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AAPS 2007 Annual Meeting, May 19 - 22, 2007, The Coeur d'Alene Resort, Coeur d'Alene, Idaho.
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Can microsurgical reconstruction of a local blockade in the lymphatic system "cure" lymphedemas?
Ruediger G. Baumeister, Prof. Dr.med. Dr. med.habil1, Mayo Weiss, PD. Dr. med.2.
1University of Munich, Dept of Surgery Grsshadern, Div. of Plast-, Hand-, Microsurgery, D 81377 Muenchen,, Germany, 2University of Munich, Dept of Nuclear Medicine, D 81377 Muenchen,, Germany.

Purpose: Breast-cancer-related lymphedema, secondary to surgical intervention in the axilla, is a distressing condition which is generally considered incurable and requires lifelong treatment. We hypothesized that surgical construction of a bypass using autologous lymphatic vessels would be able to restore the impaired lymphatic transport capacity.
Methods: Autologous lymphatic grafts were harvested from the patient's thigh and anastomosed with lymphatic vessels proximally and distally to the blockade, with ascending lymphatics at the upper arm and descending lymphatics anastomosed to the venous angulation at the neck. Operating microscopes were used to perform so-called tensionfree anastomoses with single stitches. All patients were followed periodically by circumferential measurements of the extremities (at increments of 4 centimeters to calculate arm volume in cm³) For lymphoscintigraphies, we used 70 MBq Tc99m -labelled nanocolloid and established a numerical transport index (Ti) as previously described (Ti <10 = normal transport kinetics, Ti > 10 abnormal wih Timax=45). In selected cases grafts were visualized with indirect lymphography using water soluble contrast medium (Isovist TM).A paired student t-test was used for statistical analysis.
Results: After auologous lymphatical vessel transplantation, volumes of arm lymphedemas are significantly reduced:
Prior to surgery, the mean volume of the affected arm was 3288 cm³ (SEM + 67) (n=154) compared to 2210 cm³(SEM + 38) of the healty arm. Postoperatively the mean volume was reducedto 2538 (SEM + 45 (p=0,001) on the day of discharge. The mean volume at the 2.6 year follow-up was 2587 cm³ (SEM + 51) (p=0,001) (n=154). In the patients who presented for long-term follow-up after 10 years, a significant reduction from 2873 cm³ (SEM + 147) preoperatively to 2156 cm³ (SEM + 120) at > 10 years (p=0,001) (n=12) was found.
Lymphoscintigraphies performed at 7 years postoperatively , showed a significantly improved outflow with a decrease of the transport index from 30 (SD + 9) to 13 (SD + 4) (p=0,0154) (n=12). In patients who demonstrated patent grafts on lymphoscintigraphy, normal values of lymphatic outflow were reached. Patent grafts can be demonstrated after more than 10 years by indirect lymphography.
The rate of complications was low with 2 erysipelas (prior to routine adminstration of antibiotics), 1 lymphcyst and 1 postthrombotic swelling of the lower leg (on donor sites).
Conclusion: In lymphedemas secondary to a local blockade, microsurgical construction of autologous lymphatic bypasses can achieve normalisation of the lymphatic outflow and significant long-term volume reduction. Outcome is optimal, if surgery is performed prior to the development of secondary tissue changes seen in longstanding lymphedema. In summary this data provides evidence that surgical treament significantly reduces secondary lymphedema and that a surgical "cure" of secondary lymphedema is possible in selected patients.

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