Research progress of combined surgical treatment of lymphedema based on vascularized lymph node transfer_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

JIAN Yang , DENG Chengliang ,  WEI Zairong

Department of Burns and Plastic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi Guizhou, 563003, P. R. China;

Corresponding author：

WEI Zairong, Email: zairongwei@163.com

Keywords：

Vascularized lymph node transfer; lymphedema; lymphovenous anastomosis; breast reconstruction; debulking operation

DOI：

10.7507/1002-1892.202210009

Video：

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Objective To summarize the research progress of combined surgical treatment of lymphedema based on vascularized lymph node transfer (VLNT), and to provide systematic information for combined surgical treatment of lymphedema. Methods Literature on VLNT in recent years was extensively reviewed, and the history, treatment mechanism, and clinical application of VLNT were summarized, with emphasis on the research progress of VLNT combined with other surgical methods. Results VLNT is a physiological operation to restore lymphatic drainage. Multiple lymph node donor sites have been developed clinically, and two hypotheses have been proposed to explain its mechanism for the treatment of lymphedema. But it has some inadequacies such as slow effect and limb volume reduction rate less than 60%. To address these inadequacies, VLNT combined with other surgical methods for lymphedema has become a trend. VLNT can be used in combination with lymphovenous anastomosis (LVA), liposuction, debulking operation, breast reconstruction, and tissue engineered material, which have been shown to reduce the volume of affected limbs, reduce the incidence of cellulitis, and improve patients’ quality of life. Conclusion Current evidence shows that VLNT is safe and feasible in combination with LVA, liposuction, debulking operation, breast reconstruction, and tissue engineered material. However, many issues need to be solved, including the sequence of two surgeries, the interval between two surgeries, and the effectiveness compared with surgery alone. Rigorous standardized clinical studies need to be designed to confirm the efficacy of VLNT alone or in combination, and to further discuss the subsistent issues in the use of combination therapy.

Citation： JIAN Yang, DENG Chengliang, WEI Zairong. Research progress of combined surgical treatment of lymphedema based on vascularized lymph node transfer. Chinese Journal of Reparative and Reconstructive Surgery, 2023, 37(2): 240-246. doi: 10.7507/1002-1892.202210009 Copy

