Treatment Report: Dr. Debora Pentassuglia
Diagnosis: Lymph nodes transfer
Therapist: Dr. Debora Pentassuglia
Lymphedema is defined as an abnormal accumulation of interstitial fluid rich in protein. This can result from surgical removal of lymph nodes, or from their malfunction: in relation to the genesis distinguished by primitive lymphedema that is congenital or secondary to surgical procedures. The reduction of lymphatic drainage is associated with a chronic inflammatory process which therefore establishes a pathological condition that the patient lives with for life. Limbs are the most commonly affected areas and this can greatly affect people’s quality of life.
International guidelines recognise a viable combination of therapies consisting of: Manual Lymphatic Drainage, lymphologic bandaging and therapeutic exercise. In this way it is possible to “steer” the lymphedema until it reaches the optimum volumetric reduction for the limb being treated and along with the use of an elastomeric compression sheath which serves to maintain the results obtained with the treatment.
But this is not enough. There are cases in which Combination Therapy for the treatment of lymphedema does not obtain good results: this is where you enter the possibility of autotransplant lymph node surgery.
At the 24th Congress of the International Lymphedema Society, held in Rome September 16th to 20th, 2013, there have been many proposals for surgeons from around the world. But what to keep in mind is the consistency of the long term results. Dr. Corinne Becker has triumphantly exhibited her follow-up, up to 8 years after transference lymph node surgery where the MRI (Magnetic Resonance Imaging) shows not only a reduction of the lymphedema, but also the lymphangiogenesis.
The operation consists of an autologous transplant of a flap containing lymph nodes surrounded by fatty tissue which is vital to their existence. This flap is inserted in the place where the lymph nodes are missing or malfunctioning. There were three donor areas: the laterocervical, the dorsal and the groin flaps.
If you were to operate on the lymphedema located in the lower limb, for example, the donor flap area would be taken the from the dorsal area and then inserted in the contralateral groin area. It has been demonstrated that in only 2% of cases a mild edema can arise in the donor area; in any event only three/ four lymph nodes are extracted precisely in order not to create imbalances. Adipose tissue is the essential anchor for the commencement of the lymphatic neoangiogenesis starting precisely from the newly transplanted flap. This not only allows the absorption of the already-present lymph excess, but allows the establishment of a new equilibrium that will be long-lasting and consists of the development of new lymphatic vessels. Patients who undergo this surgery should follow a serious and daily rehabilitation program that the surgeon prescribes when discharging them. After a period of intensive treatment, the “dependency” on a physiotherapist becomes only a “pleasant” memory.
The lymph node autotransplant is also indicated in preventive treatments. The approach to cancer patients is seeing the combination of radical oncology surgery and conservative/ reconstructive plastic surgery. In light of which Dr. Becker, at the Clinique Jouvenet in Paris, performs this operation in cases where it is necessary to remove the breast because of the presence of cancer. After the oncological removal is performed in the same operative session the breast reconstruction is carried out with an abdominal fat flap, rich in fatty tissue to restore the volume of the breast and lymph nodes to prevent the onset of lymphedema of the upper limb. Reconstructive surgery is nothing new, but to act in the interests of preventing future complications is.
For each and every person we have before us, our goal should always be to provide the best possible level of autonomy: every specialist studies the most suitable compromise with the patient, the combination of what the theoretical rules dictate and what the person lives.