Lymphaticovenous Bypass for Immediate Lymphatic Reconstruction in Locoregional Advanced Melanoma Patients

Abstract

Background Extremity lymphedema is a dreaded complication of ilioinguinal or axillary lymphadenectomy. In conventional lymph node dissection, no effort is performed to maintain or reestablish extremity lymphatic circulation. We hypothesized that immediate lymphatic reconstruction (ILR) could be a reproducible procedure to maintain functional lymphatic flow after ilioinguinal and axillary lymphadenectomy in patients with malignant melanoma. This is the first report describing prophylactic ILR in patients with melanoma who underwent complete lymph node dissection for gross nodal disease. Patients and Methods We report a case series of 22 malignant melanoma patients who had axillary or ilioinguinal lymph node dissection for bulky locoregional invasion with immediate lymphatic reconstruction. A novel method to identify and select lymphatics with high flow using fluorescent lymphangiogram with indocyanine green dye gradient software is described. Surgical details, common difficulties, as well as indications are discussed. Instructional videos are also provided. Results Our technique is reproducible, since we have successfully completed immediate lymphatic reconstruction in 22 cases consecutively. Intradermal indocyanine green injections allowed for visualization of 1 to 3 transected lymphatics after lymphadenectomy. An average of 1.8 lymphaticovenous bypass (range 1–3) was performed per patient. Conclusion Reestablishment of lymphatic circulation after ilioinguinal or axillary lymphadenectomy in patients with melanoma characterizes a novel method that may reduce the problem of upper and lower extremity iatrogenic lymphedema. This is particularly important given the emergence of new adjuvant treatment modalities that considerably improve patients' survival after lymphadenectomy.

Surgical Prevention of Breast Cancer-Related Lymphedema: Delayed Distal Lymphaticovenicular Anastomosis– An Alternative to the Classic LYMPHA Technique

“…[4][5][6] Therefore, many surgeons began describing this procedure as an immediate lymphatic reconstruction (ILR), rather than preventive or prophylactic. [7][8][9] Boccardo and colleagues' results have been replicated by several retrospective and prospective studies. A 2018 meta-analysis of 4 papers found that patients who underwent upper-or lower-extremity ILR had a relative risk of 0.33 for developing lymphedema when compared to controls (P<0.0001).…”

“…[4][5][6] Therefore, immediate lymphatic reconstruction (ILR) has been adopted by some as an alternative name. [7][8][9] While preliminary results are favorable, concerns exist surrounding scheduling issues, unfavorable proximal lymphovenous pressure gradients, oncologic safety, and anastomotic injury from postoperative radiation. 10 Delayed, distally-based LVA (DD-LVA) is an emerging alternative method that allows surgeons to avoid these issues.…”

Lymphatic Microsurgical Preventive Healing Approach (LYMPHA) for Lymphedema Prevention after Axillary Lymph Node Dissection—A Single Institution Experience and Feasibility of Technique

“…The application of immediate lymphatic bypass has also recently expanded beyond the scope of breast cancer and has been applied to patients undergoing lymphadenectomy for melanoma and gynecologic malignancy [ 21 , 22 , 23 ]. Takeishi et al performed intrapelvic LVA after lymph node dissection for patients with uterine cancer to prevent lower extremity lymphedema [ 23 ].…”

Eliminating the Burden of Lymphedema in Cancer Patients Requiring Nodal Dissections Using Prophylactic Immediate Lymphatic Reconstruction – A Case Report and Review of the Literature

“…Respectively, these studies have reported lymphedema rates of 4.3% and 4.5% in those undergoing ILR, representing a significant rate reduction when compared to the lymphedema rates in these patients as reported in the literature. 28,29 The results of several other studies investigating ILR at the time of axillary node dissection are outlined in Table 1. They have all shown favorable outcomes.…”