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J Reconstr Microsurg 2018; 34(07): 472-477
DOI: 10.1055/s-0038-1642637
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Omental Vascularized Lymph Node Flap: A Radiographic Analysis

Julia A. Cook
1   Division of Plastic and Reconstructive Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
,
Sarah E. Sasor
1   Division of Plastic and Reconstructive Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
,
Sunil S. Tholpady
1   Division of Plastic and Reconstructive Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
2   Division of Plastic and Reconstructive Surgery, R.L. Roudebush Veterans Administration Medical Center, Indianapolis, Indiana
,
Michael W. Chu
3   Division of Plastic and Reconstructive Surgery, Kaiser Permanente West Los Angeles Medical Center, Los Angeles, California
› Author Affiliations
Further Information

Publication History

01 December 2017

18 January 2018

Publication Date:
16 April 2018 (online)

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Abstract

Background Vascularized lymph node transfer is an increasingly popular option for the treatment of lymphedema. The omental donor site is advantageous for its copious soft tissue, well-defined collateral circulation, and large number of available nodes, without the risk of iatrogenic lymphedema. The purpose of this study is to define the anatomy of the omental flap in the context of vascularized lymph node harvest.

Methods Consecutive abdominal computed tomography angiography (CTA) images performed at a single institution over a 1-year period were reviewed. Right gastroepiploic artery (RGEA) length, artery caliber, lymph node size, and lymph node location in relation to the artery were recorded. A two-tailed Z-test was used to compare means. A Gaussian Mixture Model confirmed by normalized entropy criterion was used to calculate three-dimensional lymph node cluster locations along the RGEA.

Results In total, 156 CTA images met inclusion criteria. The RGEA caliber at its origin was significantly larger in males compared with females (p < 0.001). An average of 3.1 (1.7) lymph nodes were present per patient. There was no significant gender difference in the number of lymph nodes identified. Average lymph node size was significantly larger in males (4.9 [1.9] × 3.3 [0.6] mm in males vs. 4.5 [1.5] × 3.1 [0.5] mm in females; p < 0.001). Three distinct anatomical variations of the RGEA course were noted, each with a distinct lymph node clustering pattern. Total lymph node number and size did not differ among anatomical subgroups.

Conclusion The omentum is a reliable lymph node donor site with consistent anatomy. This study serves as an aid in preoperative planning for vascularized lymph node transfer using the omental flap.

