Freie mikrovaskulare Lymphknotentransplantation aus dem Omentum bei Lymphödem

Zusammenfassung

Hintergrund

Das Lymphödem ist eine chronische, fortschreitende Erkrankung, die primär oder sekundär nach lymphatischer Schädigung, z. B. nach Lymphadenektomie oder Radiatio, auftreten kann. Konservative Therapien bieten oft nur begrenzte Linderung, weshalb operative Verfahren wie die vaskularisierte omentale Lymphknotentransplantation (VOLT) zunehmend an Bedeutung gewinnen.

Patienten/Methoden und Material

Es werden 2 Patienten mit fortgeschrittenem sekundärem Lymphödem der unteren Extremität nach Lymphadenektomie vorgestellt. Beide wiesen in der Lymphszintigrafie und MRT eine ausgeprägte Transportstörung auf. In beiden Fällen erfolgte eine doppelte mikrovaskuläre Lymphknotentransplantation mittels VOLT, wobei das Omentum aufgrund seiner hohen Lymphknotendichte und lymphangiogenen Eigenschaften gewählt und intraoperativ geteilt wurde, um sowohl die Leiste als auch den Unterschenkel zu versorgen. Zusätzlich wurde eine systematische Literaturrecherche in PubMed durchgeführt.

Ergebnisse

Postoperativ zeigten sich in beiden Fällen eine regelrechte Perfusion der Transplantate sowie eine klinische Besserung der Lymphödemsymptomatik. Die Literaturauswertung ergab konsistente Hinweise auf eine signifikante Volumenreduktion, verbesserte Lymphdrainage und eine deutliche Senkung der Zellulitisrate nach VOLT.

Schlussfolgerung

Die VOLT stellt eine effektive Option für therapierefraktäre Lymphödeme dar und kann die Lebensqualität der Patienten verbessern. Trotz vielversprechender klinischer Ergebnisse sind weitere standardisierte, prospektive Langzeitstudien notwendig, um die Evidenz zur Wirksamkeit und Sicherheit dieser Technik zu stärken.

Abstract

Purpose

Lymphoedema is a chronic, progressive condition that may occur as a primary disorder or secondarily following lymphatic damage, such as after lymphadenectomy or radiotherapy. Conservative therapies often provide only limited relief, so that surgical approaches like vascularised omental lymph node transfer (VOLT) are increasingly relevant.

Patients/Methods and Materials

We present two cases of advanced secondary lower-limb lymphoedema following lymphadenectomy. Both patients demonstrated severe lymphatic transport dysfunction on lymphoscintigraphy and MRI. A double microsurgical lymph node transfer using VOLT was performed in each case. The omentum, selected for its high lymph node density and lymphangiogenic potential, was divided intraoperatively to reconstruct both the groin and lower leg regions. In addition, a systematic literature review on omental lymph node transfer for lymphoedema was conducted using PubMed.

Results

In both cases, postoperative assessment confirmed adequate perfusion of the grafts and clinical improvement of lymphoedema symptoms. The literature review revealed consistent evidence of significant limb volume reduction, improved lymphatic drainage, and a marked decrease in the incidence of cellulitis following VOLT.

Conclusion

VOLT is an effective surgical option for therapy-refractory lymphoedema and may substantially improve patient quality of life. Despite promising results, further standardised prospective long-term studies are required to validate its efficacy and safety.

Schlüsselwörter

Lymphödem - Lymphchirurgie - freier Lymphknotentransfer - vaskularisiertes Omentum

