Lymphedema Surgery Research Articles

Lymphedema surgery: Patient selection and an overview of surgical techniques

Evaluation of the lymphedema patients with appropriate staging is fundamental for further treatment. Treatment includes compressive decongestive therapy for stage 0 and 1 patients, lymphovenous anastomosis for stage 1 and 2 patients, vascularized lymph node transfer for stage 2 and above patients. Wedge resection, liposuction, and the Charles procedure are alternatives or additions to physiological procedures. The selection of donor lymph node flap and recipient site depends on the patient's lymphedema status and surgeon's expertise. J. Surg. Oncol. 2016;113:923-931. © 2016 Wiley Periodicals, Inc.

A comprehensive review of the natural lymphaticovenous communications and their role in lymphedema surgery.

Cancer-related lymphedema is a progressive, chronic condition that impairs quality of life. Its pathophysiology and the mechanisms of action of current reconstructive surgical treatments are not fully understood but lymphaticovenous communications may play a key role. We review the available literature on lymphaticovenous communications and their implications in lymphedema surgery, and propose a subclassification of lymphaticovenous communications. J. Surg. Oncol. 2016;113:374-380. © 2016 Wiley Periodicals, Inc.

Liposuction for Advanced Lymphedema: A Multidisciplinary Approach for Complete Reduction of Arm and Leg Swelling.

PurposeThis research describes and evaluates a liposuction surgery and multidisciplinary rehabilitation approach for advanced lymphedema of the upper and lower extremities.MethodsA prospective clinical study was conducted at an Advanced Lymphedema Assessment Clinic (ALAC) comprised of specialists in plastic surgery, rehabilitation, imaging, oncology, and allied health, at Macquarie University, Australia. Between May 2012 and 31 May 2014, a total of 104 patients attended the ALAC. Eligibility criteria for liposuction included (i) unilateral, non-pitting, International Society of Lymphology stage II/III lymphedema; (ii) limb volume difference greater than 25 %; and (iii) previously ineffective conservative therapies. Of 55 eligible patients, 21 underwent liposuction (15 arm, 6 leg) and had at least 3 months postsurgical follow-up (85.7 % cancer-related lymphedema). Liposuction was performed under general anesthesia using a published technique, and compression garments were applied intraoperatively and advised to be worn continuously thereafter. Limb volume differences, bioimpedance spectroscopy (L-Dex), and symptom and functional measurements (using the Patient-Specific Functional Scale) were taken presurgery and 4 weeks postsurgery, and then at 3, 6, 9, and 12 months postsurgery.ResultsMean presurgical limb volume difference was 45.1 % (arm 44.2 %; leg 47.3 %). This difference reduced to 3.8 % (arm 3.6 %; leg 4.3 %) by 6 months postsurgery, a mean percentage volume reduction of 89.6 % (arm 90.2 %; leg 88.2 %) [p < 0.001]. All patients had improved symptoms and function. Bioimpedance spectroscopy showed reduced but ongoing extracellular fluid, consistent with the underlying lymphatic pathology.ConclusionsLiposuction is a safe and effective option for carefully selected patients with advanced lymphedema. Assessment, treatment, and follow-up by a multidisciplinary team is essential.

Combined Surgical Treatment in Breast Cancer-Related Lymphedema.

Lymphedema is a well-known sequela of breast but no consensus has been reached about the ideal treatment. Surgical approaches, however, are receiving increased attention. Various microsurgical reconstructive techniques aim to restore anatomy and function of the lymphatic system in upper limb breast cancer-related lymphedema (BCRL). We combined two techniques, lymphaticovenous anastomosis (LVA) and autologous lymph node transplantation (ALNT) after carefully selecting those who may benefit from the surgery. We called this the "combined surgical treatment (CST)" approach. From June 2007 to December 2011, we performed CST in 106 patients with upper limb BCRL. Clinical evaluation and diagnostic imaging studies were performed preoperatively in all the patients. CST was offered to patients with stage I/II lymphedema, according to the criteria of the International Society of Lymphology (ISL). Overall 59 of the 106 patients underwent LVA, 7 underwent ALNT, and 40 underwent both the techniques. All 47 lymph node (LN)-flaps survived but 11 (22%) required surgical revision within 3 days. A total of 21 LN-flaps (45%) showed no radiotracer uptake at 1 year. Around 1 to 7 LVAs for each patient (average 3.4) were performed. Preoperative versus postoperative excess circumference decreased between 12 and 86.7% (average 39.72%). Arm circumference decreased between 0.9 and 6.1 cm (average 2.75 cm). The number of episodes of lymphangitis per year decreased from 1.8 to 0.2. Preoperative assessment is essential to select patients who can benefit from surgery for lymphedema and to choose the best surgical approach in each case. Our satisfactory results in well-selected cases encourage further research into surgical treatment for BCRL.