Keywords

omental flap - vascularized lymph node transfer - lymphedema
 

  • References

  • 1 Petrek JA, Pressman PI, Smith RA. Lymphedema: current issues in research and management. CA Cancer J Clin 2000; 50 (05) 292-307 , quiz 308–311
    CrossrefPubMedGoogle Scholar
  • 2 Beaulac SM, McNair LA, Scott TE, LaMorte WW, Kavanah MT. Lymphedema and quality of life in survivors of early-stage breast cancer. Arch Surg 2002; 137 (11) 1253-1257
    CrossrefPubMedGoogle Scholar
  • 3 Coen JJ, Taghian AG, Kachnic LA, Assaad SI, Powell SN. Risk of lymphedema after regional nodal irradiation with breast conservation therapy. Int J Radiat Oncol Biol Phys 2003; 55 (05) 1209-1215
    CrossrefPubMedGoogle Scholar
  • 4 Golshan M, Martin WJ, Dowlatshahi K. Sentinel lymph node biopsy lowers the rate of lymphedema when compared with standard axillary lymph node dissection. Am Surg 2003; 69 (03) 209-211 , discussion 212
    PubMedGoogle Scholar
  • 5 Herd-Smith A, Russo A, Muraca MG, Del Turco MR, Cardona G. Prognostic factors for lymphedema after primary treatment of breast carcinoma. Cancer 2001; 92 (07) 1783-1787
    CrossrefPubMedGoogle Scholar
  • 6 Kosir MA, Rymal C, Koppolu P. , et al. Surgical outcomes after breast cancer surgery: measuring acute lymphedema. J Surg Res 2001; 95 (02) 147-151
    CrossrefPubMedGoogle Scholar
  • 7 Meric F, Buchholz TA, Mirza NQ. , et al. Long-term complications associated with breast-conservation surgery and radiotherapy. Ann Surg Oncol 2002; 9 (06) 543-549
    CrossrefPubMedGoogle Scholar
  • 8 Paskett ED, Naughton MJ, McCoy TP, Case LD, Abbott JM. The epidemiology of arm and hand swelling in premenopausal breast cancer survivors. Cancer Epidemiol Biomarkers Prev 2007; 16 (04) 775-782
    CrossrefPubMedGoogle Scholar
  • 9 Schijven MP, Vingerhoets AJ, Rutten HJ. , et al. Comparison of morbidity between axillary lymph node dissection and sentinel node biopsy. Eur J Surg Oncol 2003; 29 (04) 341-350
    CrossrefPubMedGoogle Scholar
  • 10 Schrenk P, Rieger R, Shamiyeh A, Wayand W. Morbidity following sentinel lymph node biopsy versus axillary lymph node dissection for patients with breast carcinoma. Cancer 2000; 88 (03) 608-614
    CrossrefPubMedGoogle Scholar
  • 11 Sener SF, Winchester DJ, Martz CH. , et al. Lymphedema after sentinel lymphadenectomy for breast carcinoma. Cancer 2001; 92 (04) 748-752
    CrossrefPubMedGoogle Scholar
  • 12 Tengrup I, Tennvall-Nittby L, Christiansson I, Laurin M. Arm morbidity after breast-conserving therapy for breast cancer. Acta Oncol 2000; 39 (03) 393-397
    CrossrefPubMedGoogle Scholar
  • 13 Cheng MH, Chen SC, Henry SL, Tan BK, Lin MC, Huang JJ. Vascularized groin lymph node flap transfer for postmastectomy upper limb lymphedema: flap anatomy, recipient sites, and outcomes. Plast Reconstr Surg 2013; 131 (06) 1286-1298
    CrossrefPubMedGoogle Scholar
  • 14 Shih YC, Xu Y, Cormier JN. , et al. Incidence, treatment costs, and complications of lymphedema after breast cancer among women of working age: a 2-year follow-up study. J Clin Oncol 2009; 27 (12) 2007-2014
    CrossrefPubMedGoogle Scholar
  • 15 Cheng MH, Huang JJ, Nguyen DH. , et al. A novel approach to the treatment of lower extremity lymphedema by transferring a vascularized submental lymph node flap to the ankle. Gynecol Oncol 2012; 126 (01) 93-98
    CrossrefPubMedGoogle Scholar
  • 16 Cheng MH, Huang JJ, Wu CW. , et al. The mechanism of vascularized lymph node transfer for lymphedema: natural lymphaticovenous drainage. Plast Reconstr Surg 2014; 133 (02) 192e-198e
    CrossrefPubMedGoogle Scholar
  • 17 Raju A, Chang DW. Vascularized lymph node transfer for treatment of lymphedema: a comprehensive literature review. Ann Surg 2015; 261 (05) 1013-1023
