintaining tissue homeostasis in all multicellular organisms. Even in tissues with high cellular turnover, apoptotic cells are rarely seen because of efficient clearance mechanisms in healthy individuals. In Caenorhabditis elegans, two parallel and partly redundant conserved pathways act in cell corpse engulfment. The pathway for cytoskeletal rearrangement requires the small GTPase CED-10 Rac1 acting for an efficient surround of the dead cell. The CED-10 Rac pathway is also required for the proper migration of the distal tip cells (DTCs) during the development of the C. elegans gonad. Parkin, the mammalian homolog of the C. elegans PDR-1, interacts with Rac1 in aged human brain and it is also implicated with actin dynamics and cytoskeletal rearrangements in Parkinsons's disease, suggesting that it might act on engulfment. Our genetic and biochemical studies indicate that PDR-1 inhibits apoptotic cell engulfment and DTC migration by ubiquitylating CED-10 for degradation.

Protective effects of antithrombin on free groin flaps after secondary venous stasis in the rat model.

BACKGROUND: The anticoagulant activity of heparin is well established and led to its widespread clinical use for the prophylaxis and treatment of venous thrombosis in microsurgery. Heparin accelerates antithrombin (AT)-mediated inhibition of clotting and fibrinolytic proteinases. AIM: The aim of the study is to determine whether the focussed delivery of AT by rinsing of free adipocutaneous groin flaps shows protective effects on flap survival, following a fatal secondary venous stasis in the rat model. Further, intravital video microscopy (IVM) is used to detect substance-specific alterations in microvascular perfusion with special focus on regional differences between central and peripheral flap regions. METHODS: Free microvascular groin flaps (n = 22) were transplanted to the neck in adult Sprague-Dawley rats. The flap pedicle was re-explored and the distal stump of the flap artery was catheterised 20 h later. Animals in group I (n = 11) were treated with 1 ml of Ringer's solution administered over 10 min via intraarterial infusion. Those in group II (n = 11) received 1 ml of AT (50 IU/kg). Afterwards, the flap vein was clamped for 35 min. The skin of the flaps and the native contralateral groin was examined by IVM using the plasma-marker fluorescein isothiocyanate (FITC)-dextran and carboxyfluorescein diacetate succinimidyl ester (CFDA-SE)-labelled thrombocytes. After 14 days, the viability of the flaps was evaluated. RESULTS: The treatment with AT significantly increased the functional capillary density (FCD) of the flaps. After 14 days, flap necrosis occurred in nine animals of group I and three animals of group II, respectively. No partial flap loss was detected. CONCLUSIONS: The focussed delivery of AT resulted in significantly improved flap salvage. The results may reinforce the clinical custom of AT substitution in the setting of major surgical procedures such as elaborate microsurgical reconstructions, at least in cases with diminished AT levels.

The free groin flap in the rat: a model for improving microsurgical skills and for microvascular perfusion studies.

The goal of this study was to evaluate the free groin flap in the rat transplanted to the neck as a tool for extending microsurgical skills and to assess its suitability as a model for microvascular perfusion studies following secondary venous ischaemia. An analysis of 60 consecutive groin flap transplantations was performed in male Sprague Dawley rats with special regard to anatomy and operation times (Part I, animals No. 1-60). Following flap transplantation, the animals No. 10-30 (n = 21) were used for the determination of the critical time period of a complete venous stasis of the free groin flap resulting in a total flap loss (Part II). The flaps of animals No. 31-41 (n = 11) were used for assessing the feasibility and reproducibility of intra-vital video microscopy (IVM) of the flaps (Part III). The mean total operation time decreased from 166 (± 26) minutes ins the first 10 animals to 126 (± 21) minutes and 130 (± 12) minutes in the latter two groups of 10 animals, respectively. After a critical period of 35 minutes of a complete artificial venous stasis a complete flap necrosis occurred. IVM detected a higher functional capillary density of the skin of the transplanted groin flaps in the animals in which the flaps were rinsed with 1 ml of Ringer's lactated solution prior to I/R. In conclusion, this model is simple and reliable. The model may be a useful tool for evaluating and comparing the effects of various anticoagulants or vasomotor drugss on microvascular perfusion in critically compromised free flaps.

Self-control and its relation to emotions and psychobiology: evidence from a Day Reconstruction Method study.

