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

• Literatur

• 1 Olszewski WL. Contractility patterns of human leg lymphatics in various stages of obstructive lymphedema. Ann N Y Acad Sci 2008; 1131: 110-118
• 2 Szczesny G, Olszewski WL. The pathomechanism of posttraumatic edema of the lower limbs: II–Changes in the lymphatic system. J Trauma 2003; 55: 350-354
• 3 Olszewski WL. Contractility patterns of normal and pathologically changed human lymphatics. Ann N Y Acad Sci 2002; 979: 52-63 discussion 76-59
• 4 Miller AJ, Bruna J, Beninson J. A universally applicable clinical classification of lymphedema. Angiology 1999; 50: 189-192
• 5 Campisi C. Lymphatic microsurgery for the treatment of lymphedema. Microsurgery. 2006 26. 65-69
• 6 Weiss M, Baumeister RG, Hahn K. Dynamic lymph flow imaging in patients with oedema of the lower limb for evaluation of the functional outcome after autologous lymph vessel transplantation: an 8-year follow-up study. Eur J Nucl Med Mol Imaging 2003; 30: 202-206
• 7 Notohamiprodjo M. MR-lymphangiography at 3.0 T–a feasibility study. Eur Radiol 2009; 19: 2771-2778
• 8 Goldsmith HS. Long term evaluation of omental transposition for chronic lymphedema. Ann Surg 1974; 180: 847-849
• 9 Roy P, Clark MA, Thomas JM. Stewart-Treves syndrome – treatment and outcome in six patients from a single centre. Eur J Surg Oncol 2004; 30: 982-986
• 10 Charles RH. Elephantiasis scroti. Churchill: 1912
• 11 Modolin M. Surgical treatment of lymphedema of the penis and scrotum. Clinics (Sao Paulo) 2006; 61: 289-294
• 12 Green TM. Elephantiasis and the Kondoleon Operation. Ann Surg 1920; 71: 28-31
• 13 Dimakakos E, Arkadopoulos N, Katsenis K et al. Emmanuil Kondoleon: pioneer in surgical treatment for lymphedema. Lymphology 2009; 42: 42-45
• 14 Salgado CJ. Radical reduction of upper extremity lymphedema with preservation of perforators. Ann Plast Surg 2009; 63: 302-306
• 15 Sistrunk WE. Contribution to Plastic Surgery: Removal of Scars by Stages; an Open Operation for Extensive Laceration of the Anal Sphincter; the Kondoleon Operation for Elephantiasis. Ann Surg 1927; 85: 185-193
• 16 Hoffmann JN, Fertmann JP, Baumeister RG et al. Tumescent and dry liposuction of lower extremities: differences in lymph vessel injury. Plast Reconstr Surg 2004; 113: 718-724 discussion 725–716
• 17 Brorson H, Svensson H. Liposuction combined with controlled compression therapy reduces arm lymphedema more effectively than controlled compression therapy alone. Plast Reconstr Surg 1998; 102: 1058-1067 discussion 1068
• 18 Brorson H. From lymph to fat: complete reduction of lymphoedema. Phlebology 2010; 25 (Suppl. 01) 52-63,
• 19 Warren AG, Brorson H, Borud LJ et al. Lymphedema: a comprehensive review. Ann Plast Surg 2007; 59: 464-472
• 20 Baumeister RG, Siuda S. Treatment of lymphedemas by microsurgical lymphatic grafting: what is proved?. Plast Reconstr Surg 1990; 85: 64-74 discussion 75–66
• 21 O’Brien BM, Khazanchi RK, Kumar PA et al. Liposuction in the treatment of lymphoedema; a preliminary report. Br J Plast Surg 1989; 42: 530-533
• 22 Thompson N. Buried dermal flap operation for chronic lymphedema of the extremities. Ten-year survey of results in 79 cases. Plast Reconstr Surg 1970; 45: 541-548
• 23 Hurst PA, Stewart G, Kinmonth JB et al. Long term results of the enteromesenteric bridge operation in the treatment of primary lymphoedema. Br J Surg 1985; 72: 272-274
• 24 Laine JB, Howard JM. Experimental Lymphatico-Venous Anastomosis. Surg Forum 1963; 14: 111-112
• 25 Sedlacek J. Lymphovenous shunt as supplementary treatment of elephantiasis of lower limbs. Acta Chir Plast 1969; 11: 157-162
• 26 Degni M. A new technic of lymphatico-venous anastomosis for the treatment of lymphedema of the limbs. J Mal Vasc 1988; 13: 131-135
