Technical Considerations for Vascularized Omental Lymph Node Transfer for Advanced-stage Breast Cancer-related Lymphedema

Technical Considerations for Vascularized Omental Lymph Node Transfer for Advanced-stage Breast Cancer-related Lymphedema | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Technical Considerations for Vascularized Omental Lymph Node Transfer for Advanced-stage Breast Cancer-related Lymphedema Yujin Myung, Nakwon Choi, Sang Hoon Ahn, Akitatsu Hayashi, Joseph Kyu-hyung Park, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3367643/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Vascularized lymph node transfer (VLNT) is a promising surgical treatment for advanced-stage cancer-related lymphedema. However, the morbidity associated with the donor site should be carefully considered. Our study demonstrated that using the omentum for VLNT can be an effective and less invasive surgical approach, leading to favorable outcomes. All patients in our study presented with breast cancer-related lymphedema at stage IIb or higher and were scheduled to undergo VLNT surgery. A single-port laparoscopic approach was used to harvest the omental lymph node flap based on the right gastroepiploic artery. The flap was then inset toward lymphatic flow, with additional lymphatic connections made to the recipient vein. None of the patients had major operative complications or reoperation due to surgical site issues. Compared with preoperative measurements, the mean limb volume difference decreased from 25% to 17% at 12 months after the surgery. In contrast, the difference in interlimb impedance ratio measured by bioimpedance analysis decreased from an average of 1.63 to 1.25. The Lymph-Q questionnaire revealed a significant reduction in patients’ discomfort related to lymphedema. Using an omental lymph node flap for VLNT surgery is a promising approach that can provide patients with effective results while minimizing the risk associated with the procedure. This method can particularly benefit patients with advanced-stage lymphedema with limited treatment options. vascularized lymph node transfer omental lymph node breast cancer lymphedema Figures Figure 1 Figure 2 Technical Evolution of Vascularized Omental Lymph Node Transfer Numerous studies have shown that vascularized lymph node transfer (VLNT) surgery effectively alleviates advanced-stage breast cancer-related lymphedema (BCRL) symptoms [1-3]. Of the available donor sites for lymph node transfer, the omentum is considered one of the most efficient and safe methods, with a high number of lymph nodes per unit area [4] and no risk of iatrogenic lymphedema. Despite the numerous papers published on VLNT, studies detailing the technical aspects of omental VLNT are scarce. This study aimed to contribute to the existing body of literature by presenting several technical details related to omental VLNT that are yet to be reported. The authors of this study have implemented novel techniques in their institution and achieved positive outcomes. The study included patients with advanced-stage BCRL who underwent omental VLNT surgery between February 2020 and February 2022. All patients had International Society of Lymphology stage IIb or higher lymphedema. In addition, lymphoscintigraphy revealed no linear or functional channel, and axillary drainage that did not improve over time in all patients [5]. Non-contrast magnetic resonance imaging (MRI) scans revealed dermal thickening and subcutaneous infiltration of over 50% circumference, indicating an MRI stage III lymphedema [6]. The most critical factor in harvesting omental lymph nodes is minimizing donor-site morbidity. To this end, our surgical team is cooperating with the Department of Gastrointestinal Surgery [7] to efficiently harvest right gastroepiploic artery-based omental flaps through a single-port incision of approximately 2–3 cm near the umbilicus (Figure 1). Using this technique, patients experience only mild abdominal discomfort for approximately 1–2 days after surgery, and the surgical site leaves minimal scarring. Moreover, the harvesting procedure is shorter than 30 minutes, resulting in a surgery time <3–4 h, making it highly efficient (Video 1). When performing the insetting of the omental VLNT, it is essential to determine the optimal location for the transferred lymph node flap to function most