Evaluation of the greater omentum in the treatment of experimental lymphedema.

Despite advances in microsurgery, the most suitable operation for primary lymphedema remains unclear. A variety of tissue transplants and artificial substances have been used to facilitate drainage of peripheral lymph. The greater omentum, for example, has absorptive lymph draining capability, fights infection, and is expendable for the abdomen. Previous attempts to use the omentum in treatment of clinical lymphedema have, however, been disappointing. This discrepancy between theory and outcome prompted us to reevaluate the role of the omentum in the treatment of chronic lymphedema. In rabbits, mobilization of omentum was carefully examined by three separate techniques and the presence of natural lymph nodal-venous (L-V) shunts determined by an injection of Evans blue into the omentum with sampling later of plasma from the gastroepiploic venous blood. In dogs after promotion of unilateral chronic hindlimb lymphedema by soft tissue excision and sclerosis, the results of four methods of omental transplantation with or without L-V shunt for relief of lymphedema were compared. The results in rabbits suggest that although the greater omentum can be lengthened without jeopardizing its blood supply, it is inappropriate to lengthen it based on blood vascular arcades alone because the omental lymphatics do not strictly follow these arcades in the more distal portion, and with elongation, may be interrupted even though the blood supply remains intact. Moreover, because there is no natural L-V shunt within the greater omentum, the addition of a L-V shunt in dogs in addition to omental transplantation seems to increase effectiveness of the omentum for draining hindlimb lymph after its autotransplantation.

Autotransplantation of the greater omentum in the treatment of chronic lymphedema.

We evaluated the use of transplantation of the greater omentum in the management of chronic lymphedema in 21 patients. The omentum provides a large surface with fluid absorbing capability and potentially therefore is useful in management of patients with primary or hypoplastic peripheral lymphatics. Based on the angio- and lymphangio-architecture of the gastroepiploic architecture, we used large segments of greater omentum as a free autotransplant with microrevascularization to the femoral or axillary artery and vein thereby avoiding technical drawbacks of a pedicle graft with the feeding vessels traversing the abdomen. Elongation of the omentum must be done properly because omental lymphatic arcades do not consistently follow the blood vascular arcades in its more distal part. Accordingly, if not properly mobilized the blood supply may be retained whereas the lymph circulation is interrupted. We combined omental implantation with lymph nodal-venous anastomoses using an omental vein with a nearby systemic venous tributary. In 19 of the 21 patients followed from 3 months to 2 years after operation, remission of lymphedema was good (reduction in swelling more than 50%) in 14 patients and satisfactory in 5 (approximately 25-50% reduction in swelling) with improvement gradually increasing with the passage of time.

Enteromesenteric bridge in the treatment o primary lymphedema--a case report.

Technical details and associated problems of enteromesenteric bridging operation for primary lymphedema (proximal obstructive hypoplasia) are discussed. The short term results are encouraging.