This study aimed to ascertain whether self-control predicts heart rate, heart rate variability, and the cortisol slope, and to determine whether health behaviors and affect patterns mediate these relationships. A sample of 198 adults completed the Self-Control Scale (Tangney in J Pers 72:271-322, 2004), and reported their exercise levels, and cigarette and alcohol use. Participants provided a complete account of their emotional experiences over a full day, along with morning and evening salivary cortisol samples and a continuous measure of cardiovascular activity on the same day. High trait self-control predicted low resting heart rate, high heart rate variability, and a steep cortisol slope. Those with high self-control displayed stable emotional patterns which explained the link between self-control and the cortisol slope. The self-controlled smoked less and this explained their low heart rates. The capacity to sustain stable patterns of affect across diverse contexts may be an important pathway through which self-control relates to psychophysiological functioning and potentially health.

[The clinical yield of SPECT/CT for the assessment of lymphatic transport disorders. First experiences]. / SPECT/CT zur Untersuchung von Lymphtransportstörungen. Erste Erfahrungen zum klinischen Nutzen.

UNLABELLED: The aim of this study was to determine whether the additional use of SPECT/CT-technique improves the diagnostic value of planar lymphoscintigraphy in patients presenting with lymphatic transport disorders. PATIENTS, METHODS: For a defined period of two years 36 consecutive patients (27 women, 9 men; age 27-87 years) were included in our study. In addition to planar scintigraphy further acquisition of the affected extremities or of the trunk was performed using SPECT/CT-technique. In total, 48 anatomic lymph drainage areas were prospectively analysed by planar scintigraphy and tomographic SPECT/CT. RESULTS: In 28/48 cases (58%) the SPECT/CT-imaging provided relevant additional information before treatment compared to planar technique; among them 27 regarding the exact anatomic localization of lymphatic transport disorders and 8 cases in which the dimension of the lymphatic transport disorders were estimated to a greater extent than in single use of planar lymphoscintigraphy. In 3 cases SPECT/CT provides differential diagnosis of lymph nodes versus lymphoceles. In none of the cases lymph vessels or lymph vessel grafts could be demonstrated by the morphological CT-component. CONCLUSIONS: Additionally to planar lymphoscintigraphy, SPECT/CT specifies anatomical correlation of lymphatic transport disorders and thus the assessment of the extension of the pathology. Furthermore, SPECT/CT dissipates overlapping of anatomic structures by tomographic acquisition and enables differential diagnosis of lymph nodes versus lymphoceles.

[MR lymphangiography for assessment of focal dermal backflow for presurgical work-up in patients with peripheral lymphoedema]. / Die MR-Lymphangiografie in der präoperativen Diagnostik des fokalen "dermal backflow" bei peripheren Lymphödemen.

BACKGROUND: MR lymphangiography might provide valuable morphological information in the diagnosis of peripheral lymphedema in addition to lymphoscintigraphy. Even patients with focal dermal backflow can benefit from surgical intervention. The purpose of this study was to assess the feasibility of MR-Lymphangiography for assessment of focal dermal backflow for pre-surgical work-up. PATIENTS/MATERIALS & METHODS: 50 patients with peripheral lymphedema were included in this study. Patients showing focal dermal backflow in MR-Lymphangiography were reviewed and analyzed separately. The MR findings were correlated to lymphoscintigraphy. Concordance of the 2 modalities regarding existence and distribution of dermal backflow were examined. Furthermore the feeding vessels of the dermal backflow were assessed and visualized. RESULTS: Dermal backflow was diagnosed with MR lymphangiography in 13 patients. Dermal backflow was confirmed by lymphoscintigraphy in 12 patients (92.3%). The feeding vessels of the dermal backflow configuration could be visualized in 9 patients (69.2%) and could be visualized with 3-dimensional reconstructions. The latter is not possible with lymphoscintigraphy. CONCLUSION: MR lymphangiography provides important supplementary diagnostic information in patients with peripheral lymphedema additional to lymphoscintigraphy. Particularly in patients with focal dermal backflow and intended surgery, MR lymphangiography holds high potential for pre-surgical work-up.

[Update on special surgical approaches in the therapy for lymphedemas]. / Die Vielfalt in der chirurgischen Therapie beim Lymphödem - was ist aktuell?