effectively, considering the directionality of lymphatic flow. According to a previous study [8], lymphatic drainage from the stomach body initially flows toward the greater curvature. Then, the greater curvature’s middle portion drains to both sides through the gastroepiploic arcade. Therefore, the distal part of the lymphatic arcade is placed in the distal armpit, and the proximal part is located at the point of anastomosis (Figure 2). After harvesting the omental lymph node flap, sizable lymphatics are always found next to the flap pedicle, the right gastroepiploic artery/vein, during the dissection and preparation of the flap vessel. Once the thoracodorsal artery and vein have been connected to the gastroepiploic artery and vein, sizable venous branches are selected in the recipient area, and lympho-venous anastomosis between flap lymphatics and recipient veins is then performed (Video 2). A total of 23 patients who underwent omental VLNT were enrolled in this retrospective study. There were no cases of reoperation due to surgical site infection, bleeding, seroma, hematoma, or any other discomfort reported by the patients, except for mild surgical site pain that lasted 2–3 days after the surgery. During a minimum follow-up period of 12 months, patients’ edema significantly decreased compared with that before the surgery, and the water content, as determined by bioimpedance analysis, was also considerably reduced. Furthermore, the subjective satisfaction with the surgery, as assessed using the Lymph-Q questionnaire, showed that the discomfort caused by lymphedema decreased in most patients after the surgery (Table 1). Discussion The omentum can be considered a VLNT harvest site that minimizes the donor’s risk. However, an approach to the intra-abdominal space is required to harvest the omentum, which involves a conventional open laparotomy with a high risk of surgical complications. Furthermore, using a laparoscope enables minimally invasive omental lymph node harvesting, especially when a single-port approach is used, as is done at our institution. The risk and scarring associated with the surgery can be minimized. The location where the VLNT is inset is also important during the surgery. Although optimizing the omental VLNT surgery for cosmetic purposes is not necessary, aligning the direction of the flap to the face proximally toward the physiologic lymphatic drainage direction can improve the efficiency of lymphatic drainage. This aspect of omental VLNT surgery is also connected to the lymphatic flow-through flap (LyFT) concept for reconstructing lymph flow [9]. The LyFT flap has been reported to effectively alleviate lymphedema after surgery through studies such as ICG lymphangiography [10]. Furthermore, the authors continued beyond simply insetting the lymph node flap during VLNT surgery. Instead, we tried to identify the lymphatics of the lymph node flap and performed additional microanastomosis procedures to connect them to the recipient site. Previous animal studies have shown that lymphatic fluid drainage from the recipient site occurs inwardly toward the transferred lymph node flap [11]. Therefore, by connecting the outward-draining lymphatics of the lymph node flap to the recipient’s vein or lymphatics, functional lymphatic flow can be maintained and adequate drainage can be achieved. A limitation of this study is that it only included a relatively small number of patients. However, our goal was to use a more effective approach to omental lymph node transfer surgery, which could positively impact patient outcomes after surgery. By accumulating more details from additional surgeries in the future, we can use omental lymph node transfer more efficiently to a larger number of patients who have limited treatment options due to advanced-stage BCRL. Declarations Author contributions: All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Yujin Myung, Nakwon Choi, Sang Hoon Ahn, Akitatsu Hayashi, Joseph Kyu-hyung Park, Sun-Young Nam, and Rachmaniar Pramanasari. The first draft of the manuscript was written by Yujin Myung and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Acknowledgments: This research was supported by the Korea Health Technology R&D Project grant through the Korea Health Industry Development Institute, funded by the Ministry of Health & Welfare, Republic of Korea (grant number HR22C1363). Compliance