Jejunal Mesenteric Vascularized Lymph Node Transplantation for Lymphedema: Outcomes and Technical Modifications.

BACKGROUND: The jejunal mesentery supplied by the superior mesenteric vascular tree has emerged as a viable site for vascularized lymph node transplantation. Among other benefits, it has the advantage of avoidance of the risk of donor-site lymphedema. This article reports the technique and outcomes of a novel approach to jejunal mesenteric vascularized lymph node transplantation with flap harvest from the mesenteric root to reduce the risk of small bowel ischemic complications. METHODS: A consecutive series of patients that underwent jejunal mesenteric vascularized lymph node transplantation to treat upper extremity lymphedema were included. Preoperative and postoperative measurements were taken at fixed intervals using standardized techniques including Perometer volumetry, LDex bioimpedance spectroscopy, the Lymphedema Life Impact Scale, and the Quick Disabilities of the Arm, Shoulder and Hand tool. Demographic, treatment, and outcomes data were collected, and descriptive statistics were used. RESULTS: There were 25 patients included, all of whom had maximized their conservative therapy before undergoing surgery. At 12 months postoperatively reduction in limb volume difference was 36.7 percent (p < 0.001), reduction in LDex score was 41.4 percent (p = 0.0015), and reductions in the Lymphedema Life Impact Scale and Quick Disabilities of the Arm, Shoulder and Hand scores were 55.7 percent (p = 0.0019) and 47.5 percent (p = 0.027), respectively. In 11 patients, there was a history of cellulitis (multiple episodes in eight), and at up to 24 months' follow-up postoperatively there were no episodes reported (p < 0.001). CONCLUSION: Upper extremity lymphedema can be effectively treated surgically using the jejunal mesenteric vascularized lymph node transplantation, resulting in reduced limb volume and extracellular fluid, and improved patient-reported limb function and outcomes measures compared with optimized conservative therapy alone. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Outcomes and technical modifications of vascularized lymph node transplantation from the lateral thoracic region for treatment of lymphedema.

BACKGROUND AND OBJECTIVES: This study evaluates clinical outcomes of vascularized lymph node transplantation (VLNT) from the lateral thoracic region and technical modifications. METHODS: Consecutive patients that underwent lateral thoracic VLNT to treat extremity lymphedema were included. Demographic and treatment data were recorded, and outcomes data including limb volume, LDex score, and Lymphedema Life Impact Scale (LLIS), QuickDASH, and LEFS questionnaires, were collected prospectively. Consecutive patients that underwent single-photon emission computed tomography (SPECT/CT) lymphoscintigraphy axillary reverse lymphatic mapping (RLM) were analyzed to characterize the physiological drainage of the normal upper extremity. RESULTS: A consecutive series of 32 flaps were included. At 24 months postoperatively mean reduction in limb volume excess was 47.2% (±11.6; p = 0.0085), LDex score was 63.1% (±8.5; p < 0.001), and LLIS score was 65.1% (±7.4; p < 0.001). Preoperatively 14/31 patients (45.2%) reported cellulitis, and postoperatively there were no episodes at up to 24 months (p < 0.001). No patient developed donor extremity lymphedema at mean 18.6 (±8.3) months follow-up. SPECT/CT-RLM of 182 normal axillae demonstrated that the sentinel lymph node(s) of the upper extremity was consistently anatomically located in the upper outer quadrant of the axilla (97%). CONCLUSIONS: VLNT from the lateral thoracic region is effective and versatile for the treatment of lymphedema with a low donor site complication rate.

Outcomes of Vascularized Lymph Node Transplantation for Treatment of Lymphedema.

BACKGROUND: A growing body of evidence supports the efficacy of surgical treatments for lymphedema. This study reports the outcomes of vascularized lymph node transplantation (VLNT) for the treatment of patients with lymphedema compared with maximal conservative treatment alone. STUDY DESIGN: Consecutive patients undergoing VLNT to treat primary and secondary lymphedema affecting the upper or lower extremities were included. All patients were optimized preoperatively with conservative therapy. Demographic and treatment information was collected, and outcomes data were electronically captured prospectively; descriptive statistics were performed. RESULTS: There were 134 patients included that had achieved maximal reductions by conservative therapy preoperatively. This series included jejunal mesenteric (n = 25), groin (n = 43), lateral thoracic (n = 31), omental or right gastroepiploic (n = 21), and submental (n = 14) VLN flaps. At 24 months postoperatively, there were significant reductions in limb volume change (mean [SD] 45.7% [8.7%]; p = 0.002) LDex score (mean [SD] 59.8% [8.7%]; p < 0.001), Lymphedema Life Impact Scale score (mean [SD] 61.6% [5.9]; p < 0.001), and cellulitis episodes (97.9%; p < 0.001). At 3 and 6 months postoperatively, limb volume change was significantly greater for the upper than the lower extremity, otherwise outcomes were similar. There were no flap losses and overall outcomes were similar between the different VLN flap types. CONCLUSIONS: Treatment of lymphedema using VLNT resulted in progressive, significant reductions in limb volume, bioimpedance spectroscopy measurements of extracellular fluid, and episodes of cellulitis, with improved patient-reported outcomes and limb function measures compared with maximal conservative therapy alone. The complication rate was low and there were no significant outcomes differences between the VLNT types.