Obviating Postoperative Chyle Leaks in Vascularized Lymph Node Transfer

Abstract

Objective: Lymphedema is a progressive, debilitating condition affecting up to 250 million people worldwide. Caused by the accumulation of proteinaceous interstitial fluid secondary to lymphatic destruction, extravasation of protein-rich fluid occurs when fluid formation exceeds lymphatic transport capacity, furthermore, leading to increased intralymphatic pressure, valvular incompetence, and dermal backflow, preceding eventual irreversible extremity enlargement, progressive fibrosis with lymphatic obstruction, and luminal obliteration. In western countries, damage or removal of regional lymph nodes by surgery, radiation, tumor invasion, or as a result of infection or inflammation are the most common causes of secondary lymphedema, with the greatest prevalence among those who undergo extensive axillary surgery followed by axillary radiation, noting incidences of 24-49% after mastectomy. The variability of lymphedema and increased healthcare cost in association, reins focus and elucidates the vital importance of discovering techniques to abate disease potentiation while implementing healthful strategies. Surgical techniques aim to diminish the size of the affected extremity, with resultant improvement in appearance, function, and prevention of infection; notably, growing bodies of evidence support the effectiveness of modern surgical techniques in ameliorating the long-term disability and functional impairment. Such technique of autologous vascularized lymph node transfer will be examined here. Consequently, irrespective of surgical approach, vascularized lymph node transfer affords inherent risks of postoperative chyle leaks. While previous trials have demonstrated Adherus Dural Sealant as being 99.1% effective in preventing cerebrospinal fluid (CSF) leaks through 14 days of postoperative follow-up, we will reveal Adherus Dural Sealant results within and throughout our institution, in preventing postoperative chyle leaks after vascularized lymph node transfer. Methods: In this study, we evaluate ten patients who underwent vascularized lymph node transfer between 2018 and 2021, at our single institution. Results: Within our patient population, there were a total of 13 vascularized lymph node transfers performed, with zero postoperative chyle leaks or donor site complications. Conclusion: The core plastic surgery concept of replacing “like” with “like” is no more evident than in the restoration of healthy lymph nodes to a limb in which lymphatic flow has been disrupted. In parallel to the aforementioned concept, via utilization of Adherus Dural Sealant within the supraclavicular lymph node basin and no evidence of chyle leaks in the postoperative period, we pose a novel sealant technique in lymph node harvest that has demonstrated success in minimizing complications following vascularized lymph node transfer throughout our patient series. Further research, characterization, and long-term supraclavicular lymph node basin follow-up are vital, to clarify and potentially expand upon its indications for use. Corresponding Author: Kaitlyn Stevens, DO, 6100 E. Colony Rd., Elsie, MI 48831