State of the art surgery – Vascularized Lymph Node Transfer
(Information taken from http://www.karrilymphoedemaclinic.co.uk/ )
Vascularized lymph node transfer (VLNT) is a new surgical procedure that involves carefully removing healthy lymph nodes from one part of the body (known as harvesting), and then transferring them to a limb affected by lymphoedema.
Anatomical studies have shown there are a number of lymphatic basins (group of lymph nodes), in which there are lymph nodes that can be removed without disturbing the lymphatic drainage of the arms or legs. These lymphatic basins include the lateral chest wall, groin or neck. The choice of where the lymph nodes are harvested from depends on a number of factors, including previous surgery, availability of the lymph nodes, and patient preference.
The harvested lymph nodes are encased in fat and are removed along with the blood vessels that supply them. This mass of tissue is collectively known as the ‘lymph node flap’.
When the lymph node flap is transferred to the lymphoedematous limb, it may be placed proximally or distally in the limb, known as recipient sites. For example, in the lower limb this may be the groin or foot. The blood vessels of the lymph node flap are attached to the blood vessels found in the recipient site, with the aid of a microscope. This restores blood supply to the lymph nodes and allows them to survive and function.
Women who undergo VLNT for arm lymphoedema may also need extensive removal of scar tissue from the armpit prior to placement of the lymph nodes. This may be necessary as the scar tissue may be compressing the axillary vein thereby contributing to the arm lymphoedema.
Patients who have undergone VLNT report a number of improvements, notably;
- Reduction in the size of the limb or normal contour of the limb returning
- The limb feeling less heavy and/or painful
- Improved joint mobility
- Improved of skin quality / texture
- Reduced frequency or complete disappearance of cellulitis
Most importantly, many patients no longer need compression garments after the surgery.
VLNT is most effective in patients in whom the excess volume of the limb is predominantly due to accumulation of lymphatic fluid and not an increase in fat.
VLNT is a technically demanding operation and should only be performed by surgeons with successful experience. Dr Vasu Karri is only one of a few plastic surgeons in the UK with both extensive microsurgical and VLNT experience.
How does VLNT work?
The mechanism of action of VLNT is not clear-cut and two theories have been proposed:
- The newly transferred lymph nodes act as a ‘shunt’, redirecting lymph into the venous system. It is already know from microscopy studies that there are numerous connections between lymphatics and veins within lymph nodes. The ‘shunting’ of lymph into the venous system via newly transferred lymph nodes has been demonstrated using special imaging.
- The newly transferred lymph nodes restore continuity of the disrupted lymphatic network.Central to both theories is the observation that lymph nodes are highly lymphangiogenic i.e. they readily make lymphatic connections with the pre-existing lymphatic network and/or other lymph nodes (Tobbia PRS).
Lymph node transfer can be performed in combination with DIEP (Deep Inferior Epigastric Perforator) flap breast reconstruction. This approach simultaneously reconstructs the breast and treats the arm lymphoedema.