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2.	Dayan JH, Ly CL, Kataru RP, et al. Lymphedema: Pathogenesis and novel therapies. Annu Rev Med, 2018, 69: 263-276.
3.	Schaverien MV, Coroneos CJ. Surgical treatment of lymphedema. Plast Reconstr Surg, 2019, 144(3): 738-758.
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7.	Ogunleye AA, Nguyen DH, Lee GK. Surgical treatment of lymphedema. JAMA Surg, 2020, 155(6): 522-523.
8.	Cheng MH, Pappalardo M, Lin C, et al. Validity of the novel Taiwan Lymphoscintigraphy Staging and correlation of Cheng Lymphedema Grading for unilateral extremity lymphedema. Ann Surg, 2018, 268(3): 513-525.
9.	Winters H, Tielemans HJP, Hummelink S, et al. DIEP flap breast reconstruction combined with vascularized lymph node transfer for patients with breast cancer-related lymphedema. Eur J Surg Oncol, 2022, 48(8): 1718-1722.
10.	Di Taranto G, Coleman GJ, Hardwicke J, et al. A comparative study between deep inferior epigastric artery perforator flap breast reconstruction and DIEP flap breast reconstruction coupled with vascularized lymph node transfer: Improving the quality of life of patients with breast cancer related lymphedema without affecting donor site outcomes. Microsurgery, 2022. doi: 10.1002/micr.30924.
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13.	Ward J, King I, Monroy-Iglesias M, et al. A meta-analysis of the efficacy of vascularised lymph node transfer in reducing limb volume and cellulitis episodes in patients with cancer treatment-related lymphoedema. Eur J Cancer, 2021, 151: 233-244.
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27.	Lin CH, Ali R, Chen SC, et al. Vascularized groin lymph node transfer using the wrist as a recipient site for management of postmastectomy upper extremity lymphedema. Plast Reconstr Surg, 2009, 123(4): 1265-1275.
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36.	Qiu SS, Chen HY, Cheng MH. Vascularized lymph node flap transfer and lymphovenous anastomosis for klippel-trenaunay syndrome with congenital lymphedema. Plast Reconstr Surg Glob Open, 2014, 2(6): e167. doi: 10.1097/GOX.0000000000000099.
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1. Grada AA, Phillips TJ. Lymphedema: Pathophysiology and clinical manifestations. J Am Acad Dermatol, 2017, 77(6): 1009-1020.
2. Dayan JH, Ly CL, Kataru RP, et al. Lymphedema: Pathogenesis and novel therapies. Annu Rev Med, 2018, 69: 263-276.
3. Schaverien MV, Coroneos CJ. Surgical treatment of lymphedema. Plast Reconstr Surg, 2019, 144(3): 738-758.
4. Liu NF. Lymphedema in China—experiences and prospects. Lymphology, 2007, 40(4): 153-156.
5. Chang DW, Dayan J, Greene AK, et al. Surgical treatment of lymphedema: A systematic review and meta-analysis of controlled trials. Results of a consensus conference. Plast Reconstr Surg, 2021, 147(4): 975-993.
6. Tourani SS, Taylor GI, Ashton MW. Vascularized lymph node transfer: A review of the current evidence. Plast Reconstr Surg, 2016, 137(3): 985-993.
7. Ogunleye AA, Nguyen DH, Lee GK. Surgical treatment of lymphedema. JAMA Surg, 2020, 155(6): 522-523.
8. Cheng MH, Pappalardo M, Lin C, et al. Validity of the novel Taiwan Lymphoscintigraphy Staging and correlation of Cheng Lymphedema Grading for unilateral extremity lymphedema. Ann Surg, 2018, 268(3): 513-525.
9. Winters H, Tielemans HJP, Hummelink S, et al. DIEP flap breast reconstruction combined with vascularized lymph node transfer for patients with breast cancer-related lymphedema. Eur J Surg Oncol, 2022, 48(8): 1718-1722.
10. Di Taranto G, Coleman GJ, Hardwicke J, et al. A comparative study between deep inferior epigastric artery perforator flap breast reconstruction and DIEP flap breast reconstruction coupled with vascularized lymph node transfer: Improving the quality of life of patients with breast cancer related lymphedema without affecting donor site outcomes. Microsurgery, 2022. doi: 10.1002/micr.30924.
11. Sekigami Y, Char S, Mullen C, et al. Cost-effectiveness analysis: Lymph node transfer vs lymphovenous bypass for breast cancer-related lymphedema. J Am Coll Surg, 2021, 232(6): 837-845.
12. Ito R, Suami H. Overview of lymph node transfer for lymphedema treatment. Plast Reconstr Surg, 2014, 134(3): 548-556.