Keywords

lymphedema - lymphatic surgery - free lymph node transfer - vascularized omentum

Publication History

Received: 13 April 2025

Accepted after revision: 25 August 2025

Article published online:
02 October 2025

• Literatur

• 1 Null M, Arbor TC, Agarwal M. Anatomy, Lymphatic System. (StatPearls [Internet]; ). Treasure Island (FL): StatPearls Publishing; 2023
• 2 Davis MJ, Zawieja SD, King PD. Transport and Immune Functions of the Lymphatic System. Annu Rev Physiol 2025; 87: 151-172
• 3 Cueni LN, Detmar M. The lymphatic system in health and disease. Lymphat Res Biol 2008; 6: 109-122
• 4 Földi E, Baumeister RGH, Bräutigam P. et al. Zur Diagnostik und Therapie des Lymphödems. Dtsch Arztebl 1998; 95: 740
• 5 Paskett ED. Symptoms: Lymphedema. Adv Exp Med Biol 2015; 862: 101-113
• 6 Földi M, Földi E, Kubik S. Lehrbuch Lymphologie für Ärzte, Physiotherapeuten und Masseure, med. Bademeister. 7. München: ElsevierUrban & Fischer; 2010
• 7 Greene AK, Goss JA. Diagnosis and Staging of Lymphedema. Semin Plast Surg 2018; 32: 12-16
• 8 Gesellschaft Deutschsprachiger Lymphologen e.V. (GDL). S2k Leitlinie Diagnostik und Therapie der Lymphödeme. AWMF Reg.-Nr. 058–001.. 2017 Accessed September 01, 2025 at: https://register.awmf.org/assets/guidelines/058-001l_S2k_Diagnostik_und_Therapie_der_Lymphoedeme_2019-07-abgelaufen.pdf
• 9 Gallagher K, Marulanda K, Gray S. Surgical Intervention for Lymphedema. Surg Oncol Clin N Am 2018; 27: 195-215
• 10 Mortimer PS. The pathophysiology of lymphedema. Cancer 1998; 83 (Suppl. 12) 2798-2802
• 11 Varghese SA. Secondary lymphedema: Pathogenesis. J Skin Sexually Transm Dis 2021; 3: 7-15
• 12 Grada AA, Phillips TJ. Lymphedema: Pathophysiology and clinical manifestations. J Am Acad Dermatol 2017; 77: 1009-1020
• 13 Anuszkiewicz K, Jankau J, Kur M. What do we know about treating breast-cancer-related lymphedema? Review of the current knowledge about therapeutic options. Breast Cancer 2023; 30: 187-199
• 14 Cucchi F, Rossmeislova L, Simonsen L. et al. A vicious circle in chronic lymphoedema pathophysiology? An adipocentric view. Obes Rev 2017; 18: 1159-1169
• 15 Ricci V, Ricci C, Gervasoni F. et al. From physical to ultrasound examination in lymphedema: a novel dynamic approach. J Ultrasound 2022; 25: 757-763
• 16 Nuwayhid R, Warg ML, Heister S. et al. Translation, Cross-Cultural Adaptation and Validation of the Lymphedema Quality of Life Questionnaire (LYMQOL) in German-Speaking Patients with Lymphedema of the Lower Limbs. Healthcare (Basel) 2024; 12: 409
• 17 Schulz T, Warg ML, Heister S. et al. Translation, Cross-Cultural Adaptation and Validation of the Lymphedema Quality of Life Questionnaire (LYMQOL) in German-Speaking Patients with Upper Limb Lymphedema. Healthcare (Basel) 2024; 12: 1881
• 18 Gerber LH. A review of measures of lymphedema. Cancer 1998; 83 (Suppl. 12) 2803-2804
• 19 Scaglioni MF, Arvanitakis M, Chen YC. et al. Comprehensive review of vascularized lymph node transfers for lymphedema: Outcomes and complications. Microsurgery 2018; 38: 222-229
• 20 Scaglioni MF, Fontein DB, Arvanitakis M. et al. Systematic review of lymphovenous anastomosis (LVA) for the treatment of lymphedema. Microsurgery 2017; 37: 947-953
• 21 Taylor R, Jayasinghe UW, Koelmeyer L. et al. Reliability and validity of arm volume measurements for assessment of lymphedema. Phys Ther 2006; 86: 205-214
• 22 Etzel L, Schenck TL, Giunta RE. et al. Digital leg volume quantification: Precision assessment of a novel workflow based on single capture three-dimensional whole-body surface imaging. J Digit Imaging 2021; 34: 1171-1182
• 23 Yamamoto T, Yoshimatsu H, Narushima M. et al. Indocyanine green lymphography findings in primary leg lymphedema. Eur J Vasc Endovasc Surg 2015; 49: 95-102
