• #16-1. Surgical treatments of lymphedema



    The purpose of surgical treatments of lymphedema is to physiologically restore lymph circulation or remove subcutaneous tissues with edema. Limb amputation may be necessary in cases with severe lymphedema accompanied with skin necrosis.


    Surgical removal of excess tissue


    This surgery is performed at the last stage of lymphedema with excess proliferation of lymphatic tissues. An incision is made from the hips to toes to remove excessive lymphatic tissues. A skin flap is used to cover the muscles. This surgery is carried out in severe cases. In theory, the surgery is thought to be only effective when the deep lymphatic system is intact and can cause various complications which can include the following.


    1. Paresthesia due to severe nerve damage.

    The patient does not feel pain when stabbed with a knife in some areas but feels excessive pain when touched in other areas.

    Edema recurs and leg deformity is seen.

    Fibrous changes are accelerated.

    Fibrous changes refer to worsening lymphedema and excessive hardening of the leg. Damaged arteries and veins lead to thrombosis and diagnosis with ultrasound or X-ray is not possible.

    2. Inflammation

    When inflammation follows fibrous changes of the leg, treatment becomes ineffective. Oral antibiotics is not helpful and IV antibiotic therapy should be given for at least 2 weeks.


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    3. Skin changes

    Despite topical therapy, warty changes and severe crusting of the skin continue.

    4. Malignant lymphoma develops.

    Fibrosis exacerbates with radiotherapy. In particular, when Stewart Treves Syndrome that progresses to lymphosarcoma is diagnosed, survival beyond 6 months is unlikely. Skin graft in the persistent wound has poor survival.


    Other surgical treatments include Sistrunk Procedure, Homan Procedure, and Chales Procedure. Complications of these procedures include hematoma, skin necrosis, inflammation, deep vein thrombosis, pulmonary embolism, hypertrophic scar, and lymphedema recurrence, etc. Therefore, surgical resection is rarely performed today. As a very limited indication, localized resection of severe fibrosis can be beneficial.


    - To be continued

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