Die Vielfalt in der chirurgischen Therapie beim Lymphödem – was ist aktuell?

Zusammenfassung

Primäre und sekundäre Lymphödeme entstehen trotz des medizinischen Fortschritts weiterhin und führen bei den Betroffenen oft zur deutlichen Einschränkung der Lebensqualität und zu einer Stigmatisierung im alltäglichen Leben. Durch die axiale Anordnung der Lymphbahnen sind vornehmlich Extremitäten und das äußere männliche Genitale betroffen, aber auch die weibliche Brust kann einen Manifestationsort darstellen. In vielen Fällen steht man vor einer therapeutischen Herausforderung. Primär findet sich ein vermehrtes Flüssigkeitvolumen in dem betroffenen Körperabschnitt, erst sekundär kommt es zu einer Vermehrung soliden Gewebes in der gestauten Körperregion. Therapeutisch gilt es den Flüssigkeitsgehalt und ggf. auch Gewebeüberschüsse zu reduzieren.

Bei der Therapie unterscheidet man die konservativen von den operativen Verfahren. Die konservativen Maßnahmen (Kompressionsbandagierung, manuelle Lymphdrainage, apparative intermittierende Kompression) zielen in erster Linie auf eine Entstauung durch Verbesserung des Abtransports der Lymphe. Bei den operativen Maßnahmen handelt es sich entweder um Eingriffe zur chirurgischen Gewebereduktion (symptomatische/ablative Therapieformen) oder/und um den Lymphabfluss verbessernde Eingriffe (kausale Therapieformen). Die chirurgische Gewebereduktion kann offen oder durch kanülierte Absaugung vorgenommen werden. Die älteren kausalen chirurgischen Verfahren stellen Versuche dar durch lokale Lappenplastiken die Lymphe aus den gestauten Regionen zu lenken. Den modernen kausalen mikrochirurgischen Therapieansatz teilen sich anatomische Rekonstruktionsverfahren der Lymphbahnkontinuität bzw. Lymphbahnaugmentationen sowie Eingriffe mit dem Ziel der extra-anatomischen Ableitung von Lymphe in periphere Venen. In dieser Übersichtsarbeit werden die am weitesten verbreiteten Methoden der speziellen chirurgischen Therapie von Lymphödemen beschrieben und an Hand aktueller Literatur und eigener klinischer und experimenteller Erfahrungen diskutiert.

Abstract

Despite recent medical progress primary and secondary lymphedemas still represent a therapeutic challenge and they often lead to a significant reduction in quality of life. Lymphedemas usually develop in the extremities, the male external genitals as well as the female breast as a consequence to the axial alignment of the lymphatic collectors. Early stages are characterized by an excess of lymph fluid increasing the volume of the affected part of the body whereas later stages represent an increasing amount of solid tissue. Thus therapeutic efforts can focus on the reduction of the surplus of liquid and/or solid components. Generally there are conservative and operative strategies. Conservative measures mainly focus on the improvement of fluid mobilization and drainage and comprise compression garments, manual lymphatic drainage, and apparative intermittent compression. Operative approaches comprise procedures for surgical tissue reduction (symptomatic/ablative approaches) and/or procedures with the intention of enhancing lymphatic transport (causal approaches). Surgical tissue reduction can be performed by open resection and/or liposuction. Traditional surgical causal techniques such as transposition of local flaps aim at leading lymph away from the congested region of the body. Modern microsurgical causal approaches contain methods of reconstruction of interrupted lymphatic pathways as well as techniques for the conduction of lymph into local veins. In this review we depict and discuss the features of the multiform spectrum of the surgical therapy of lymphedemas on the basis of literature as well as our own clinical and experimental experience.

Schlüsselwörter

Lymphödem - Fettabsaugung - Liposuktion - Lympholiposuktion - lympho-venöse - lymphonodo-venöse - lympho-lymphatische - lympho-lymphonoduläre Anastomose - Veneninterponat - Lymphbahntransplantation - Lymphknotentransplantation

Key words

lymphedema - liposuction - lympholiposuction - lympho-venous - lymphonodo-venous - lympho-lymphatic - lympho-lymphonodal anastomosis - vein graft - lymphatic vessel transplantation - lymph node transplantation

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