Abstracts LymphForsch 1/2019

– full text in German –

Microsurgical therapy of lymphedema of the leg – a prospective study

A. Stepniewski, S. M. Weiß, G. Felmerer
LymphForsch 23 (1) 2019;6-15

Summary
Secondary lymphedema of the leg is a chronic and progressive disease. In most cases it occurs as a complication of tumor surgery with irradiation of the pelvis, groin or leg. The goal of this prospective study was to compare surgical treatments comprising lymphovenous anastomosis, autologous transplantation of lymph vessels and autologous lymph node transplantation. The postoperative outcome of these procedures was compared with patients’ quality of life as assessed through a questionnaire. The correlation between postoperative clinical status and leg circumference, tissue water content and tissue bioimpedance was also evaluated. In addition, we investigated the feasibility of using technical devices for examinations in an outpatient setting and their suitability for postsurgical follow-up.

The study took place between May 2012 and May 2015 and included 16 patients (1 man, 15 women) during 12-month postsurgical follow-up. No significant changes in average leg circumference values were observed (42.6 ± 2.4 cm preoperatively vs. 42.7 ± 2.6 cm postoperatively). The average L-Dex value decreased (50.5 ± 16.9 preoperatively vs. 40.0 ± 13.6 postoperatively) and average tissue water content also decreased (55.2 ± 1.3 % preoperatively vs. 54.6 ± 1.5 % postoperatively). The average questionnaire score dropped from 15.4 ± 2.9 preoperatively to 12.2 ± 3.4 postoperatively. In summary, the findings suggest that the above-mentioned surgical procedures are good methods for treating secondary lymphedema of the leg, although none of the procedures was clearly superior.

Keywords:
lymphedema surgery, plastic surgery, leg circumference, prospective study, microsurgery, tissue water content, bioimpedance

E-mail: gunther.felmerer@med.unigoettingen.de

Surgical treatment of lymphedema (congenital and iatrogenic) and lipedema – Strategic approach

C. Becker
LymphForsch 23 (1) 2019;16-22

Summary
In subclinical cases in which the patient requests breast reconstruction, the indication for an additional autologous lymph node flap depends on whether preoperative MRI detects the presence of lymphatic pathology. The MRI may identify specific pathologies such as vessel hypoplasia due to chronic infection, absence of lymph nodes and/or vessels in the axilla following lymphadenectomy, radiotherapy and chronic infection, as well as the occlusion of lymph vessels.

The inguinal lymph node flap can be integrated into the flap of the adjacent skin and the fat in the lower abdomen, based on the superficial lower epigastric vessels or the deeperlying epigastric vessels. To harvest the nodes, the incisions of the abdominal lobe must be lowered to the level of the iliac crest, including the inguinal lymph node flap described above.

In patients with bilateral lymphedema or elephantiasis, combinations of multiple lymph node transfers, wrinkle resections and liposculptures are mandatory, but can significantly improve patients’ quality of life, reducing the infection rate, limb size, strength of compression garments and need for physiotherapy. In addition, in 80 % of patients below the age of 60, this method promotes the ability to return to work.

Keywords:
lymph node transfer, ALNT, DIEP, congenital lymphedema, iatrogenic lymphedema, oncological treatments, inguinal flap, cervical area, thoracic flap, elephantiasis, fat deposits, lymph node MRI, pin point.

E-mail: corinne.becker.md@gmail.com

Lymphatic imaging and interventional therapy of the abdominothoracic lymphatic system

C. C. Pieper
LymphForsch 23 (1) 2019;23-35

Summary
Pathologies of the abdominothoracic lymphatic system (often associated with chylolymphatic leakages) are rare, but difficult-to-treat clinical problems that can be associated with considerable morbidity and mortality. Modern imaging techniques (e.g., MR lymphangiography) enable delineation of abdominothoracic lymphatics and lymphatic flow and can be used as diagnostic tools for various pathologies (especially chylothorax, chylopericardium, chylous ascites, cutaneous lymphatic leakage, lymphoceles, genital lymphedema, plastic bronchitis). New interventional radiological treatment options have been developed based on these imaging techniques.

Keywords:
lymphangiography, magnetic resonance imaging, chylothorax, chylous ascites, lymphocele, lymphedema

E-mail: pieper.lymphatic@gmail.com

Using indocyanine green lymphography in lymphatic surgery

T. Aung, S. Härteis, V. Brebant, T. Papathemelis, A. Scharl, L. Prantl
LymphForsch 23 (1) 2019;36-40

Summary
Indocyanine green (ICG) lymphography is used both for diagnostic classification of lymphatic disorders and for preoperative planning of lymphatic surgical procedures. Intraoperatively, ICG lymphography has been used successfully to visualize reconstructive lymphatic drainage (patency test). In tumor surgery, ICG fluorescence technique may also enhance safety. Furthermore, ICG lymphography can be used postoperatively to evaluate the success of lymphatic surgery. Overall, based on the latest scientific findings and clinical experience, ICG lymphographyappears to be a reliable diagnostic method with low rates of complication, easy handlingand a high level of specificity and sensitivity and is thus superior to other diagnostic techniques. However, prospective studies and other tests are necessary to provide conclusive evidence.

