Lymphaticovenular Bypass Surgery for Lymphedema Management in Breast Cancer Patients

Abstract

Historically, the reported incidence of upper extremity lymphedema in breast cancer survivors who have undergone axillary lymph node dissection has ranged from 9% to 41% [1] [2] [3] [4] [5] [6] In the past 2 decades, sentinel lymph node biopsy has become popular as a way to minimize the morbidity associated with axillary dissection without compromising the cure rate for breast cancer patients [6] [7] [8]. However, even with sentinel node biopsy, the postoperative incidence of upper limb lymphedema in breast cancer patients remains at 4–10% [5] [6] [9] [10]. Lymphedema occasionally emerges immediately after surgery but most often appears after a latent period [11]. Obesity, postoperative seroma, and radiation therapy have been reported as major risk factors for upper extremity lymphedema, but the etiology of lymphedema is still not fully understood [12]. Common symptoms of upper limb lymphedema are increased volume and weight of the affected limb and increased skin tension. The increased volume of the affected limb not only causes physical impairments in wearing clothes and in dexterity but also affects patients’ emotional and mental status. Surgical management of lymphedema can be broadly categorized into physiologic methods and reductive techniques. Physiologic methods such as flap interposition, lymph node transfers, and lymphatic bypass procedures aim to decrease lymphedema by restoring lymphatic drainage. In contrast, reductive techniques such as direct excision or liposuction aim to remove fibrofatty tissue generated as a consequence of sustained lymphatic fluid stasis. Currently, microsurgical variations of lymphatic bypass, in which excess lymph trapped within the lymphedematous limb is redirected into other lymphatic basins or into the venous circulation, have gained popularity [13] [14] [15].

Zusammenfassung

Nachweislich liegt die Inzidenz von Lymphödemen an der oberen Extremität bei Brustkrebspatientinnen nach axillärer Lymphknotendissektion bei 9–41%. Innerhalb der letzten 2 Jahrzehnte etablierte sich die Sentinel-Lymphknotenbiopsie (SLNB) als überlegene Alternative durch ihre geringere Morbidität bei identischer Heilrate. Trotzdem verbleibt bei der SLNB laut Literatur eine Inzidenz von Armlymphödemen von 4–10%. Lymphödeme entstehen gelegentlich direkt postoperativ, meistens aber erst nach einer Latenzperiode. Adipositas, postoperative Serome und Strahlentherapie werden als Hauptrisikofaktoren für die Entwicklung von Armlymphödemen angesehen, aber ihre Ätiologie ist noch nicht vollständig geklärt. Die Symptomatik bei Armlymphödemen umfasst ein erhöhtes Volumen und Gewicht der betroffenen Extremität sowie eine erhöhte Hautspannung. Die Volumenvergrößerung führt nicht nur zu körperlichen Behinderungen wie beim Tragen von Kleidungsstücken oder eingeschränkter Geschicklichkeit, sondern wirkt sich auch emotional und mental aus. Die chirurgischen Therapieverfahren beim Lymphödem können grob in physiologische und rezezierende Verfahren eingeteilt werden. Die physiologischen Verfahren wie z. B. Lappenplastiken, die Lymphknotentransplantation und Lymphgefäßtranspositionen bzw. -transplantationen haben das Ziel der Verbesserung des Lymphabflusses. Dagegen beruhen resezierende Verfahren wie z. B. Exzisionen oder auch die Liposuktion auf der Beseitigung von fibroadipösem Gewebe welches sich in Regionen mit chronischem Lymphstau bildet. Heutzutage haben Variationen der lymphatischen Bypässe Verbreitung gefunden, wobei die Lymphe eines gestauten Körperabschnitts in andere lymphatische Abflussgebiete oder aber das venöse System umgeleitet wird.

Key words

breast surgery - lymphatics - upper limb - microsurgery

Schlüsselwörter

Brustchirurgie - Lymphgefäße - obere Extremität - Mikrochirurgie

• References

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