    CrossrefPubMedGoogle Scholar
  • 18 Althubaiti GA, Crosby MA, Chang DW. Vascularized supraclavicular lymph node transfer for lower extremity lymphedema treatment. Plast Reconstr Surg 2013; 131 (01) 133e-135e
    CrossrefPubMedGoogle Scholar
  • 19 Ozturk CN, Ozturk C, Glasgow M. , et al. Free vascularized lymph node transfer for treatment of lymphedema: a systematic evidence based review. J Plast Reconstr Aesthet Surg 2016; 69 (09) 1234-1247
    CrossrefPubMedGoogle Scholar
  • 20 Nguyen AT, Suami H. Laparoscopic free omental lymphatic flap for the treatment of lymphedema. Plast Reconstr Surg 2015; 136 (01) 114-118
    PubMedGoogle Scholar
  • 21 Liebermann-Meffert D. The greater omentum. Anatomy, embryology, and surgical applications. Surg Clin North Am 2000; 80 (01) 275-293 , xii
    CrossrefPubMedGoogle Scholar
  • 22 Lasso JM, Pinilla C, Castellano M. New refinements in greater omentum free flap transfer for severe secondary lymphedema surgical treatment. Plast Reconstr Surg Glob Open 2015; 3 (05) e387
    CrossrefPubMedGoogle Scholar
  • 23 Losken A, Carlson GW, Culbertson JH. , et al. Omental free flap reconstruction in complex head and neck deformities. Head Neck 2002; 24 (04) 326-331
    CrossrefPubMedGoogle Scholar
  • 24 Boulton BJF. S. The technique of omentum harvest for intrathoracic use. Oper Tech Thorac Cardiovasc Surg 2010; 15 (01) 53-60
    CrossrefPubMedGoogle Scholar
  • 25 Benoit L, Boichot C, Cheynel N. , et al. Preventing lymphedema and morbidity with an omentum flap after ilioinguinal lymph node dissection. Ann Surg Oncol 2005; 12 (10) 793-799
    CrossrefPubMedGoogle Scholar
  • 26 Fraley C, Raftery AE. How many clusters? Which clustering method? Answers via model-based cluster analysis. Comput J 1998; 41 (08) 578-588
    CrossrefPubMedGoogle Scholar
  • 27 Chu YY, Allen Jr RJ, Wu TJ, Cheng MH. Greater omental lymph node flap for upper limb lymphedema with lymph nodes-depleted patient. Plast Reconstr Surg Glob Open 2017; 5 (04) e1288
    CrossrefPubMedGoogle Scholar
  • 28 Goldsmith HS, De los Santos R, Beattie Jr EJ. Relief of chronic lymphedema by omental transposition. Ann Surg 1967; 166 (04) 573-585
    CrossrefPubMedGoogle Scholar
  • 29 van Wingerden JJ, Coret ME, van Nieuwenhoven CA, Totté ER. The laparoscopically harvested omental flap for deep sternal wound infection. Eur J Cardiothorac Surg 2010; 37 (01) 87-92
    CrossrefPubMedGoogle Scholar
  • 30 El Gamel A, Yonan NA, Hassan R. , et al. Treatment of mediastinitis: early modified Robicsek closure and pectoralis major advancement flaps. Ann Thorac Surg 1998; 65 (01) 41-46 , discussion 46–47
    CrossrefPubMedGoogle Scholar
  • 31 Hakelius L. Fatal complication after use of the greater omentum for reconstruction of the chest wall: case report. Plast Reconstr Surg 1978; 62 (05) 796-797
    CrossrefPubMedGoogle Scholar
  • 32 Salameh JR, Chock DA, Gonzalez JJ, Koneru S, Glass JL, Franklin Jr ME. Laparoscopic harvest of omental flaps for reconstruction of complex mediastinal wounds. JSLS 2003; 7 (04) 317-322
    PubMedGoogle Scholar
  • 33 Zaha H, Inamine S, Naito T, Nomura H. Laparoscopically harvested omental flap for immediate breast reconstruction. Am J Surg 2006; 192 (04) 556-558
    CrossrefPubMedGoogle Scholar
  • 34 Saltz R, Stowers R, Smith M, Gadacz TR. Laparoscopically harvested omental free flap to cover a large soft tissue defect. Ann Surg 1993; 217 (05) 542-546 , discussion 546–547
    CrossrefPubMedGoogle Scholar
  • 35 Gharb BB, Rampazzo A, Spanio di Spilimbergo S, Xu ES, Chung KP, Chen HC. Vascularized lymph node transfer based on the hilar perforators improves the outcome in upper limb lymphedema. Ann Plast Surg 2011; 67 (06) 589-593