Lymphatic mapping and lymphedema surgery in the breast cancer patient.

Upper limb lymphedema can be an unfortunate sequela following the oncologic treatment of breast cancer. The surgical treatment of lymphedema has had a recent renewed clinical interest paralleling innovative descriptions of surgical techniques and imaging modalities. In addition, an improved understanding of the physiology and pathophysiology of lymphedema has allowed improved translation to the clinical condition. Various surgical options exist to decrease the symptom-burden of upper limb lymphedema, including vascularized lymph node (VLN) transfer, lymphovenous bypass (LVB), liposuction, lymphatic grafting, and excisional procedures. Modern imaging techniques help to improve the consistency and accuracy of these surgical treatment options. A multi-modal treatment plan utilizing non-operative and surgical therapies has the potential to improve various factors related to overall patient quality of life. This review details all of the current operative treatment strategies and modern imaging modalities used in the treatment of lymphedema.

Lymph Node Flap Based on the Right Transverse Cervical Artery as a Donor Site for Lymph Node Transfer

Lymph node transfer is a novel technique in lymphedema surgery. In this study, we present our experience in harvesting lymph nodes flap based on the right transverse cervical artery. In a period of 7 months, we harvested 11 cervical lymph node flaps based on the right transverse cervical artery (TCA). The reliable anatomy of the TCA and the low complication rate of the donor site make this lymph node flap ideal for transfer in the treatment of lymphedema. Knowledge of the regional anatomy and the anatomic variations of the TCA are mandatory for safe dissection of this flap. We also present the preliminary results of our first 2 cases in which we performed cervical lymph node transfer for secondary lower extremity lymphedema.

The link between lymphedema, breast reconstruction and microsurgery

SUMMARY This management perspective will explore the relationship between lymphedema and breast reconstruction surgery. Little data exist, but early reports suggest breast reconstruction may be associated with a lower risk of lymphedema. Theories surrounding this relationship, as well as available data on lymphatic repair theories, will be discussed. In addition, the emerging role of lymphatic surgery to prevent or reverse lymphedema will be discussed. The refinement of advanced microsurgical techniques has resulted in a renewed interest in lymphatic surgery to cure lymphedema. However, efficacy, validation of surgical results, and surgery's ability to eliminate from patients the need for daily compression garments and therapy need further study.

Surgical procedures in lymphedema management.

Lymphedema has a high incidence and various causes. It reduces patients' quality of life and productivity and currently lacks a cure. Management is based on lifelong physical therapies. Many surgical procedures have been proposed for lymphedema without significant acceptance. This study evaluates surgical procedures aimed at the management of lymphedema and highlights present evidence. Based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and the Grading of Recommendations Assessment, Development and Evaluation consensus, a systematic literature search (MEDLINE and The Cochrane Library) was performed to identify studies evaluating treatment outcomes after lymphedema surgery. The authors evaluated all articles found with the keywords "lymphedema" and "surgery," including experimental studies in animals. Cross referencing was made. Next, a protocol was created to assess the degree of quality of publications in this field. An overview of the complete medical literature was performed. Thereafter, publications meeting inclusion criteria were attributed a score according to the assessment protocol. This allowed an overview of the scientific quality of all surgical procedures for lymphedema. A total of 108 article texts were read and 70 publications included in this study according to predefined criteria. Lymphedema operative procedures were classified according to type. The outcomes highlighted the importance of individual patient analysis, as most interventions are not sufficiently studied to sustain clinical recommendations. Risk factors for acquired lymphedema, such as lymph node excision and radiation therapy, are well identified and should allow primary prevention. Improved diagnosis, classification, standardized volume measurement, staging, and follow-up of lymphedema patients can facilitate their management and allow valid retrospective studies. Currently, there is no evidence of any treatment yielding high long-term cure rates. Therefore, lymphedema management must be based on interdisciplinary approaches, with curative or palliative therapy options discussed openly with the patient. Therapeutic plans should not exclude surgery. Nevertheless, additional studies arerecommended to prove the validity of some surgical approaches.