13. Ward J, King I, Monroy-Iglesias M, et al. A meta-analysis of the efficacy of vascularised lymph node transfer in reducing limb volume and cellulitis episodes in patients with cancer treatment-related lymphoedema. Eur J Cancer, 2021, 151: 233-244.
14. Winters H, Tielemans HJP, Paulus V, et al. A systematic review and meta-analysis of vascularized lymph node transfer for breast cancer-related lymphedema. J Vasc Surg Venous Lymphat Disord, 2022, 10(3): 786-795.
15. Chen SH, Cem Yildirim ME, Mousavi SA, et al. Long-term functional outcomes upon application of split-thickness skin graft around major joints in HCC (Hung-Chi Chen)-modified Charles’ procedure for advanced lymphedema. Asian J Surg, 2021, 44(1): 169-173.
16. Ciudad P, Agko M, Huang TCT, et al. Comprehensive multimodal surgical treatment of end-stage lower extremity lymphedema with toe management: The combined Charles’, Homan’s, and vascularized lymph node transfer (CHAHOVA) procedures. J Surg Oncol, 2019, 119(4): 430-438.
17. Cornelissen AJ, Qiu SS, Lopez Penha T, et al. Outcomes of vascularized versus non-vascularized lymph node transplant in animal models for lymphedema. Review of the literature. J Surg Oncol, 2017, 115(1): 32-36.
18. Raju A, Chang DW. Vascularized lymph node transfer for treatment of lymphedema: a comprehensive literature review. Ann Surg, 2015, 261(5): 1013-1023.
19. Li Y, Dong R, Li Z, et al. Intra-abdominal vascularized lymph node transfer for treatment of lymphedema: A systematic literature review and meta-analysis. Microsurgery, 2021, 41(8): 802-815.
20. Cheng MH, Huang JJ, Nguyen DH, et al. A novel approach to the treatment of lower extremity lymphedema by transferring a vascularized submental lymph node flap to the ankle. Gynecol Oncol, 2012, 126(1): 93-98.
21. Althubaiti GA, Crosby MA, Chang DW. Vascularized supraclavicular lymph node transfer for lower extremity lymphedema treatment. Plast Reconstr Surg, 2013, 131(1): 133e-135e.
22. Coriddi M, Wee C, Meyerson J, et al. Vascularized jejunal mesenteric lymph node transfer: A novel surgical treatment for extremity lymphedema. J Am Coll Surg, 2017, 225(5): 650-657.
23. Visconti G, Constantinescu T, Chen PY, et al. The venous lymph node flap: Concepts, experimental evidence, and potential clinical implications. J Reconstr Microsurg, 2016, 32(8): 625-631.
24. Visconti G, Constantinescu T, Araki J, et al. The venous lymph node flap for the treatment of peripheral lymphedema: Preliminary evidence. Microsurgery, 2017, 37(1): 86-87.
25. Becker C, Vasile JV, Levine JL, et al. Microlymphatic surgery for the treatment of iatrogenic lymphedema. Clin Plast Surg, 2012, 39(4): 385-398.
26. Miranda Garcés M, Pons G, Mirapeix R, et al. Intratissue lymphovenous communications in the mechanism of action of vascularized lymph node transfer. J Surg Oncol, 2017, 115(1): 27-31.
27. Lin CH, Ali R, Chen SC, et al. Vascularized groin lymph node transfer using the wrist as a recipient site for management of postmastectomy upper extremity lymphedema. Plast Reconstr Surg, 2009, 123(4): 1265-1275.
28. Cheng MH, Chen SC, Henry SL, et al. Vascularized groin lymph node flap transfer for postmastectomy upper limb lymphedema: flap anatomy, recipient sites, and outcomes. Plast Reconstr Surg, 2013, 131(6): 1286-1298.
29. Chocron Y, Azzi AJ, Bouhadana G, et al. Axilla versus wrist as the recipient site in vascularized lymph node transfer for breast cancer-related lymphedema: A systematic review and meta-analysis. J Reconstr Microsurg, 2022, 38(7): 539-548.
30. Hsu SY, Lin CY, Cheng MH. Heparin-induced thrombocytopenia and thrombosis in primary lymphedema patients who underwent vascularized lymph node transplantations. J Surg Oncol, 2022, 125(6): 958-967.
31. Cheng MH, Liu TT. Lymphedema microsurgery improved outcomes of pediatric primary extremity lymphedema. Microsurgery, 2020, 40(7): 766-775.
32. Kwiecien GJ, Gharb BB, Tadisina KK, et al. Quantity of lymph nodes in the vascularized lymph node transfer influences its lymphaticovenous drainage. J Reconstr Microsurg, 2018, 34(1): 41-46.
