Double-Level Vascularized Lymph Node Transfer for Treatment of Extremity Lymphedema

Surgical treatments for lymphedema, such as vascularized lymph node transfer, are becoming more popular. Reported donor sites include the groin, axilla, submentum, supraclavicular, omental, and recently described, the jejunal mesentery.[1] [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15] [16] [17] [18] [19] [20] Improvements in lymphedema following vascularized lymph node transfer have varied greatly. Placement of the vascularized lymph node can be either proximal or distal on the extremity. Literature has shown improvements in lymphedema regardless of recipient site; however, some suggest that the benefit may be greater when placed distally.[8] Others believe that release of scar tissue in the axilla or groin prior to inset of the vascularized lymph node contributes greatly to the effectiveness of the procedure.

Here, we describe an innovative combination of these techniques: jejunal mesenteric vascularized lymph node transfer to the distal wrist and scar release/excision with free omental flap to the axilla. Additionally, we propose a scar scale to categorize scarring of the previously dissected nodal basin.

The jejunal mesenteric lymph node transfer is performed as previously described to the distal wrist.[17] Briefly, the flap is harvested through a midline mini-laparotomy, supraumbilical incision approximately 5 cm in length. The jejunum is delivered through the incision and run proximally toward the ligament of Trietz. A cluster of lymph nodes in the proximal jejunal mesentery with an appropriately sized artery and vein is identified by transillumination and palpation. The flap is raised with the cluster of lymph nodes and mesenteric vascular pedicle en bloc while preserving bowel continuity. The flap is anastomosed to the distal wrist, typically in an end-to-side fashion to the radial artery and end-to-end fashion to the radial vein or cephalic vein. Inset is performed by removing subcutaneous tissue, creating a pocket for the flap. Primary closure is usually obtained ([Fig. 1]). A full-thickness skin graft can be harvested as an ellipse adjacent to the abdominal incision and used if primary closure cannot be obtained. Flap monitoring can be achieved by an implantable doppler crystal inserted directly into the flap or percutaneously with a hand-held doppler.

Fig. 1 Double-level vascularized lymph node transfer. Photographs of standard patient before surgical intervention (top), after anastomosis of the omental flap to the axillary vessels (left center) and jejunal mesenteric lymph node flap to the wrist (right center), and after inset and closure (bottom).

Attention is then turned to the axilla where the area of scar is released and excised. This usually includes a careful dissection of the axillary vein, which is often encased in scar and may be narrowed by scar bands. We then utilize the open abdomen from the harvest of the vascularized jejunal lymph node transfer to harvest a portion of the omentum for placement into the axilla. The omentum is examined to determine if the right or left gastroepiploic artery and vein would provide a better pedicle and identify the position of any nodes, which are usually located along the greater curvature of the stomach. Once this decision is made, the omentum adjacent to the pedicle is dissected free from the transverse colon, stomach, and remaining omentum. The harvested omentum generally measures 10 × 20 cm. The gastroepiploic artery and vein are then anastomosed in an end-to-end fashion to previously prepared vessels on the lateral chest wall. These vessels are generally the lateral thoracic or the serratus branch of the thoracodorsal. The omental flap is inset to fill the dead space created by scar release and excision ([Fig. 1]).

The postoperative course includes elevation and abduction of the upper extremity for 1 week. Patients are slowly progressed to full range of motion. Clear liquid diet is initiated immediately postoperatively and the diet is advanced as tolerated on postoperative day 1. To date, five patients have received double lymph node transfers. Preliminary results are promising and will be reported once adequate follow-up (greater than 1 year) has been achieved.

By using the abdomen as a donor site for vascularized lymph node transfer, we are able to harvest both a jejunal mesenteric vascularized lymph node and omental flap simultaneously. Therefore, we can gain the benefits of both a distal node placement on the extremity, axillary/groin scar release, and proximal vascularized node flap inset to assist with lymphangiogenesis. Placing the omental flap in the axilla/groin fills the dead space and prevents rescarring of the axilla. Using the jejunal mesenteric vascularized lymph node at the wrist allows for a primary closure in most cases as this flap is small. Additional benefits of using the abdomen as a donor site include decreased risk for donor site lymphedema, reliable vascular anatomy, and well-concealed scar.

As surgical treatments for lymphedema become more popular, it is essential to determine the efficacy of these procedures and establish criteria to select the proper procedure for the patient. To create these criteria, it is necessary to have standard definitions that outline the factors contributing to the development of lymphedema. Factors such as radiation and lymph node dissection are objectively reported. However, axillary scarring does not have an objective measurement tool. To our knowledge, there is no metric to describe severity of scarring after cancer-related treatments. In the absence of a specific instrument, we propose the Ohio State scar scale as a simple and descriptive tool for use in diagnosing and communicating the degree of scarring after lymph node removal ([Table 1]).

Table 1 The Ohio scar scale (for axillary or inguinal node dissections)

Grade	Description
0	No scar, no surgical intervention to area
1	Superficial scar, mobile (no tethering, adequate subcutaneous fat layer)
2	Scar extending into subdermal structures, deep palpable scar, remains mobile against deeper structures (i.e., chest wall, groin, fascia/musculature)
3	Visible tethering of skin, scar tethering skin to underlying deeper structure (i.e., chest wall, deep fascia of the groin), scar is usually depressed/dimpling
4	Painful tethered scar

We believe the double-level vascularized lymph node transfer, the distal placement of the jejunal mesenteric lymph node flap and simultaneous axillary scar release with omental flap placement, maximizes benefits for patients. Using the abdomen as a donor site allows for harvest of more than one flap and has a decreased risk of donor site lymphedema. Using the Ohio scar scale will assist in clarifying the degree of scarring due to cancer-related treatments, which is useful when reporting outcomes of lymphedema surgery.

Conflict of Interest

None.

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