• 27 Rao YG. Factors influencing response to lymphonodovenous shunt in filarial lymphoedema. Natl Med J India 1999; 12: 55-58
• 28 Boccardo FM. Surgical prevention of arm lymphedema after breast cancer treatment. Ann Surg Oncol 2011; 18: 2500-2505
• 29 Schunemann H, Willich N. Lymphoedema of the arm after primary treatment of breast cancer. Anticancer Res 1998; 18: 2235-2236
• 30 Koshima I, Inagawa K, Urushibara K et al. Supermicrosurgical lymphaticovenular anastomosis for the treatment of lymphedema in the upper extremities. J Reconstr Microsurg. 2000 16. 437-442
• 31 O’Brien BM. Long-term results after microlymphaticovenous anastomoses for the treatment of obstructive lymphedema. Plast Reconstr Surg 1990; 85: 562-572
• 32 Huang GK. Microlymphaticovenous anastomosis in the treatment of lower limb obstructive lymphedema: analysis of 91 cases. Plast Reconstr Surg 1985; 76: 671-685
• 33 Huang GK. Results of microsurgical lymphovenous anastomoses in lymphedema – report of 110 cases. Langenbecks Arch Chir 1989; 374: 194-199
• 34 Wallmichrath J. Experimental study on the microsurgical or spontaneous formation of lympho-lymphonodular anastomoses in the rat model. J Plast Reconstr Aesthet Surg 2011;
• 35 Ho LC, Lai MF, Kennedy PJ. Micro-lymphatic bypass in the treatment of obstructive lymphoedema of the arm: case report of a new technique. Br J Plast Surg 1983; 36: 350-357
• 36 Baumeister RG, Seifert J, Wiebecke B et al. Experimental basis and first application of clinical lymph vessel transplantation of secondary lymphedema. World J Surg 1981; 5: 401-407
• 37 Kleinhans E. Evaluation of transport kinetics in lymphoscintigraphy: follow-up study in patients with transplanted lymphatic vessels. Eur J Nucl Med 1985; 10: 349-352
• 38 Horstmann E. Über die funktionelle Struktur der mesenchymalen Lymphgefäße Vol. 91: 483-510 (Gegenbaurs morphol. Jahrb., 1952)
• 39 Schmid-Schonbein GW. Microlymphatics and lymph flow. Physiol Rev 1990; 70: 987-1028
• 40 Caro C, Pedley T, Schroter R et al. The mechanics of the circulation. Oxford University; New York-Toronto: 1978
• 41 Olszewski WL, Engeset A. Intrinsic contractility of prenodal lymph vessels and lymph flow in human leg. Am J Physiol 1980; 239: H775-H783
• 42 Campisi C. Microsurgery for treatment of peripheral lymphedema: long-term outcome and future perspectives. Microsurgery 2007; 27: 333-338
• 43 Chipp E, Ferguson L, Rayatt S. Vascularized groin lymph node transfer using the wrist as a recipient site for management of postmastectomy upper extremity lymphedema. Plast Reconstr Surg 2010; 125: 751-752 author reply 752-753
• 44 Becker C, Assouad J, Riquet M et al. Postmastectomy lymphedema: long-term results following microsurgical lymph node transplantation. Ann Surg 2006; 243: 313-315
• 45 Sommer T. Improved Regeneration of Autologous Transplanted Lymph Node Fragments by VEGF-C Treatment. Anat Rec (Hoboken) 2012; 295: 786-791
• 46 Tammela T. Therapeutic differentiation and maturation of lymphatic vessels after lymph node dissection and transplantation. Nat Med 2007; 13: 1458-1466
• 47 Rothkotter HJ, Pabst R. Autotransplantation of lymph node fragments. Structure and function of regenerated tissue. Scand J Plast Reconstr Surg Hand Surg 1990; 24: 101-105
• 48 Tobbia D, Semple J, Baker A et al. Experimental assessment of autologous lymph node transplantation as treatment of postsurgical lymphedema. Plast Reconstr Surg 2009; 124: 777-786
• 49 Chen HC, O’Brien BM, Rogers IW et al. Lymph node transfer for the treatment of obstructive lymphoedema in the canine model. Br J Plast Surg 1990; 43: 578-586
• 50 Saaristo AM. Microvascular breast reconstruction and lymph node transfer for postmastectomy lymphedema patients. Ann Surg 2012; 255: 468-473