• #15-3. Surgical treatments of lymphedema




    Chronic lymphedema develops when collateral lymphatics are obstructed. Thanks to the advent of surgical microscope, microsurgery developed, making various surgical techniques available; lymphovenous anastomosis (LVA), lymph vein lymph graft (LIL), lymph graft (LG), lymph anastomosis (LLA), lymph node graft (LNG), free lymphatic flap autotransplantation, lymphovenous valvoplasty, etc.

    CT imaging is needed for screening malignancy in the inferior regions and MRI for screening lower vascular anomaly. A diagnostic Doppler ultrasound is useful for examining venous occlusion and venous valve function. Also, lymphscintigram is essential for making lymph-specific diagnosis.  Lymphangiography is important as it screens chylos reflux and thoracic duct dysfunction. In particular, this method identifies the anatomical structures of the lymphatic ducts such as size and location of healthy lymphatic ducts.

    However, despite such advancements in microsurgery, caution is advised as the lymphatic ducts of the affected lower limb in primary lymphedema are abnormal.


    Lymphovenous anastomosis

    In the 1960s, Jacobson proposed lymphatic duct and lymphovenous anastomosis and in 1968, Nielubowics developed lymph node and lymphovenous anastomosis. These methods are reported to be effective in patients with localized lymph damage and without recent inflammation or cellulitis.

    Before microsurgery, all patients should receive conservative therapies, i.e., lymph drainage massage and microsurgery is contraindicated in cases of venous hypertension. Patients who are likely to benefit the most from surgery have lymphatic duct occlusion in proximal, perineum region and dilated lymphatic duct in the distal inguinal region. The surgery is carried out under general anesthesia using a 5-20X magnification microscope.


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    Surgical outcome

    O’Brien’s results: In subjective assessment, symptom improvement was reported in 73% and long-term effect in 42%.

    Campisi’s results: Among 446 patients, 69% had volume reduction with symptom improvement and 85% did not require conservative treatment.

    It is important to recognize that surgical outcome is positive in early stage secondary lymphedema with a large number of healthy lymphatic ducts.


    Supermicro lymphovenous anastomosis

    In this procedure, lymphatic ducts and veins are connected under the microscope to drain the fluid retention. The effect is not lasting as the drained lymphatic ducts are occluded after some time. In clinical practice, lymphedema very rarely improves after lymphovenous anastomosis.


    Lymph graft, lymph lymph anastomosis

    Lymph graft is free from lymphatic duct occlusion by venous blood which can occur with lymphovenous anastomosis. In lateral lymphedema, the lymphatic duct on the healthy side is harvest for transplantation and pre-surgical lymphscintigraphy is needed. In a patient with history of lumpectomy, several lymphatic ducts of the leg are grafted in the arm. The one end of the lymphatic duct descending from the neck is connected at the site of surgery and the other end is connected to the healthy lymphatic duct around the fascia of the arm. In the leg, rotation flap technique is carried out where a flap of the normal lymphatic duct is taken and transferred to the lesion. Baumeister Siuda reported that the surgery had 80% efficacy and the transport capacity of the lymphatic duct was maintained for three years. However, this surgery cannot be said to have long-term efficacy.


    -To be  continued-

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