Free vascularized lymph node transfer for treatment of lymphedema: A systematic evidence based review

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Summary

Background

Free vascularized lymph node transfer (VLNT) is a relatively novel technique for treatment of lymphedema. The purpose of this systematic review was to evaluate the current evidence on VLNT and to determine if there is objective data concerning improved outcomes.

Methods

A literature search of PubMed, EMBASE and CENTRAL electronic databases was conducted to identify articles written in the English language on VLNT for treatment of lymphedema. Publications were selected according to inclusion criteria. Papers reporting adjunct techniques and those that did not describe outcomes were excluded. Data including patient demographics, surgical technique, complications and outcomes were extracted. A quality score was calculated for each article.

Results

Eighteen studies were included with an overall study population of 305 patients. Mean quality score of articles was 5.3 with levels of evidence range from II to IV. Among 182 patients who underwent limb circumference assessment, 165 (91%) showed postoperative improvement. Reduction of limb volume was noted in 98 of 114 (86%) patients. Ninety two patients underwent lymphoscintigraphy/lymphangiography and 55 (60%) demonstrated moderate or significant improvement of flow. Patient satisfaction was questioned in 105 patients and with exception of 7 patients, all reported a high satisfaction level with significant relief in symptoms and improved quality of life. Publications also reported a reduction in infectious episodes.

Conclusion

VLNT appears to provide improvement in lymphedema. More studies with standardized methods for reporting outcomes and uniform patient selection are needed to evaluate this technique thoroughly.

Introduction

Lymphedema is caused by disruption of lymphatic drainage systems that subsequently result in enlargement of the affected site. In the early stages, the swelling is due to accumulation of fluid in the interstitial space, however as the condition progresses, the amount of fat and fibrotic tissue also increase. Acquired etiology is more prevalent and is commonly due to iatrogenic removal of lymph nodes, and radiation treatment.1 The patients usually present with swelling, heaviness and enlargement of the affected limb, skin atrophy and recurrent episodes of cellulitis.2

Lymphedema is initially managed by decongestive physiotherapy that consists of compression garments, exercise, mechanical measures and manual drainage.3, 4 Late phase, chronic lymphatic dysfunction is difficult to cure and does not respond well to conservative management. For such cases, debulking procedures and physiologic operations to increase lymphatic outflow have been advocated.5, 6, 7, 8, 9, 10 Excisional procedures are beneficial, however they may result in the destruction of remaining lymphatics and poor cosmetic results.11 Physiologic operations like lymphovenous anastomoses are technically challenging due to requirement of supermicrosurgery as lymphatic vessels are usually less than 1 mm in diameter. Free vascularized lymph node transfer (VLNT) is a relatively novel technique which aims to bring functional lymph nodes into the affected site to promote lymphangiogenesis via growth factors and acting as a pump.12, 13 The lymph nodes are usually transferred en-block with surrounding soft tissue and microsurgical anastomoses are performed at the recipient site. The lymphatic tissue transfer could also be incorporated into major reconstructive surgery such as autologous breast reconstruction.14, 15

There is emerging evidence that VLNT could potentially improve lymphedema, however more evidence is needed to provide a rationale for harvesting lymph nodes from a distant site. The primary goals of this review are to evaluate the published evidence on VLNT and determine if there is objective data on improvement. Existing literature reviews on VLNT are mostly narrative and are broad including a mixture of techniques. The objective of this systematic review was to evaluate recent literature reporting solely on VLNT.

Section snippets

Literature search

A literature search of PubMed, EMBASE and Cochrane Central Register of Controlled Trials (CENTRAL) electronic databases was conducted to identify all articles involving microsurgical lymphatic surgery techniques, specifically VLNT, to treat lymphedema. The following search strings were used: (1) Pubmed: (lymphedema) AND (flap) OR (grafting) OR grafts) OR graft) OR transplantation) OR transplant) OR transfers) OR transfer)) AND (“lymph vessel”) OR lymphatic) OR “lymph node”) OR (“lymphatic

Results

Seventy one studies underwent full text review and 18 were included in the analysis (Figure 1). The mean quality score of the 18 reviewed articles was 5.3 (min = 3; max = 7). The level of evidence for the manuscripts included in this review ranges from Level II to Level IV. Specifically, 3 papers were graded as Level II, 13 at Level III and 2 were at Level IV (Table 2).

Overall, the study population consisted of 305 patients, 309 limbs and 316 flaps due to the existence of multiple flaps in one

Discussion

Chronic lymphedema is a debilitating condition that is unlikely to resolve with conservative therapy alone. Surgical treatment is recommended for refractory cases. However, there is also rationale for physiologic procedures to be performed early on, before tissues become fibrotic and lymphatic vessels are nonfunctional.14, 33 Debulking surgery, lymphovenous shunts and more recently VLNT are among the techniques utilized alone or in combination to improve lymphedema.8, 9, 10 With VLNT, the lymph

Conclusion

Based on the published literature, there is evidence ranging from Level II to IV to support the benefit of VLNT which appears to improve lymphedema in its early stages or mild to moderate lymphedema cases; however, it is still in an exploratory stage, without direct evidence on how transplanted nodes interact with the native lymphatic system. More studies with improved methods of reporting outcomes and uniform patient selection are needed to evaluate this technique thoroughly. Future studies

Conflict of interest

None.

Funding

None.

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