Review of Current Surgical Treatments for Lymphedema

The current mainstay of lymphedema therapy has been conservative nonsurgical treatment. However, surgical options for lymphedema have been reported for over a century. Early surgical procedures were often invasive and disfiguring, and they often had only limited long-term success. In contrast, contemporary surgical techniques are much less invasive and have been shown to be effective in reducing excess limb volume, the risk of cellulitis, and the need for compression garment use and lymphedema therapy. Microsurgical procedures such as lymphaticovenous anastomosis and vascularized lymph node transfer lymphaticolymphatic bypass can treat the excess fluid component of lymphedema swelling that presents as pitting edema. Suction-assisted protein lipectomy is a minimally invasive procedure that addresses the solid component of lymphedema swelling that typically occurs later in the disease process and presents as chronic nonpitting lymphedema. These surgical techniques are becoming increasingly popular and their success continues to be documented in the medical literature. We review the efficacy and limitations of these contemporary surgical procedures for lymphedema. A Medline literature review was performed of lymphedema surgery, vascularized lymph node transfer, lymphaticovenous anastomosis, lymphatic liposuction, and lymphaticolymphatic bypass with particular emphasis on developments within the past 10 years. A literature review of technique, indications, and outcomes of the surgical treatments for lymphedema was undertaken. Surgical treatments have evolved to become less invasive and more effective. With proper diagnosis and the appropriate selection of procedure, surgical techniques can be used to treat lymphedema safely and effectively in many patients when combined with integrated lymphedema therapy.

The effect of lymphatico-venous anastomosis for an intractable ulcer at the lower leg in a marked obese patient

Secondary lymphedema occurs after trauma, cancer surgery, or obesity, and wounds in lymphedema can easily become intractable. We report positive results using lymphatico-venous anastomosis (LVA) to treat a post-traumatic lymph fistula and an intractable ulcer in a severely obese patient. A 41-year-old male (BMI 51.8), one year prior, had a traffic injury, and had an 18-cm contusion in his right leg. Six months later, lymph leakage in a 14 cm × 8 cm region and a 5 cm × 3 cm skin ulcer occurred in the center of the wound. We made a diagnosis of lymphedema resulting from obesity, accompanied with lymphorrhea and intractable ulcer. He was unable to reach his legs owing to obesity, making complex physical therapy impossible. We performed LVA under local anesthesia. The lymphorrhea healed 2 weeks after the operation and had not recurred 3 months after the operation. The leg lymphedema improved after the surgery without the compression therapy. In cases of intractable ulcers, suspected of being caused by lymphostasis, treatments indicated for lymphedema, for example LVA, may possibly allow satisfactory wound healing. © 2013 Wiley Periodicals, Inc. Microsurgery 34:64-67, 2014.

Reconstructive surgery for chronic lymphedema: a viable option, but

The aim of the paper is to assess the efficacy of reconstructive lymphatic surgery in the treatment of chronic lymphedema via retrospective analysis. Lymphovenous anastomotic surgery (LVAS) or free lymph node transplant surgery (FLTS) was performed on 32 patients who failed to respond to complex decongestive therapy (CDT) alone for a minimum of a one-year period. In LVAS, three patients with good compliance among 19 were able to maintain initial improvement through the four-year follow-up period. All three had secondary lymphedema in clinical stage II. In FLTS, among 13 patients, three compliant patients with the secondary lymphedema in clinical stage II kept initial improvement through the four-year follow-up. In conclusion, reconstructive lymphatic surgery (LVAS and FLTS) appears to be more effective in secondary lymphedema versus primary lymphedema when performed in the early stages. Patient compliance to maintain CDT postoperatively remains the most critical factor in maintaining durable long-term results. FLTS seems to have an additional risk involved to the donor lymph node harvest and a limited role compared to LVAS. Further extended study on FLTS is required to demonstrate its efficacy compared with LVAS.