with Ethical Standards Conflict of interest: The authors have no financial interest to declare in relation to the content of this article. Ethical approval: This retrospective study was conducted with the approval of the Institutional Review Board (IRB) at Seoul National University Bundang Hospital. Informed consent: Informed consent was obtained from all individual participants included in the study. References Scaglioni MF, Arvanitakis M, Chen YC, Giovanoli P, Chia-Shen Yang J, Chang EI. Comprehensive review of vascularized lymph node transfers for lymphedema: outcomes and complications. Microsurgery 2018;38:222–9. doi:10.1002/micr.30079. Pappalardo M, Patel K, Cheng MH. Vascularized lymph node transfer for treatment of extremity lymphedema: an overview of current controversies regarding donor sites, recipient sites and outcomes. J Surg Oncol 2018;117:1420–31. doi:10.1002/jso.25034. Ciudad P, Agko M, Perez Coca JJ, Manrique OJ, Chang WL, Nicoli F, et al. Comparison of long‐term clinical outcomes among different vascularized lymph node transfers: 6‐year experience of a single center’s approach to the treatment of lymphedema. J Surg Oncol 2017;116:671–82. doi:10.1002/jso.24730. Agko M, Ciudad P, Chen HC. Histo-anatomical basis of the gastroepiploic vascularized lymph node flap: the overlooked ‘micro’ lymph nodes. J Plast Reconstr Aesthet Surg 2018;71:118–20. doi:10.1016/j.bjps.2017.08.011. Park JK-H, Seo J, Yang EJ, Kang Y, Heo CY, Myung Y. Association of lymphatic flow velocity with surgical outcomes in patients undergoing lymphovenous anastomosis for breast cancer-related lymphedema. Breast Cancer 2022;29:835–43. doi:10.1007/s12282-022-01363-z. Myung Y, Park S, Kim BR, Yang EJ, Park JK, Kang Y. Validation of a lymphedema index score based on noncontrast magnetic resonance lymphangiography: correlation with clinical staging and indocyanine green lymphangiography. Lymph Res Biol 2023;21:70–7. doi:10.1089/lrb.2021.0092. Park JK-h, Myung Y. Two-team approach in lymphovenous anastomosis and omental lymph node flap harvest for upper limb lymphedema. Arch Plast Surg 2021;48:131–2. doi:10.5999/aps.2020.01291. Tokunaga M, Ohyama S, Hiki N, Fukunaga T, Yamada K, Sano T, et al. Investigation of the lymphatic stream of the stomach in gastric cancer with solitary lymph node metastasis. World J Surg 2009;33:1235–9. doi:10.1007/s00268-009-9985-6. di Summa PG, Guillier D. The lymphatic flow-through (LyFT) flap: proof of concept of an original approach. J Plast Reconstr Aesthet Surg 2020;73:983–1007. doi:10.1016/j.bjps.2020.01.014. Yamamoto T, Iida T, Yoshimatsu H, Fuse Y, Hayashi A, Yamamoto N. Lymph flow restoration after tissue replantation and transfer: importance of lymph axiality and possibility of lymph flow reconstruction without lymph node transfer or lymphatic anastomosis. Plast Reconstr Surg 2018;142:796–804. doi:10.1097/PRS.0000000000004694. Cheng MH, Huang JJ, Wu CW, Yang CY, Lin CY, Henry SL, et al. The mechanism of vascularized lymph node transfer for lymphedema: natural lymphaticovenous drainage. Plast Reconstr Surg 2014;133:192e–8e. doi:10.1097/01.prs.0000437257.78327.5b Tables Table 1. Operative outcomes after omental lymph node transfer. Patients, n (%) 23 Volume compared to contralateral limb preoperative 1.23 ± 0.19 6 months 1.20 ± 0.21 12 months 1.17 ± 0.17 Bioimpedance analysis Interlimb impedence ratio (1 kHz) preoperative 1.65 ± 0.25 6 months 1.47 ± 0.18 12 months 1.31 ± 0.21 Interlimb impedence ratio (5 kHz) preoperative 1.64 ± 0.27 6 months 1.46 ± 0.38 12 months 1.29 ± 0.24 Lymph Q questionnaire Total score preoperative 72 6 months 59 12 months 49 Supplementary Files Video1.mp4 Video2.mp4 coidisclosure1.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3367643","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":239008815,"identity":"08f957e6-79b9-47af-8b75-6a0780358390","order_by":0,"name":"Yujin 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have shown that vascularized lymph node transfer (VLNT) surgery effectively alleviates advanced-stage breast cancer-related lymphedema (BCRL) symptoms\u0026nbsp;[1-3]. Of the available donor sites for lymph node transfer, the omentum is considered one of the most efficient and safe methods, with a high number of lymph nodes per unit area\u0026nbsp;[4]\u0026nbsp;and no risk of iatrogenic lymphedema. Despite the numerous papers published on VLNT, studies detailing the technical aspects of omental VLNT are scarce. This study aimed to contribute to the existing body of literature by presenting several technical details related to omental VLNT that are yet to be reported. The authors of this study have implemented novel techniques in their institution and achieved positive outcomes.