    CrossrefPubMedGoogle Scholar
  • 36 Cook JA, Tholpady SS, Momeni A, Chu MW. Predictors of internal mammary vessel diameter: a computed tomographic angiography-assisted anatomic analysis. J Plast Reconstr Aesthet Surg 2016; 69 (10) 1340-1348
    CrossrefPubMedGoogle Scholar
  • 37 Gusenoff JA, Coon D, De La Cruz C, Rubin JP. Superficial inferior epigastric vessels in the massive weight loss population: implications for breast reconstruction. Plast Reconstr Surg 2008; 122 (06) 1621-1626
    CrossrefPubMedGoogle Scholar
  • 38 Hanssen H, Siegrist M, Neidig M. , et al. Retinal vessel diameter, obesity and metabolic risk factors in school children (JuvenTUM 3). Atherosclerosis 2012; 221 (01) 242-248
    CrossrefPubMedGoogle Scholar
  • 39 Broer PN, Weichman KE, Tanna N. , et al. Venous coupler size in autologous breast reconstruction--does it matter?. Microsurgery 2013; 33 (07) 514-518
    CrossrefPubMedGoogle Scholar
  • 40 Moran SL, Serletti JM. Outcome comparison between free and pedicled TRAM flap breast reconstruction in the obese patient. Plast Reconstr Surg 2001; 108 (07) 1954-1960
    CrossrefPubMedGoogle Scholar
  • 41 Langheinrich AC, Kampschulte M, Crössmann C. , et al. Role of computed tomography voxel size in detection and discrimination of calcium and iron deposits in atherosclerotic human coronary artery specimens. J Comput Assist Tomogr 2009; 33 (04) 517-522
    CrossrefPubMedGoogle Scholar
  • 42 Fansa H, Schirmer S, Cervelli A, Gehl HB. Computed tomographic angiography imaging and clinical implications of internal mammary artery perforator vessels as recipient vessels in autologous breast reconstruction. Ann Plast Surg 2013; 71 (05) 533-537
    CrossrefPubMedGoogle Scholar
  • 43 Gonzalez RG, Hirsch JA, Koroshetz WJ. Acute Ischemic Stroke: Imaging and Intervention. New York, NY: Springer; 2011
    Google Scholar
  • 44 Tavakol M, Ashraf S, Brener SJ. Risks and complications of coronary angiography: a comprehensive review. Glob J Health Sci 2012; 4 (01) 65-93
    PubMedGoogle Scholar
  • 45 Rozen WM, Stella DL, Bowden J, Taylor GI, Ashton MW. Advances in the pre-operative planning of deep inferior epigastric artery perforator flaps: magnetic resonance angiography. Microsurgery 2009; 29 (02) 119-123
    CrossrefPubMedGoogle Scholar
  • 46 Murray AC, Rozen WM, Alonso-Burgos A, Ashton MW, Garcia-Tutor E, Whitaker IS. The anatomy and variations of the internal thoracic (internal mammary) artery and implications in autologous breast reconstruction: clinical anatomical study and literature review. Surg Radiol Anat 2012; 34 (02) 159-165
    CrossrefPubMedGoogle Scholar
  • 47 Kim H, Lim SY, Pyon JK, Bang SI, Oh KS, Mun GH. Preoperative computed tomographic angiography of both donor and recipient sites for microsurgical breast reconstruction. Plast Reconstr Surg 2012; 130 (01) 11e-20e
    CrossrefPubMedGoogle Scholar
  • 48 Smit JM, Klein S, Werker PM. An overview of methods for vascular mapping in the planning of free flaps. J Plast Reconstr Aesthet Surg 2010; 63 (09) e674-e682
    CrossrefPubMedGoogle Scholar
  • 49 Rozen WM, Stella DL, Phillips TJ, Ashton MW, Corlett RJ, Taylor GI. Magnetic resonance angiography in the preoperative planning of DIEA perforator flaps. Plast Reconstr Surg 2008; 122 (06) 222e-223e
    CrossrefPubMedGoogle Scholar
  • 50 Masia J, Clavero JA, Larrañaga JR, Alomar X, Pons G, Serret P. Multidetector-row computed tomography in the planning of abdominal perforator flaps. J Plast Reconstr Aesthet Surg 2006; 59 (06) 594-599
    CrossrefPubMedGoogle Scholar