• 24 Yamamoto T, Narushima M, Doi K. et al. Characteristic indocyanine green lymphography findings in lower extremity lymphedema: the generation of a novel lymphedema severity staging system using dermal backflow patterns. Plast Reconstr Surg 2011; 127: 1979-1986
• 25 de Sire A, Fusco N, Sajjadi E. et al. Lymphedema rehabilitation using self-adaptive inelastic compression in breast cancer: A proof-of-principle study. Appl Sci 2021; 11: 1901
• 26 Granzow JW, Soderberg JM, Kaji AH. et al. An effective system of surgical treatment of lymphedema. Ann Surg Oncol 2014; 21: 1189-1194
• 27 Hirche C, Engel H, Seidenstuecker K. et al. Rekonstruktive Mikrochirurgie des sekundären Lymphödems: Konsensus der Deutschsprachigen Arbeitsgemeinschaft für Mikrochirurgie der peripheren Nerven und Gefäße (DAM) zur Indikation, Diagnostik und Therapie mittels Lymphovenöser Anastomosen (LVA) und vaskularisierter Lymphknotentransplantation (VLKT). Handchir Mikrochir Plast Chir 2019; 51: 424-433
• 28 Hahn BA, Kleeven A, Richir MC. et al. Objectifying Clinical Outcomes After Lymphaticovenous Anastomosis and Vascularized Lymph Node Transfer in the Treatment of Extremity Lymphedema: A Systematic Review and Meta-Analysis. Microsurgery 2025; 45: e70050
• 29 Grünherz L, von Reibnitz D, Lindenblatt N. Robotisch-assistierte Lymphchirurgie. Handchir Mikrochir Plast Chir 2024; 56: 122-127
• 30 Harder Y, Hirche C, Hamdi M. et al. Modern Surgical Management of Chronic Lymphedema. Stuttgart: Thieme; 2024.
• 31 Karlsson T, Hoffner M, Brorson H. Liposuction and controlled compression therapy reduce the erysipelas incidence in primary and secondary lymphedema. Plast Reconstr Surg Glob Open 2022; 10: e4314
• 32 Greene AK, Maclellan RA. Operative treatment of lymphedema using suction-assisted lipectomy. Ann Plast Surg 2016; 77: 337-340
• 33 Ciudad P, Manrique OJ, Adabi K. et al. Combined double vascularized lymph node transfers and modified radical reduction with preservation of perforators for advanced stages of lymphedema. J Surg Oncol 2019; 119: 439-448
• 34 Manrique OJ, Bustos SS, Kapoor T. et al. Gastroepiploic vascularized lymph node transfer for the treatment of extremity lymphedema: comparison between middle and distal inset. Gland Surg 2020; 9: 528-538
• 35 Ciudad P, Manrique OJ, Date S. et al. Double gastroepiploic vascularized lymph node tranfers to middle and distal limb for the treatment of lymphedema. Microsurgery 2017; 37: 771-779
• 36 Kenworthy EO, Nelson JA, Verma R. et al. Double vascularized omentum lymphatic transplant (VOLT) for the treatment of lymphedema. J Surg Oncol 2018; 117: 1413-1419
• 37 Skladman R, Moritz WR, Tenenbaum EJ. et al. Vascularized omental tissue transfer for the treatment of lymphedema: a review. Plast Aesthet Res 2023; 10: 66
• 38 Tian C, Gao X, Wang K. et al. Vascularized Omentum Lymphatic Transplantation as a Treatment for Chronic Inguinal Ulceration and Lymphedema. Plast Reconstr Surg Glob Open 2024; 12: e6049
• 39 Nguyen AT, Suami H, Hanasono MM. et al. Long-term outcomes of the minimally invasive free vascularized omental lymphatic flap for the treatment of lymphedema. J Surg Oncol 2017; 115: 84-89
• 40 Jarvis NR, Torres RA, Avila FR. et al. Vascularized omental lymphatic transplant for upper extremity lymphedema: A systematic review. Cancer Rep (Hoboken) 2021; 4: e1370
• 41 Forte AJ, Cinotto G, Boczar D. et al. Omental Lymph Node Transfer for Lymphedema Patients: A Systematic Review. Cureus 2019; 11: e6227
• 42 Brown S, Mehrara BJ, Coriddi M. et al. A Prospective Study on the Safety and Efficacy of Vascularized Lymph Node Transplant. Ann Surg 2022; 276: 635-653