Travis, E.C., Shugg, S., & McEwan, W.M. (2015). Lymph node grafting in the treatment of upper limb lymphoedema: A clinical trial. ANZ Journal of Surgery, 85, 631–635. 

DOI Link

Study Purpose

To explore the safety and efficacy of simple lymph node grafting

Intervention Characteristics/Basic Study Process

The lymph node grafting procedure was performed in a day-surgery setting with local anesthetic infiltration at the donor site (groin) and the two recipient sites (wrist and supratrochlear area). A small dose of intravenous ketamine or midazolam was given as sedation. The nodes were grafted into the superficial soft tissue of the affected limb. Subcuticular absorbable sutures were used to close the wounds. Patients did not use their regular compressive therapy for the first six weeks postoperatively so as not to compress the superficial vessels supplying the graft. Each patient received five days of oral flucloxacillin (250 mg every eight hours) as prophylaxis against opportunistic infection.

Sample Characteristics

  • N = 10
  • AVERAGE GE = 64 years (range = 41–78 years)
  • MALES: 10%, FEMALES: 90%
  • KEY DISEASE CHARACTERISTICS: Lymphedema
  • OTHER KEY SAMPLE CHARACTERISTICS: Eight patients (80%) had breast cancer-related lymphedema, one (10%) had melanoma as the primary malignancy, and one (10%) had metastatic squamous cell carcinoma requiring axillary dissection. The average duration of lymphedema was 3.5 years, and all patients had tried conservative management since onset. All 10 patients were using compressive bandaging on a daily basis prior to involvement in the study. Four patients (40%) had International Society of Lymphology (ISL) stage 3 lymphedema, and the remaining six patients (60%) had ISL stage 2 lymphedema. Nine (90%) patients reported a subjective improvement in their lymphedema. The patient who had no subjective or objective improvement had ISL stage 3 lymphedema that had been established for five years.

Setting

  • SITE: Single site    
  • SETTING TYPE: Outpatient    
  • LOCATION: Central Health and Disability Ethics Committee, New Zealand

Phase of Care and Clinical Applications

  • PHASE OF CARE: Late effects and survivorship
  • APPLICATIONS: Palliative care 
 

Study Design

Prospective, interventional study with repeated measures at two, six, and 12 weeks

Measurement Instruments/Methods

  • Total circumferential volume (TCV) measurements were taken at the ulnar styloid and in 10 cm increments up the arm with patients in a seated position with arms hanging by their sides.

Results

Seven (70%) patients had an objective decrease in the TCV of the affected limb, giving an average decrease of 89.6 ml (SD = 136.5, 95% CI, -141.1−320.4). The volume difference between baseline and 12 weeks was not statistically significant with a T-test (p = 0.4249). 
 
One patient developed a minor seroma at the groin donor site, which was noted at the two-week follow-up appointment. There were no incidences of graft loss, fat necrosis, donor limb lymphedema, wound dehiscence, or infection during the study period.

Conclusions

Lymph node grafting is was a safe procedure and should be investigated as an alternative to a microsurgical procedure as treatment for upper limb lymphedema.

Limitations

  • Small sample (< 30)
  • Baseline sample/group differences of import
  • Risk of bias (no control group)
  • Risk of bias (no blinding)
  • Risk of bias (no random assignment) 
  • Risk of bias (no appropriate attentional control condition)
  • Risk of bias (sample characteristics)
  • Measurement validity/reliability questionable
  • Intervention expensive, impractical, or training needs

Nursing Implications

Lymph node grafting needs to be investigated. Nurses should advise patients according to the current evidence.