Surgery for radiation induced lymphedema of the periorbita: A case report

Surgery for radiation induced lymphedema of the periorbita: A case report

Surgery in Congential Lymphedema: A Follow-Up of 50 Years

Surgical methods have been widely used in the past to treat patients with congential lymphedema. There are only scant data in recent literature about the long-term outcome of these mostly historical methods. On the other hand, the subject is not only of interest to those concerned with the history of medicine but also may raise a couple of questions about treating such patients today. The authors report on a 77-year-old female patient with congential lymphedema with a 50-year follow-up after lymphedema resection and focus on practical problems of bandaging today.

Place de la chirurgie dans le traitement des lymphœdèmes

Treatment of lymphedema includes essentially complex decongestive physiotherapy. Surgical methods are various but the main problem is to select patients. Genital organs may benefit from excisional procedures. Results of surgery in upper or lower limb lymphedema are variable. Secondary lymphedema is considered as the best indication using microlymphaticovenous anastomosis. Surgery in lymphedema should be considered as an additional tool of treatment.

Lymphologie 2002.Du diagnostic au traitement des lymphœdèmes

Lymphedema are primary (lower limb) or secondary for the upper limb after treatment of breast cancer. Genetic research allows to explain better pathophysiology of lymphedema. Lymphoscintigraphy is the main imaging technique for lymphedema. Venous or compressive etiologies may be first excluded. Treatment of lymphedema includes decongestive physiotherapy: manual lymph drainages, bandages, elastic stockings, exercises, skin care to avoid infections. Other treatments may be associated: weight loss, drugs (procyanidolic oligomers), surgery for genital lymphedema, pneumatic compression pumps for lymphovenous insufficiency.

Why does surgery for lymphedema give poor results?

Why does surgery for lymphedema give poor results?

Microlymphaticovenous and resectional surgery in obstructive lymphedema

Microlymphaticovenous and resectional surgery in obstructive lymphedema

Role of microlymphaticovenous surgery in obstructive lymphedema

Role of microlymphaticovenous surgery in obstructive lymphedema

Microlymphaticovenous and resectional surgery in obstructive lymphedema.

AbstractIn many cases of moderate obstructive lymphedema, there are sufficient lymphatics still remaining at a proximal level in the limb to anastomose them under the operating microscope to small veins, thus bypassing a proximal axillary or inguinal obstruction. Most of the cases reported in this article followed surgical and irradiation treatment of the breast for malignancy, and the majority occurred in the upper limb. The microtechnique of microlymphaticovenous anastomoses is described and a series of 136 patients is analyzed. Preoperative conservative therapy with elevation, stockingette, and pumping are used, but now only for a few days. Lymphangiograms have been found harmful, and this investigation has been discontinued. The usual sites of anastomoses of lymphatics are the medial aspect of the thigh or upper arm. Increasingly, microsurgery is being combined with a segmentai reduction on the outer aspect of the upper arm or thigh. Microlymphaticovenous surgery was performed in 40 patients, and 35 of these were available for follow‐up studies. The patients were assessed post‐operatively on objective and subjective grounds. Two‐thirds of the patients showed a significant reduction of the excess limb volume, and a higher percentage of patients showed encouraging subjective signs of improvement. Twenty‐one patients were not suitable for microlymphaticovenous surgery, and a one‐stage surgical reduction was carried out with a very useful result, although not as natural as that following microlymphaticovenous surgery. Cellulitis was significantly reduced in both groups following this surgery. The ultimate reduction of excess volume was related to age, primary diagnosis, and primary mode of therapy. An adequate result was not obtained in patients in whom only 1 anastomosis was performed, and such procedures are no longer carried out. Regular follow‐up has been performed with volumetric and circumferential measurements, and there have been no major complications of microlymphaticovenous surgery.

Microlymphaticovenous anastomoses for obstructive lymphedema.

Microlymphatic surgery appears to have a worthwhile clinical application in the treatment of secondary obstructive lymphedema. We prefer 3 or more lymphaticovenous anastomoses at, or above, the elbow; otherwise ablative procedures are recommended. In the selected cases there are some advantages of anastomoses over surgical reduction procedures: (1) the incidence of postoperative cellulitis is significantly less; (2) the microlymphatic techniques are applicable to both upper and lower limbs and perhaps could be extended to localized cases of obstructive lymphedema following trauma and congenital constriction bands. Considerable experience in microvascular surgery is required for doing this type of work. A long-term evaluation of the results of microlymphatic surgery in obstructive secondary lymphedema is required before judging its potential--especially in view of the fluctuating history of lymphedema--but the results reported are encouraging.