\u003c/p\u003e\n\u003cp\u003eThe study included patients with advanced-stage BCRL who underwent omental VLNT surgery between February 2020 and February 2022. All patients had International Society of Lymphology stage IIb or higher lymphedema. In addition, lymphoscintigraphy revealed no linear or functional channel, and axillary drainage that did not improve over time in all patients\u0026nbsp;[5]. Non-contrast magnetic resonance imaging (MRI) scans revealed dermal thickening and subcutaneous infiltration of over 50% circumference, indicating an MRI stage III lymphedema\u0026nbsp;[6].\u003c/p\u003e\n\u003cp\u003eThe most critical factor in harvesting omental lymph nodes is minimizing donor-site morbidity. To this end, our surgical team is cooperating with the Department of Gastrointestinal Surgery\u0026nbsp;[7]\u0026nbsp;to efficiently harvest right gastroepiploic artery-based omental flaps through a single-port incision of approximately 2\u0026ndash;3 cm near the umbilicus (Figure 1).\u0026nbsp;Using this technique, patients experience only mild abdominal discomfort for approximately 1\u0026ndash;2 days after surgery, and the surgical site leaves minimal scarring. Moreover, the harvesting procedure is shorter than 30 minutes, resulting in a surgery time \u0026lt;3\u0026ndash;4 h, making it highly efficient (Video 1).\u003c/p\u003e\n\u003cp\u003eWhen performing the insetting of the omental VLNT, it is essential to determine the optimal location for the transferred lymph node flap to function most effectively, considering the directionality of lymphatic flow. According to a previous study\u0026nbsp;[8], lymphatic drainage from the stomach body initially flows toward the greater curvature. Then, the greater curvature\u0026rsquo;s middle portion drains to both sides through the gastroepiploic arcade. Therefore, the distal part of the lymphatic arcade is placed in the distal armpit, and the proximal part is located at the point of anastomosis\u0026nbsp;(Figure 2).\u003c/p\u003e\n\u003cp\u003eAfter harvesting the omental lymph node flap, sizable lymphatics are always found next to the flap pedicle, the right gastroepiploic artery/vein, during the dissection and preparation of the flap vessel. Once the thoracodorsal artery and vein have been connected to the gastroepiploic artery and vein, sizable venous branches are selected in the recipient area, and lympho-venous anastomosis between flap lymphatics and recipient veins is then performed (Video 2).\u003c/p\u003e\n\u003cp\u003eA total of 23 patients who underwent omental VLNT were enrolled in this retrospective study. There were no cases of reoperation due to surgical site infection, bleeding, seroma, hematoma, or any other discomfort reported by the patients, except for mild surgical site pain that lasted 2\u0026ndash;3 days after the surgery. During a minimum follow-up period of 12 months, patients\u0026rsquo; edema significantly decreased compared with that before the surgery, and the water content, as determined by bioimpedance analysis, was also considerably reduced. Furthermore, the subjective satisfaction with the surgery, as assessed using the Lymph-Q questionnaire, showed that the discomfort caused by lymphedema decreased in most patients after the surgery (Table 1).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe omentum can be considered a VLNT harvest site that minimizes the donor\u0026rsquo;s risk. However, an approach to the intra-abdominal space is required to harvest the omentum, which involves a conventional open laparotomy with a high risk of surgical complications. Furthermore, using a laparoscope enables minimally invasive omental lymph node harvesting, especially when a single-port approach is used, as is done at our institution. The risk and scarring associated with the surgery can be minimized.