Keywords:
ICG lymphography, lymphedema, lymphatic surgery, lymphovenous anastomosis

E-Mail: thiha.aung@ukr.de

Surgical aspects of the use of lymphovenous anastomoses and vascularized lymph node transfer for lymphedema treatment

J. Steinbacher, C. H. J. Tzou
LymphForsch 23 (1) 2019;41-44

Summary
Lymphedema is a chronic, progressive disease accompanied by physical, psychological and social limitations. Diagnostic and technological advances in the field of microsurgery have opened up new surgical opportunities to alleviate symptoms.

Keywords:
lymphedema, lymphovenous anastomosis (LVA), vascularized lymph node transfer (VLNT), indocyanine green (ICG)

E-mail: johannes.steinbacher@khgh.at
E-mail: science@tzou.at

The role of night-time compression in out-patient lymphedema therapy today

H. Pritschow
LymphForsch 23 (1) 2019;45-48

Summary
The S2k guideline on diagnosis and treatment of lymphedema (2017) particularly emphasizes „education and training for individual self-therapy of the patient.“ Basic knowledge of the anatomy, physiology, pathophysiology of the lymphatic system, as well as complete physical decongestive therapy (CDT), as well as do’s and don‘ts, are prerequisites for manual lymph drainage therapists to cooperate well with their patients. Lymphedema therapy delivered at the “neighborhood” massage or physiotherapy practice enables closely monitored therapeutic care of the patient and, if necessary, prompt, efficient response in the event of complications. In phase II of CDT, adequate night-time compression helps to maintain or improve the good decongestion results.

Keywords:
lymphatic system, lymphedema, complete physical decongestive therapy (CDT), out-patient lymphedema therapy, night-time compression, economic efficiency

E-mail: zmlpritschow@t-online.de

Lipedema – an enigmatic condition: a commentary

K. Schrader
LymphForsch 23 (1) 2019;49-55

Summary
Lipedema has attracted a great deal of attention lately. When it comes to therapy, a paradigm shift has even been called for. Ultimately, however, new convictions are not enough to offset the lack of scientific knowledge. My insights are based on 30 years of experience in a vascular medical practice focusing on lymphedema management. For me is certain that:

• Lipedema is a condition regularly accompanied by edema.
• Lipedema is a psychosomatic disorder. Mental distress and physical complaints are interdependent.
• Complete physical decongestive therapy (CDT) in all its aspects offers good prospects of success in conservative therapy if used prudently.
• Harmonization of body proportions can only be achieved with liposuction.
• Obesity is a complicating factor.
• Primary prevention of obesity and lipedema must begin in children and adolescents.
• In the long run, the progression of lipedema depends largely on the development of body weight.
• Bariatric surgery is nutritional science’s admission of defeat. 

You may have had other experiences. Lipedema, especially after the philippic by T. Bertsch and G. Erbacher, still remains enigmatic. We lymphologists are just beginning to have a unified voice. We should work together, and from the many expert opinions out on the subject of lipedema, we should distill efforts for joint action. There will be no randomized controlled trials. But perhaps one day a national lipedema register will be available as a first step.

Keywords:
Lipedema, obesity, complete physical decongestive therapy, liposuction

E-mail: post@gefaesspraxis-hochfranken.de

Why do the results of MLD therapy in practice differ from those found in research studies?

R. Harris
LymphForsch 23 (1) 2019;56-58

Summary
A well-designed research study is dependent upon planning and organisation that fits into a research methodology. The physician David L. Sackett from McMaster University, Hamilton/ Canada pioneered evidence-based medicine (EBM). Although widely accepted, the ranking of evidence according to this hierarchy is not always relevant to clinical practice. There appear to be gaps between what we achieve with our patients as therapists and what is published in the literature. Much of the current research on manual lymph drainage (MLD) focuses on its use in lymphedema management within the context of complete physical decongestive therapy (CDT). Examples will be given of higher-level MLD studies and those that reflect clinical practice with the intent to provoke discussion on enabling research in MLD and in particular, the importance of case reports.

Keywords:
Evidence-based medicine, manual lymph drainage, complete physical decongestive therapy

E-mail: rharris@vodderschool.com