Handchir Mikrochir Plast Chir
DOI: 10.1055/a-2322-1325
Übersichtsarbeit

Evidenz der modernen Diagnostik, der konservativen und chirurgischen Therapie des sekundären Lymphödems

Evidence of modern diagnostic, conservative, and surgical therapy of secondary lymphoedema
Patrick Will
1   Klinik für Plastische und Handchirurgie, Universitätsklinikum Carl Gustav Carus, Dresden, Germany
,
Adrian Dragu
1   Klinik für Plastische und Handchirurgie, Universitätsklinikum Carl Gustav Carus, Dresden, Germany
,
Joachim Zuther
2   Lymphatic Unit, Academy of Lymphatic Studies, Sebastian, United States
,
Jörg Heil
3   Brustzentrum Heidelberg, St. Elisabeth Klinik, Heidelberg, Germany
,
De-Hua Chang
4   Klinik für diagnostische und interventionelle Radiologie, UniversitätsKlinikum Heidelberg, Heidelberg, Germany
,
Jürg Traber
5   Gefäßchirurgische Klinik, Venenklinik Bellvue Kreuzlingen, Kreuzlingen, Switzerland
,
Christoph Hirche
6   Klinik für Plastische Chirurgie, Hand- und Rekonstruktive Mikrochirurgie, Handtrauma- und Replantationszentrum, BG Unfallklinik Frankfurt am Main, Frankfurt am Main, Germany
› Author Affiliations

Zusammenfassung

Hintergrund Das sekundäre Lymphödem (SL) stellt eine der häufigsten und zugleich bedeutsamsten Folgen und Komplikation der modernen onkologischen Therapie dar. Obwohl eine gründliche Anamnese und körperlicher Untersuchung für den Verdacht ausreichen, ist eine funktionelle Bildgebung des Lymphsystems für die gezielte Diagnose und Ermittlung des Schweregrads essenziell. Hierfür wurden in den letzten Jahren Techniken wie die MR-und die ICG-Lymphographie sowie die ultrahochfrequenten Ultraschalluntersuchungen entwickelt und validiert. Die selektive Anwendung dieser Techniken hat die individualisierte Indikationsstellung und erfolgreiche stadienabhängige Behandlung mit den (super-) mikrochirurgischen Techniken zur Wiederherstellung des regionalen Lymphabflusses im Kontext einer intensivierten konservativen Therapie erst möglich gemacht.

Methode Systematischer Review der Literatur zur Diagnose und Therapie des SL mit anschließender Analyse und Klassifikation der Ergebnisse in Evidenzlevel gemäß Oxford Centre for Evidence-Based Medicine sowie gemäß der GRADE Skala.

Ergebnisse Zur etablierten und validierten Diagnostik des SL gehören Bildgebungen (ICG Fluoreszenzlymphographie, MR-Lymphographie und Tc-99 Funktionslymphszintigraphie) bei klinischem Verdacht und Hochrisikopatienten. Komplexe physikalische Entstauungstherapie (KPE) ist der Physiotherapie oder Kompression allein überlegen. Die (Super-)Mikrochirurgie des SL ermöglicht eine postoperative Reduktion der Frequenz der KPE, Reduktion von Erysipelraten, Volumenreduktion der lymphomatösen Extremität und bei prophylaktischer Durchführung eine geringere Inzidenz des SL. Saugungsverfahren können langfristig stabile Umfangsreduktionen und eine Verbesserung der Lebensqualität erzeugen.

Schlussfolgerung Patienten mit SL profitieren von einer konservativen Therapie mit regelmäßiger Reevaluation. Hochrisikopatienten für ein SL oder Patienten mit einer klinischen Verschlechterung oder gleichbleibendem Leidensdruck unter leitliniengerechter konservativer Therapie können von (super-)mikrochirurgischen Therapien nach individualisierter Funktionsdiagnostik des Lymphsystems profitieren. Exzisionale Dermolipektomien oder Lympholiposuktionen sind für fortgeschrittene und therapierefraktäre Stadien verfügbar und wirksam.

Abstract

Background Secondary lymphoedema (SL) is one of the most common and, at the same time, most significant consequences and complications of modern oncological therapy. Although a thorough patient history and physical examination are sufficient to substantiate a suspicion, it is essential to perform functional imaging of the lymphatic system for a targeted diagnosis and determination of severity. For this purpose, techniques such as MR and ICG lymphography as well as ultra-high-frequency ultrasound examinations have been developed and validated in recent years. The selective use of these techniques has allowed for individualized indications and successful stage-dependent treatment using (super)microsurgical techniques to restore regional lymphatic drainage in the context of intensified conservative therapy.

Method Systematic review of the literature on the diagnosis and treatment of SL with subsequent analysis and classification of the results into evidence levels according to the Oxford Centre for Evidence-Based Medicine and the GRADE Scale.

Results The established and validated diagnosis of SL includes imaging (ICG fluorescence lymphography, MR lymphography and Tc-99 functional lymphoscintigraphy) in case of a clinical suspicion and in high-risk patients. Complex physical decongestion therapy (CPE) is superior to physical therapy or compression alone. (Super)microsurgery of SL allows for a postoperative reduction in the frequency of CPE, a reduction of erysipelas rates, a volume reduction of the lymphomatous extremity and, if carried out prophylactically, a lower incidence of SL. Suction-assited lipectomy can produce long-term, stable reductions in circumference and an improvement in quality of life.

Conclusion Patients with SL benefit from conservative therapy with regular re-evaluation. Patients with a high risk for SL or with clinical deterioration or persistent symptoms under guideline-based conservative therapy can benefit from (super)microsurgical therapy after an individualized functional diagnostic evaluation of the lymphatic system. Excisional dermolipectomies or lympholiposuctions are available and effective for advanced and refractory stages.



Publication History

Received: 11 November 2023

Accepted: 25 April 2024

Article published online:
24 June 2024

© 2024. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 
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