\u003c/p\u003e\n\u003cp\u003eThe location where the VLNT is inset is also important during the surgery. Although optimizing the omental VLNT surgery for cosmetic purposes is not necessary, aligning the direction of the flap to the face proximally toward the physiologic lymphatic drainage direction can improve the efficiency of lymphatic drainage. This aspect of omental VLNT surgery is also connected to the lymphatic flow-through flap (LyFT) concept for reconstructing lymph flow\u0026nbsp;[9]. The LyFT flap has been reported to effectively alleviate lymphedema after surgery through studies such as ICG lymphangiography\u0026nbsp;[10].\u003c/p\u003e\n\u003cp\u003eFurthermore, the authors continued beyond simply insetting the lymph node flap during VLNT surgery. Instead, we tried to identify the lymphatics of the lymph node flap and performed additional microanastomosis procedures to connect them to the recipient site. Previous animal studies have shown that lymphatic fluid drainage from the recipient site occurs inwardly toward the transferred lymph node flap\u0026nbsp;[11]. Therefore, by connecting the outward-draining lymphatics of the lymph node flap to the recipient\u0026rsquo;s vein or lymphatics, functional lymphatic flow can be maintained and adequate drainage can be achieved.\u003c/p\u003e\n\u003cp\u003eA limitation of this study is that it only included a relatively small number of patients. However, our goal was to use a more effective approach to omental lymph node transfer surgery, which could positively impact patient outcomes after surgery. By accumulating more details from additional surgeries in the future, we can use omental lymph node transfer more efficiently to a larger number of patients who have limited treatment options due to advanced-stage BCRL.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor contributions: \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Yujin Myung, Nakwon Choi, Sang Hoon Ahn, Akitatsu Hayashi, Joseph Kyu-hyung Park, Sun-Young Nam, and Rachmaniar Pramanasari. The first draft of the manuscript was written by Yujin Myung and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u003c/strong\u003e This research was supported by the Korea Health Technology R\u0026amp;D Project grant through the Korea Health Industry Development Institute, funded by the Ministry of Health \u0026amp; Welfare, Republic of Korea (grant number HR22C1363).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompliance with Ethical Standards\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest:\u003c/strong\u003e The authors have no financial interest to declare in relation to the content of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval:\u003c/strong\u003e This retrospective study was conducted with the approval of the Institutional Review Board (IRB) at Seoul National University Bundang Hospital.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed consent:\u003c/strong\u003e Informed consent was obtained from all individual participants included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eScaglioni MF, Arvanitakis M, Chen YC, Giovanoli P, Chia-Shen Yang J, Chang EI. Comprehensive review of vascularized lymph node transfers for lymphedema: outcomes and complications. Microsurgery 2018;38:222\u0026ndash;9. doi:10.1002/micr.30079.\u003c/li\u003e\n\u003cli\u003ePappalardo M, Patel K, Cheng MH. Vascularized lymph node transfer for treatment of extremity lymphedema: an overview of current controversies regarding donor sites, recipient sites and outcomes. J Surg Oncol 2018;117:1420\u0026ndash;31. doi:10.1002/jso.25034.\u003c/li\u003e\n\u003cli\u003eCiudad P, Agko M, Perez Coca JJ, Manrique OJ, Chang WL, Nicoli F, et al. Comparison of long‐term clinical outcomes among different vascularized lymph node transfers: 6‐year experience of a single center\u0026rsquo;s approach to the treatment of lymphedema. J Surg Oncol 2017;116:671\u0026ndash;82. doi:10.1002/jso.24730.\u003c/li\u003e\n\u003cli\u003eAgko M, Ciudad P, Chen HC. Histo-anatomical basis of the gastroepiploic vascularized lymph node flap: the overlooked \u0026lsquo;micro\u0026rsquo; lymph nodes. J Plast Reconstr Aesthet Surg 2018;71:118\u0026ndash;20. doi:10.1016/j.bjps.2017.08.011.\u003c/li\u003e\n\u003cli\u003ePark JK-H, Seo J, Yang EJ, Kang Y, Heo CY, Myung Y. Association of lymphatic flow velocity with surgical outcomes in patients undergoing lymphovenous anastomosis for breast cancer-related lymphedema. Breast Cancer 2022;29:835\u0026ndash;43. doi:10.1007/s12282-022-01363-z.