33. Gustafsson J, Chu SY, Chan WH, et al. Correlation between quantity of transferred lymph nodes and outcome in vascularized submental lymph node flap transfer for lower limb lymphedema. Plast Reconstr Surg, 2018, 142(4): 1056-1063.
34. Phan R, Seifman MA, Dhillon R, et al. Use of submental and submandibular free vascularized lymph node transfer for treatment of scrotal lymphedema: Report of two cases. Microsurgery, 2020, 40(7): 808-813.
35. Abdelfattah U, Elbanoby T, Ayad W, et al. Treatment of secondary scrotal and lower extremity lymphedema using combined pedicled lymph node transfer and lymphaticovenous anastomosis: A case report. Microsurgery, 2020, 40(8): 901-905.
36. Qiu SS, Chen HY, Cheng MH. Vascularized lymph node flap transfer and lymphovenous anastomosis for klippel-trenaunay syndrome with congenital lymphedema. Plast Reconstr Surg Glob Open, 2014, 2(6): e167. doi: 10.1097/GOX.0000000000000099.
37. Cheng MH, Tee R, Chen C, et al. Simultaneous ipsilateral vascularized lymph node transplantation and contralateral lymphovenous anastomosis in bilateral extremity lymphedema with different severities. Ann Surg Oncol, 2020, 27(13): 5267-5276.
38. Cheng MH. ASO Author Reflections: Simultaneous ipsilateral vascularized lymph node transplantation and contralateral lymphovenous anastomosis in bilateral different-severities extremity lymphedema. Ann Surg Oncol, 2020, 27(13): 5277-5278.
39. Garza RM, Beederman M, Chang DW. Physical and functional outcomes of simultaneous vascularized lymph node transplant and lymphovenous bypass in the treatment of lymphedema. Plast Reconstr Surg, 2022, 150(1): 169-180.
40. Yang JC, Wu SC, Hayashi A, et al. Lower limb lymphedema patients can still benefit from supermicrosurgical lymphaticovenous anastomosis (LVA) after vascularized lymph node flap transfer (VLNT) as delayed lymphatic reconstruction-A retrospective cohort study. J Clin Med, 2021, 10(14): 3121. doi: 10.3390/jcm10143121.
41. Akita S, Yamaji Y, Tokumoto H, et al. Improvement of the efficacy of vascularized lymph node transfer for lower-extremity lymphedema via a prefabricated lympho-venous shunt through lymphaticovenular anastomosis between the efferent lymphatic vessel and small vein in the elevated vascularized lymph node. Microsurgery, 2018, 38(3): 270-277.
42. Yamamoto T, Yoshimatsu H, Yamamoto N. Complete lymph flow reconstruction: A free vascularized lymph node true perforator flap transfer with efferent lymphaticolymphatic anastomosis. J Plast Reconstr Aesthet Surg, 2016, 69(9): 1227-1233.
43. Yamamoto T, Yamamoto N, Yamashita M, et al. Efferent lymphatic vessel anastomosis: Supermicrosurgical efferent lymphatic vessel-to-venous anastomosis for the prophylactic treatment of subclinical lymphedema. Ann Plast Surg, 2016, 76(4): 424-427.
44. Akita S, Mitsukawa N, Kuriyama M, et al. Comparison of vascularized supraclavicular lymph node transfer and lymphaticovenular anastomosis for advanced stage lower extremity lymphedema. Ann Plast Surg, 2015, 74(5): 573-579.
45. Granzow JW, Soderberg JM, Dauphine C. A novel two-stage surgical approach to treat chronic lymphedema. Breast J, 2014, 20(4): 420-422.
46. Cook KH, Park MC, Lee IJ, et al. Vascularized free lymph node flap transfer in advanced lymphedema patient after axillary lymph node dissection. J Breast Cancer, 2016, 19(1): 92-95.
47. Nicoli F, Constantinides J, Ciudad P, et al. Free lymph node flap transfer and laser-assisted liposuction: a combined technique for the treatment of moderate upper limb lymphedema. Lasers Med Sci, 2015, 30(4): 1377-1385.
48. Bolletta A, di Taranto G, Losco L, et al. Combined lymph node transfer and suction-assisted lipectomy in lymphedema treatment: A prospective study. Microsurgery, 2022, 42(5): 433-440.
49. Agko M, Ciudad P, Chen HC. Staged surgical treatment of extremity lymphedema with dual gastroepiploic vascularized lymph node transfers followed by suction-assisted lipectomy-A prospective study. J Surg Oncol, 2018, 117(6): 1148-1156.
50. Leppäpuska IM, Suominen E, Viitanen T, et al. Combined surgical treatment for chronic upper extremity lymphedema patients: Simultaneous lymph node transfer and liposuction. Ann Plast Surg, 2019, 83(3): 308-317.
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