Despite recent medical progress primary and secondary lymphedemas still represent a therapeutic challenge and they often lead to a significant reduction in quality of life. Lymphedemas usually develop in the extremities, the male external genitals as well as the female breast as a consequence to the axial alignment of the lymphatic collectors. Early stages are characterized by an excess of lymph fluid increasing the volume of the affected part of the body whereas later stages represent an increasing amount of solid tissue. Thus therapeutic efforts can focus on the reduction of the surplus of liquid and/or solid components. Generally there are conservative and operative strategies. Conservative measures mainly focus on the improvement of fluid mobilization and drainage and comprise compression garments, manual lymphatic drainage, and apparative intermittent compression. Operative approaches comprise procedures for surgical tissue reduction (symptomatic/ablative approaches) and/or procedures with the intention of enhancing lymphatic transport (causal approaches). Surgical tissue reduction can be performed by open resection and/or liposuction. Traditional surgical causal techniques such as transposition of local flaps aim at leading lymph away from the congested region of the body. Modern microsurgical causal approaches contain methods of reconstruction of interrupted lymphatic pathways as well as techniques for the conduction of lymph into local veins. In this review we depict and discuss the features of the multiform spectrum of the surgical therapy of lymphedemas on the basis of literature as well as our own clinical and experimental experience.

Experimental study on the microsurgical or spontaneous formation of lympho-lymphonodular anastomoses in the rat model.

BACKGROUND: The restoration of the lymphatic function in chronic lymphoedemas can be achieved by microsurgical lymphatic vessel transplantation. Usually, end-to-end anastomoses are performed between the lymphatic vessels. Sometimes, the lack of appropriate lymphatic recipient vessels impels the idea of connecting the grafts to local lymph nodes. This study focusses on the microsurgical completion of durable lympho-lymphonodular anastomoses and further the detection of a spontaneous formation. METHODS: In 36 Sprague-Dawley rats the retroperitoneal lymphatic structures were prepared after staining with patent blue V dye. In group A (n = 12), the left lumbar trunk was cut cranially and its distal part was turned over to the right lumbar lymph node where a microsurgical lympho-lymphonodular anastomosis was performed. In group B (n = 12), treatment was similar but without anastomosing. In group C (n = 12), the left lumbar trunk was transected and the capsule of the contralateral lumbar lymph node was incised. Finally, the lumbar region was re-exposed and the lymphatic drainage was examined using patent blue in four animals of each group after 8, 12 and 16 weeks, respectively, to examine the development of possible spontaneous formations of lymphatic connections. RESULTS: In 12/12 animals of group A, patent transposed lymph vessels and anastomoses with blue staining of the right lumbar lymph node were observed. Only 1/12 animals of group B and 2/12 animals of group C showed a blue staining of the right lumbar lymph node. CONCLUSIONS: The microsurgical fabrication of lympho-lymphonodular anastomoses leads to a safe and durable lymphatic connection. The known plasticity of lymphatic vessels with the potential of spontaneous anastomosing seems to be higher between lymphatic vessels than between lymphatic vessels and a lymph node.

Changes in quality of life of patients with lymphedema after lymphatic vessel transplantation.

There are multiple treatment options for patients with chronic lymphedema, and one successful approach is lymph vessel transplantation. As quality of life assessments are frequently not utilized in standard treatment regimes, we investigated the change in quality of life for patients with chronic lymphedema (total = 212) who had undergone lymphatic vessel transplantation and conservative therapy for at least 6 months prior to operation. Quality of life was assessed by a modified standard questionnaire examining the physiological and psychological status of the patients. Results document a significant improvement in quality of life and underscore success of autologous lymphatic vessel transplantation as a therapy for lymphedema.

[Re-intervention after carpal tunnel release]. / Revisionseingriffe nach Karpaldachspaltung.

In the last eight years we performed 63 re-interventions because of recurrent carpal tunnel syndromes. Intact parts of the retinaculum were the reason for persistent symptoms in 38 patients. 21 patients suffered from scar tethering, two patients from circumferential fibrosis of the nerve. In one patient a ganglion and in another patient a direct injury to the median nerve was detected. In 21 patients short incisions were performed in the primary procedures. Since the introduction of endoscopic carpal tunnel release, an open decompression via a short incision is recommended as an alternative. Since then we encounter an increase of necessary operative revisions after short incisions. Optical tools may increase the survey especially in short incisions. In extended teno-synovialitis of the flexor tendons, a longer incision over the wrist enables adequate conditions for a safe teno-synovialectomy. The length of the incision has to be chosen according to the pathologic-anatomic situation, the disposable equipment and the experience of the surgeon.