\u003c/li\u003e\n\u003cli\u003eMyung Y, Park S, Kim BR, Yang EJ, Park JK, Kang Y. Validation of a lymphedema index score based on noncontrast magnetic resonance lymphangiography: correlation with clinical staging and indocyanine green lymphangiography. Lymph Res Biol 2023;21:70\u0026ndash;7. doi:10.1089/lrb.2021.0092.\u003c/li\u003e\n\u003cli\u003ePark JK-h, Myung Y. Two-team approach in lymphovenous anastomosis and omental lymph node flap harvest for upper limb lymphedema. Arch Plast Surg 2021;48:131\u0026ndash;2. doi:10.5999/aps.2020.01291.\u003c/li\u003e\n\u003cli\u003eTokunaga M, Ohyama S, Hiki N, Fukunaga T, Yamada K, Sano T, et al. Investigation of the lymphatic stream of the stomach in gastric cancer with solitary lymph node metastasis. World J Surg 2009;33:1235\u0026ndash;9. doi:10.1007/s00268-009-9985-6.\u003c/li\u003e\n\u003cli\u003edi Summa PG, Guillier D. The lymphatic flow-through (LyFT) flap: proof of concept of an original approach. J Plast Reconstr Aesthet Surg 2020;73:983\u0026ndash;1007. doi:10.1016/j.bjps.2020.01.014.\u003c/li\u003e\n\u003cli\u003eYamamoto T, Iida T, Yoshimatsu H, Fuse Y, Hayashi A, Yamamoto N. Lymph flow restoration after tissue replantation and transfer: importance of lymph axiality and possibility of lymph flow reconstruction without lymph node transfer or lymphatic anastomosis. Plast Reconstr Surg 2018;142:796\u0026ndash;804. doi:10.1097/PRS.0000000000004694.\u003c/li\u003e\n\u003cli\u003eCheng MH, Huang JJ, Wu CW, Yang CY, Lin CY, Henry SL, et al. The mechanism of vascularized lymph node transfer for lymphedema: natural lymphaticovenous drainage. Plast Reconstr Surg 2014;133:192e\u0026ndash;8e. doi:10.1097/01.prs.0000437257.78327.5b\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1. Operative outcomes after omental lymph node transfer.\u003c/p\u003e\n\u003ctable border=\"1\" width=\"873\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"341\"\u003e\n\u003cp\u003ePatients, n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"265\"\u003e\n\u003cp\u003e \u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e \u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"167\"\u003e\n\u003cp\u003e23\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"341\"\u003e\n\u003cp\u003e \u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"265\"\u003e\n\u003cp\u003e \u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e \u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"167\"\u003e\n\u003cp\u003e \u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"341\"\u003e\n\u003cp\u003eVolume compared to contralateral limb\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"265\"\u003e\n\u003cp\u003e \u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003epreoperative\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"167\"\u003e\n\u003cp\u003e1.23 \u0026plusmn; 0.19\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"341\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"265\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e6 months\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"167\"\u003e\n\u003cp\u003e1.20 \u0026plusmn; 0.21\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"341\"\u003e\n\u003cp\u003e \u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"265\"\u003e\n\u003cp\u003e \u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e12 months\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"167\"\u003e\n\u003cp\u003e1.17 \u0026plusmn; 0.17\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"341\"\u003e\n\u003cp\u003eBioimpedance analysis\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"265\"\u003e\n\u003cp\u003eInterlimb impedence ratio (1 kHz)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003epreoperative\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"167\"\u003e\n\u003cp\u003e1.65 \u0026plusmn; 0.25\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"341\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"265\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e6 months\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"167\"\u003e\n\u003cp\u003e1.47 \u0026plusmn; 0.18\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"341\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"265\"\u003e\n\u003cp\u003e \u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e12 months\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"167\"\u003e\n\u003cp\u003e1.31 \u0026plusmn; 