Microsurgical Lymphatic Vessel Transplantation for Chronic Lymphedema: Long-Term Evaluation of Volume Reduction and Lymphatic Transport Kinetics

Abstract

This study investigates long-term volume reduction after microsurgical autologous lymphatic vessel transplantation (LVT) in patients with chronic lymphoedema. Lymphoedema is caused by inadequate lymphatic drainage and leads to swelling, pain, and a reduced quality of life. Conservative treatments often show only limited success, which is why surgical procedures such as LVT are increasingly gaining in importance. In a retrospective long-term analysis, patients who underwent LVT between 1988 and 2010 were examined on average 21.7 years after surgery. The examination included pre- and post-operative volume measurements, which were supplemented by modern 3D body scanner analyses and lymphoscintigraphy. The results show a significant volume reduction both in the short term (p < 0.01) and at the follow-up examination (p = 0.04). There was no significant difference between manual volumetry with circumferential measurements and 3D volumetry (p = 0.775). The improvement in lymph transport capacity was considerable (p = 0.078). This study provides valuable insights for the further development of lymphatic surgery. While preferred surgical methods change over time, this study demonstrates that LVT can make a decisive contribution to improving the quality of life of lymphedema patients.

Keywords: 3D imaging; lymphatic vessel transplantation; lymphoedema; lymphoscintigraphy; microsurgery.

Figure 1

Schematic representation of the microsurgical autologous lymphatic vessel transplantation. The lymphatic vessel to be taken is dissected. During the interposition to the other leg (left), the vessel remains connected to the lymph collectors of the right leg and is guided through an incracutaneous channel to the region with lymphoedema and fixed there microsurgically. In the case of interposition to the arm (right), the entire vessel is removed, microsurgically fixed to the arm, guided intracutaneously to the neck lymph collectors, and connected to these by an end-to-side anastomosis.

Figure 2

Flowchart of the study process.

Figure 3

Changes in the volume of the lymphoedema. Data are represented as from the 25th to 75th percentiles (boxes) with the median (line in the box). The X-axis shows the time of the data collection, respectively, preoperatively, and postoperatively at the end of the inpatient stay, at the time of the postoperative follow-up examination, at the time of a late postoperative follow-up examination, and at the time of our study. The Y-axis shows the relative differences in volume. The p-value was determined using the t-test for independent samples.

Figure 4

Distribution of volume differences of both measurement methods as a function of the measured volume. Each point represents an individual data set from the cohort. The X-axis shows the volume measured by the Vectra WB 360 Scanner and the Sculptor Software. The Y-axis shows the differences in volume between the methods. The inserted vertical lines correspond to the standard deviation from the mean value, respectively, 317.18 ± 151.5.

Figure 5

Changes in the TI of the lymphatic grafts. Data are represented as from the 25th to 75th percentiles (boxes) with the median (line in the box). The X-axis shows the time of the data collection, respectively, before and after the LVT. The Y-axis shows the calculated score of the TI. The p-value was determined using the t-test for independent samples.

Figure 6

Lymph vessel scintigraphy of the affected right leg preoperatively (left) and postoperatively (right).

Figure 7

A 59-year-old patient with lymphoedema of the right leg after lymphadenectomy within the surgical treatment of cervical carcinoma treated by LVT with lymphatic vessels from the left thigh. The circumference and volume measurements of the affected right leg and the left leg, as the donor side, are depicted 21 years after LVT as three-dimensional images taken with the Vectra 360 Whole Body Scanner from the front (a) and from behind (b).

Figure 8

A 59-year-old patient with lymphoedema of the right leg after lymphadenectomy within the surgical treatment of cervical carcinoma, treated by LVT with lymphatic vessels from the left thigh. Three-dimensional image taken with the Vectra 360 WB Scanner showing the healthy leg colored blue and the affected leg in grey, 21 years after LVT.

Figure 9

A 59-year-old patient with lymphoedema of the right leg after lymphadenectomy, within the surgical treatment for cervical carcinoma treated by LVT with lymphatic vessels from the left thigh. These three-dimensional images taken with the Vectra 360 WB Scanner show the affected leg (in grey) and the healthy leg (in blue) overlaid from the front (a), the side (b), and the back (c).