C. elegans metallothioneins: new insights into the phenotypic effects of cadmium toxicosis.

Metallothioneins are considered to be the primary player in the detoxification of and protection from cadmium, a teratogen, mutagen and potentially lethal heavy metal. The nematode Caenorhabditis elegans has only two metallothioneins, mtl-i and mtIl-2, thus making it an ideal organism to investigate the phenotypic effects of cadmium toxicosis. The functional importance of metallothioneins in cadmium trafficking was highlighted through the generation of viable green fluorescent protein (GFP) expressing transgenes, a metallothionein null allele, as well as RNAi mediated metallothionein knock-downs. A highly sensitive dose and temporal transcriptional response to cadmium, but not copper or zinc, was shown to be equally prevalent in both isoforms. No measurable compensatory up-regulation of mtl-l could be observed in the null allele of mtl-2, suggesting that both isoforms are independent and not synergistic in their mode of action. Exposure to cadmium affected all demographic indices measured, manifested by a reduction in body size, generation time, brood size and lifespan. These effects were magnified in the knock-out or wild-type subjected to a knock down by RNAi, however, only in the presence of cadmium. This substantiates the notion that metallothioneins play a pivotal role in the protection from cadmium toxicosis. Finally, an earthworm metallothionein-GFP construct could be activated in C. elegans upon exposure to cadmium, the results providing further evidence that the transcriptional control of metallothioneins is fundamentally divergent in lower invertebrates and not mediated via MTF-1 as in more complex organisms.

[The microsurgical lymph vessel transplantation]. / Die mikrochirurgische Lymphgefässtransplantation.

Using advanced microsurgical techniques, single lymph vessels can be safely anastomosed and segments of lymphatics can bridge localized lymphatic blockades which are mostly due to lymphadenectomies. Lymphatic grafts are harvested from the patient's thigh with a length up to about 30 cm. In the case of an axillary blockade they are anastomosed with ascending lymph vessels at the upper arm and lymph vessels at the supraclavicular region. Unilateral oedemas of lower extremities are treated by transferring the grafts via the symphysis and anastomosing them with ascending lymphatics at the affected side. Lymphoedemas of the penis and the scrotum as well as lymphoedemas due to a localized peripheral lymphatic blockade can be treated by lymphatic grafts. In 127 arm oedemas the original difference in volume between the affected and the healthy arm was reduced at two third from 3368 cm (3) to 2567 cm(3) (p < 0.001). After a follow-up period of 2.6 years the volume was reduced to 2625 cm(3) (p < 0.001). The group of patients with a follow-up of at least ten years showed a volume of 2273 cm(3) (p < 0.001). The volume of unilateral lower extremity-lymphoedemas was reduced from 13 098 cm(3) to 10 578 cm(3) (p < 0.001) and showed a volume of 11 074 cm(3) after 1.7 years (p < 0.001) and 10 692 cm(3) after four years (p < 0.001). The original mean volume of the healthy contralateral leg was 9371 cm(3). Bridging localized gaps in the lymphatic system by autologous lymphatic grafts showed long lasting stable results. Starting the treatment of lymphoedemas by conservative procedures, one should not wait too long to ascertain the possibility of a microsurgical reconstruction in order to avoid increasing secondary tissue changes.

[Planning and monitoring of autologous lymph vessel transplantation by means of nuclear medicine lymphoscintigraphy]. / Therapieplanung und Erfolgskontrolle der autologen Lymphgefäss-Transplantation mittels nuklearmedizinischer Lymphabflussszintigraphie.

Autologous lymph vessel transplantation significantly improves the lymph drainage in patients with primary and secondary lymphedema. The aim of the present study was to prove whether scintigraphic long-term follow-up could demonstrate the function of autologous lymph vessels and the persisting success of this microsurgical technique respectively. In this study, visual and semiquantitative lymphoscintigraphy was used to prove the function of lymphatic vessel grafts in 20 patients comparing a preoperative baseline study with postoperative follow-up investigations once a year for a period of seven years. The reason for microsurgical lymph vessel transplantation was a primary (n = 4) or a secondary (n = 16) lymphedema. In 12 cases the transplantation site was at the upper extremity, in eight cases at the lower limb. In 17/20 patients lymphatic function significantly improved after autologous lymph vessel transplantation compared to the preoperative findings, as verified by visual improvement of lymph drainage and decrease of a numeric transport index. In 5/20 cases the vessel graft could be visualized directly. In these patients with scintigraphic visualization of the vessel graft, the transport index decreased to a significantly greater extent compared to the preoperative baseline study. 3/20 patients did not benefit from microsurgical treatment. Lymphoscintigraphy has shown to be an easy, reliable and readily available technique to assess lymphatic function on the long run. Scintigraphic visualization of the vessel graft showed a significantly better postoperative outcome than those without. The scintigraphic visualization of the vessel graft therefore seems to indicate a favourable prognosis regarding lymph drainage.