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Settling the Controversy: Lymph Node Transfer or Multiple Lympho-venous Anastomoses? A Prospective Long-term Case-control Experimental Study in Pigs
Alexandru Nistor, M.D., Ph.D.1, Miclaus Gratian, M.D.2, Petru Matusz, M.D., Ph.D.1, Bogdan Hoinoiu, DVM1, Mihai Ionac, M.D., Ph.D.1.
1Victor Babes University of Medicine and Pharmacy, Timisoara, Romania, 2Neuromed Imaging Center, Timisoara, Romania.

PURPOSE:
The best surgical approach for limb lymphedema is highly debated, with long-term histological evidence still lacking to support either the transfer of lymph nodes (LNT) or performing multiple lympho-venous anastomoses (MLVA) as the best solution. The purpose of this study is to objectively quantify and compare LNT and MLVA efficiency in improving lymphatic flow in a pig experimental model.
METHODS:
A prospective experimental study was designed using 14 common breed pigs (Sus scrofa domesticus), with surgically induced lymphedema, which were divided into 4 groups: LNT heterotopic transfer (n=4), MLVA (n=4) LNT+MLVA orthotopic transfer (n=4) and control group (n=2).
Indocyanine green (ICG) near-infrared fluorescence imaging and Dark Blood MR lymphangiography with dual agent relaxivity contrast (DARC) were used to assess the pre-op and the 5 months post-op lymphatic status. Histological analysis was performed using monoclonal D2-40 antibody and HE staining.
RESULTS:
Both ICG and DARC successfully identified new lymphatic vessels, allowing for a objective quantification of lymphangiogenesis, confirmed by the histological findings. At five months post-op LNT showed a 33% increase in lymphangiogenesis compared to MLVA, LNT+MLVA showed a 62% increase compared to the control group.
CONCLUSION:
While MLVA provide superficial lymphatic return flow, LNTs generate a regional response with lymphangiogenesis and improved superficial as well as deep lymphatic drainage. Ideally, where ICG imaging indicates a benefit from MLVA, surgeons should combine both techniques in order to maximize lymphatic flow.


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