0.21\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"341\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"265\"\u003e\n\u003cp\u003eInterlimb impedence ratio (5 kHz)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003epreoperative\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"167\"\u003e\n\u003cp\u003e1.64 \u0026plusmn; 0.27\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"341\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"265\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e6 months\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"167\"\u003e\n\u003cp\u003e1.46 \u0026plusmn; 0.38\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"341\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"265\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e12 months\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"167\"\u003e\n\u003cp\u003e1.29 \u0026plusmn; 0.24\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"341\"\u003e\n\u003cp\u003eLymph Q questionnaire\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"265\"\u003e\n\u003cp\u003eTotal score\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003epreoperative\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"167\"\u003e\n\u003cp\u003e72\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"341\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"265\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e6 months\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"167\"\u003e\n\u003cp\u003e59\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"341\"\u003e\n\u003cp\u003e \u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"265\"\u003e\n\u003cp\u003e \u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e12 months\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"167\"\u003e\n\u003cp\u003e49\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"vascularized lymph node transfer, omental lymph node, breast cancer, lymphedema","lastPublishedDoi":"10.21203/rs.3.rs-3367643/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3367643/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"Vascularized lymph node transfer (VLNT) is a promising surgical treatment for advanced-stage cancer-related lymphedema. However, the morbidity associated with the donor site should be carefully considered. Our study demonstrated that using the omentum for VLNT can be an effective and less invasive surgical approach, leading to favorable outcomes. All patients in our study presented with breast cancer-related lymphedema at stage IIb or higher and were scheduled to undergo VLNT surgery. A single-port laparoscopic approach was used to harvest the omental lymph node flap based on the right gastroepiploic artery. The flap was then inset toward lymphatic flow, with additional lymphatic connections made to the recipient vein. None of the patients had major operative complications or reoperation due to surgical site issues. Compared with preoperative measurements, the mean limb volume difference decreased from 25% to 17% at 12 months after the surgery. In contrast, the difference in interlimb impedance ratio measured by bioimpedance analysis decreased from an average of 1.63 to 1.25. The Lymph-Q questionnaire revealed a significant reduction in patients’ discomfort related to lymphedema. Using an omental lymph node flap for VLNT surgery is a promising approach that can provide patients with effective results while minimizing the risk associated with the procedure. This method can particularly benefit patients with advanced-stage lymphedema with limited treatment options.","manuscriptTitle":"Technical Considerations for Vascularized Omental Lymph Node Transfer for Advanced-stage Breast Cancer-related Lymphedema","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-10-13 20:05:12","doi":"10.21203/rs.3.rs-3367643/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"95cc4d3a-98dc-4470-bbbc-f419ca51e1d1","owner":[],"postedDate":"October 13th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2023-10-27T15:42:40+00:00","versionOfRecord":[],"versionCreatedAt":"2023-10-13 20:05:12","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3367643","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3367643","identity":"rs-3367643","version":["v1"]},"buildId":"WrCJVZZCHTDjtuVLN7oU0","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}