IATROGENIC LEG LYMPHEDEMA
Symptomatic lymphoedema is frequently associated to severe morbidity, including pain and feeling of heaviness of the affected limb, disability on the daily activities and serious aesthetic concerns. Moreover, lymphoedema patients are prone to develop recurrent infection episodes, which may present as cellulitis, erysipelas or lymphangitis, requiring oral antibiotic treatment and -quite frequently- long hospitalization for intravenous antibiotic therapy. The psychosocial impact of lymphoedema in breast cancer related lymphoedema (BCRL) patients has been described to be as distressing, as the initial diagnosis of breast cancer.
Management of lymphoedema traditionally consisted of conservative treatments, including manual lymphatic drainage, compression garments, pneumatic pumps and multilayer bandaging. Recently, microsurgical procedures, namely vascularized lymph node transfers, lymphaticovenous anastomoses, lymphatic-venous-lymphatic plasties and lymphaticolymphatic grafts are being used in an increased fashion and considered to offer an effective treatment to severe lymphoedema cases.
Corinne Becker has pioneered the introduction of vascularized lymph node flap and described the lymph node transfer (LNT) technique as a logical reconstructive approach of the lymphoedema sequelae; the flap bridges the injured and interrupted lymphatic pathways and reestablishes the lymphatic flow by promoting lymphangiogenesis. Saaristo et al, studied the mechanism of lymphagiogenesis following LNT and advocated that the vascularized lymph nodes promote the procedure by activating growth factors, such as VEGF-C. The long-term advantages of this microsurgical approach include permanent limb volume reduction, decreased number of infection episodes and total improvement in the quality of patients’ life.
When does it appear ?
Secondary lymphedemas are common in oncologic treatment, especially after lymph node dissection and radiotherapy.
Cancers, whose treatments are commonly associated with lymphedema, include pelvic tumors (i.e., enlarged hysterectomies and prostatectomies), Hodgkin’s tumors, sarcoma and melanoma.
Alternatively, lymphedema may also be caused by non-oncologic procedures such as saphenous vein removal, hernia repair, or thigh lifts, internal liposuctions.
The lymphedema can appear immediately or many years after the surgery. Chronic infections can destroy all the remaining lymphatic collectors and elephantiasis can occur with skin thickening, folds , redness, fibrosis.
The diagnosis is made by clinical exam, isotopy and lymph MRI.
Physiotherapy with manual drainages, bandages, compression garments is necessary, but sometimes inefficient.
Indications for Surgery
The clinical evaluation, examination of the scars and the lymphatic MRI permit to evaluate the lack of drainage and the indication for autologous lymph nodes transplantation.
Wedge excisions in elephantiasis are sometimes needed to avoid mycosis in the deep folds, and to allow bandaging. Free nodes transplantation are done the same day.
Autologous Lymph Nodes Transfers
The reimplantation of some nodes to reestablish the connections between the remaining nodes and chains can improve the drainage of the limb. Because healthy nodes contain VGEFc, a natural lymphatic growing hormone, they promote the development of new channels. Sometimes 2 flaps are needed to improve the results :one in the inguinal area, one in the knee region.
Autologous Lymph Node Transfer can be combined with local liposculptures, with the SPY machine to localize the lymphatic vessels, to improve the results. A selective external liposculpture can remove the « entrapped » fat and improve the esthetic results.
The fat macromolecules are carried by the lymphatic vessels. In case of hypotrophy or lesions of these channels, the triglycerides do not circulate anymore and the fat stays in the limb.
Surgical technique in details
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For the lower leg, the results are really correlated to the duration of the lymphedema, the fibrosis and, of course, the bilateral defect of the iliac lymphatic chains.
The lymphatic MRI shows new lymphatic pathways normalization of the lymphatic pathways in moderated cases.
In long term lymphedema, 1 year after LNT, transformation in lipedema can occur.
This lymphedema is 10 years old and appeared after an enlarged hysterectomy. Results are 2 years after lymph nodes transplantation.
This lymphedema appeared after a total hysterectomy and adenectomy. Results are 2 years after ALNT.
This lymphedema appeared after treatment for Hodgkin disease 12 years ago. Results are 1 year after LNT: complete resolution
The following results are 2 years after 2 ALNT, in the inguinal and knee regions, for a lymphedema resulting from treatment for melanoma, having had that lymphedema resisting to all physiotherapic treatments for 12years.