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Handchir Mikrochir Plast Chir 2019; 51(06): 424-433
DOI: 10.1055/a-0874-2212
Consensus Statement
© Georg Thieme Verlag KG Stuttgart · New York

Rekonstruktive Mikrochirurgie des sekundären Lymphödems: Konsensus der Deutschsprachigen Arbeitsgemeinschaft für Mikrochirurgie der peripheren Nerven und Gefäße (DAM) zur Indikation, Diagnostik und Therapie mittels Lymphovenöser Anastomosen (LVA) und vaskularisierter Lymphknotentransplantation (VLKT)

Lympho-reconstructive microsurgery for secondary lymphedema: Consensus of the German-Speaking Society for Microsurgery of Peripheral Nerves and Vessels (DAM) on indication, diagnostic and therapy by lymphovenous anastomosis (LVA) and vascularized lymph node transfer (VLNT)
Christoph Hirche
1   Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Mikrochirurgie, Schwerbrandverletztenzentrum, Klinik für Plastische und Handchirurgie an der Universität Heidelberg
,
Holger Engel
1   Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Mikrochirurgie, Schwerbrandverletztenzentrum, Klinik für Plastische und Handchirurgie an der Universität Heidelberg
2   Klinik für Plastisch-rekonstruktive, Ästhetische und Handchirurgie, Klinikum Kassel
,
Katrin Seidenstuecker
3   Abteilung für Plastische Chirurgie II, Rekonstruktive Mikro- und Lymphchirurgie, Sana-Kliniken Düsseldorf, Standort Benrath
,
Christian Taeger
4   Abteilung für Plastische, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Regensburg
,
Hans-Günther Machens
5   Klinik für Plastische Chirurgie und Handchirurgie, Klinikum rechts der Isar der Technischen Universität München, Deutschland
,
Andreas Frick
6   Abteilung für Handchirurgie, Plastische Chirurgie und Ästhetische Chirurgie Campus Innenstadt und Großhadern der Ludwig-Maximilians Universität Münche
,
Yves Harder
7   Klinik für Plastische, Rekonstruktive und Ästhetische Chirurgie, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale, Lugano, Schweiz
› Institutsangaben
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Publikationsverlauf

18. Dezember 2018

02. März 2019

Publikationsdatum:
08. Mai 2019 (online)

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Zusammenfassung

Das sekundäre Lymphödem ist eine komplexe Erkrankung, die durch chronische Inflammation und reduzierte Immunkompetenz, Ansammlung von Lymphflüssigkeit und Proteinablagerungen sowie sekundärer Fettablagerung und Fibrosierung bei der Stadienmigration charakterisiert ist. Während die Domäne der Behandlung immer noch eine lebenslange komplexe physikalische Entstauungstherapie (KPE) ist, wird der Fokus auf chirurgische Verfahren zur physiologischen Rekonstruktion gesetzt. Die lymphovenösen Anastomosen (LVA) und die freie, vaskularisierte Lymphknotentransplantation (VLKT) sind die am verbreitetsten angewendeten, rekonstruktiven Techniken, die die Wiederherstellung oder Verbesserung der physiologischen Lymphtransportkapzität adressieren. Der vorliegende Artikel fasst die Empfehlungen eines Expertenpanels zur Diagnostik, Indikation und Therapie von LVA und VLKT bei sekundären Lymphödemen während der 40. Jahrestagung der Deutschsprachigen Arbeitsgemeinschaft für Mikrochirurgie der peripheren Nerven und Gefäße (DAM) in Lugano, Schweiz, zusammen und diskutiert sie. Das Expertengremium befasste sich mit der Diagnostik für die lymphorekonstruktive Chirurgie, einschließlich der essentiellen Anwendung der Fluoreszenz-Lymphangiographie mit Indocyaningrün (ICG) und der intraoperativen Navigation für beide Techniken sowie dem „reverse mapping“, um die Rate des Hebestellen-Lymphödems nach VLKT zu reduzieren, sowie die Verwendung von Lymphödem-spezifischen Fragebögen zur Lebensqualität. Sowohl LVA als auch VLKT werden einschließlich Tipps und Tricks zur Identifizierung funktioneller Lymphkollektoren, Ausrüstung, Anastomosenarten und Dokumentation für LVA sowie Auswahl der Spender- und Empfängerstelle, Anzahl der inkludierten Lymphknoten und Herangehensweise an spezifische Spenderstellen, wie z. B. jejunal-mesenterial für den VLKT, beschrieben. Die synchrone und sequentielle Anwendung von LVA, VLKT und/oder ablativer Liposuktion wird vor dem Hintergrund der Wirksamkeit und Morbidität diskutiert. Schließlich werden Empfehlungen zur postoperativen Behandlung und Diagnostik erörtert. Die vorliegende Konsensusarbeit adressiert eine Erhöhung des Standardisierungsgrades der Behandlung für weitere multizentrische Studien im deutschsprachigen Raum in diesem aufstrebenden Gebiet der Lymphödemtherapie.

Abstract

Secondary lymphedema is a complex and devastating disease including chronic inflammation and reduced immunofunction, lymphatic fluid and protein accumulation due to misdirected lymphatic transport, and secondary fat deposition followed by fibrosis. While the domain of treatment still is lifelong complex decongestive therapy, it is more and more widespread to treat the disease with a surgical focus on physiologic, reconstructive strategies or debulking surgery. Lymphovenous Anastomosis (LVA) and Vascularized lymph node transplantation (VLNT) are the mostly frequently applied, reconstructive techniques which address restoration or improvement of physiologic lymph clearance. The article summarizes and discusses the recommendations of an expert panel on the diagnostic, indication and therapy of LVA and VLNT in secondary lymphedema during the 40th Meeting of the Germanspeaking Society of Microsurgery in Lugano, Switzerland, 2018. The expert panel addressed the basic diagnostics prior to lymphoreconstructive surgery, including the inevitable application of Indocyanine Green (ICG) based fluorescence lymphangiography and navigation for both techniques including reverse mapping to reduce the rate of donor-site lymphedema for VLNT as well as the use of lymphedema-specific quality of life questionnaires. Both LVA and VLNT are elaborately described, including tips and tricks on identifying functional lymphatic collectors, equipment, types of anastomosis and documentation for LVA and choice of donor and recipient site, number of includable lymph nodes and management of specific donor sites, e. g. jejunal mesenteric for VLNT. The synchronous and sequential application of LVA, VLNT and/or ablative liposuction is discussed against the background of the effectivity and morbidity of both reconstructive, physiologic techniques. Finally, recommendations on post-operative treatment and diagnostics are discussed. The present consensus paper intends to improve the level of standardization for further multicenter studies in the germanspeaking countries in this aspiring field of lymphedema treatment.

Schlüsselwörter

Lymphödem - sekundär - lymphovenöse Anastomosen (LVA) - vaskularisierter Lymphknotentransfer - Konsensus - rekonstruktiv - Mikrochirurgie

Key words

lymphedema - secondary - lymphovenous anastomosis (LVA) - vascularized lymph node transfer (VLNT) - consensus - reconstructive - microsurgery
 

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