Surgical Management of Inoperable Lymphedema: The Re-emergence of Abandoned Techniques

Abstract

In the era of microsurgical lymph node transfer and lymphatic bypass, there are still a significant number of patients with debilitating lymphedema not amenable to these technically advanced procedures. Radical surgical management is often the only option for these patients, who are frequently counseled that they have inoperable problems. They often become medical nomads, wandering from physician to physician, while symptoms progress and treatment options become fewer and more radical. Unfortunately, the principles of reductive management for end-stage lymphedema have been largely abandoned over the last half-century.This report highlights 2 such cases and presents a review of both the history and literature on this topic. Lymphedema is caused by an imbalance in the flow of lymphatic fluid into and out of the interstitium, and it primarily affects the dermal and subcutaneous tissues. Increased lymphatic inflow can be due to changes in capillary permeability, venous hypertension, and decreased oncotic pressure in the capillaries. Obstacles to lymphatic out-flow can be diided into primary (congenital) and secondary (acquired) etilogies, of which the latter are more common. Malignancy and its treatment (surgery, radiation) are the most common secondary causes of lymphedema in the US. Elsewhere, espeially in parts of the developing world, infection by Wuchereria ancrofti (filariasis) is the most common cause. Conservative, nonsurgical, management of lymphedema is ften the first line treatment. However, it cannot address the hanges that arise in the setting of severe, end-stage disease ypified by chronic fibrosis. It is the patients who suffer from his spectrum of disease who require a reductive intervention.