• #15-2. Surgical treatments of lymphedema




    Liposuction was developed by plastic surgeons in the 1980s for the purpose of removing subcutaneous fat and is sporadically used in lymphedema. Some scholars argue that removal of fluids and local fat does not prevent recurrence and even damages the remaining healthy lymphatic system. However, others reported that in a patient with lymphedema of the upper arm developing after lumpectomy, liposuction stimulated fat tissues and reduced fibrosis compared to the lower limb. I think liposuction can be effective in patients with lipedema.

    In Sweden, Dr. Brorson uses liposuction to treat lymphedema with outcomes better than what some scholars predicted. Liposuction carried out with caution in patients with lymphedema can make a viable treatment option.

    A key benefit of liposuction is that it causes less scarring compared to surgery. As fat is aspirated through punctures less than 1cm wide, it is a relatively safe procedure.


    Bypass surgery


    In 1912, Kondoleon believed that resecting the deep fascia can help treat the condition by connecting subcutaneous lymph to the deep lymphatic system. However, this method was not effective. In 1908, one scholar planted a thread in the subcutaneous tissues with lymphedema under the assumption that the thread will absorb the fluid but it also failed. In the 1960s, tube drainage procedures using a very thin nylon or polyethylene tube failed to treat the condition and led to fibrosis of the adjacent tissues. Transplanting autologous healthy subcutaneous and dermal tissues to the affected area to create a skin bridge in the leg also failed due to fibrosis of surrounding tissues. In 1962, Thompson’s buried skin flap technique also failed due to the same reason. In 1966 and 1968, Nielubowics and Olszewski tried connecting the lymph node capsule and vein to no avail. A Korean university hospital once tried transferring the greater omentum but it was ineffective. Using the anatomical characteristic of the small intestine that is rich in lymphatic ducts, a section of the small intestine was harvested and transplanted in the leg with lymphedema in a small-intestine bypass surgery. This method turned out to be a failure in a long-term follow-up. Complications of this surgery included inflammation, small bowel obstruction, small bowel perforation, and deep vein thrombosis.


    Antireflux surgery of the thoracic duct


    There are internal and external causes for lymph fluid seeping into the veins from the thoracic duct. The lymphatic duct has valves that guide one-directional movement of the lymph. The smallest lymphatic ducts are without valves but most lymphatic ducts have valves in the interval of 0.5-1cm. Such a close arrangement of valves indicates that the lymph fluid is pushed with a low pressure. It is difficult to diagnose lymph reflux. If the lymphatic duct expands, lymphangiography allows direct examination of the reflux with contrast media.

    When there is chylous reflux due to obstructed thoracic duct, an antireflux surgery of the thoracic duct is needed. Surgery techniques include ligation, lymphovenous anastomosis, and transplantation of healthy lymphatic duct, etc.


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    -To be continued-

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