Surgical perspectives and challenges
An interview with Dr. Wei Chen of the Cleveland Clinic
Our first interview with Dr. Chen, published in Summer 2021 Pathways, addressed patient-related questions and broad concerns about lymphedema. In this interview with Dr. Towers and Anna Kennedy, Dr. Chen provides an insider’s view of the challenges faced by surgeons to developing and implementing surgical techniques to treat lymphedema and the important methodological problems associated with tracking long-term outcomes.
What’s next in lymphedema surgery?
We have made great strides in lymphedema surgery in the past decade. New procedures were created and old procedures were refined/ retired. The results of lymphedema surgery also have been phenomenally favorable. The fact that the feasibility of lymphedema “cure”
What would really benefit patients is to stimulate interest from physicians, as we definitely need more physicians to pitch in to help this patient population.
is being discussed and debated demonstrates the optimism shared by many leading surgeons in the field. The next tasks for us would be 1) to recruit more physicians/surgeons to help this previously neglected patient population, 2) to get insurance carriers to properly cover lymphedema patients so they can receive the
care they need, 3) to extend our lymphedema treatment to preventing lymphedema from happening in the first place, and 4) to continue to advanced the field with research.
Stimulating interest from more physicians and surgeons
What would really benefit patients is to stimulate interest from physicians, as we definitely need more physicians to pitch in to help this patient population. We already have lymphedema therapists who are committed to helping lymphedema patients, but physicians and surgeons are set back by several different factors.
Factors such as lack of knowledge/ awareness and widespread misinformation about lymphedema being untreatable are related to the novelty of the field, and I expect this will improve with time. The more challenging problem is the poor insurance coverage. All too frequently, the surgeons and hospitals found that they had performed these complex surgeries without being paid
Dr. Wei Chen is a professor of plastic surgery at Cleveland Clinic and serves as the head of microsurgery and super microsurgery and co-director of Cleveland Clinic’s multidisciplinary lymphedema center. He is internationally renowned for his expertise in lymphatic super microsurgery, pioneering several procedures for lymphedema reconstruction.
Dr. Anna Towers runs the lymphedema program at McGill University Health Centre (Montreal, Quebec) and is on the Editorial Board of Pathways Anna Kennedy (Toronto, Ontario) is the Editor of Pathways magazine.
An interview with Dr. Wei Chen of the Cleveland Clinic AnnaKennedyandDr.AnnaTowersrecentlyinterviewedDr.WeiChen,whokindly addressedsomepatient-relatedconcernsandquestions.Weappreciatehisperspectiveand enthusiasmtoeducatepatients,therapistsandphysicians.
at all or were only paid at a fraction of what they were supposed to. As a result, few hospitals/surgeons are willing to help this patient population.
Challenges for surgeons
Clinical lymphedema research is difficult because, in its current state, the bulk of it takes place on the individual surgeon’s nights and weekends. Surgeons are under-supported and underfunded. We hope to improve this situation with education and by raising awareness. The lack of understanding and awareness also contribute to the insurance carriers’ reluctance to cover these procedures. And this current situation just fuels the insurance companies’ ability to label these procedures as investigational. Because when you look at the literature, lymphedema surgical outcomes are all over the place. The key reason for the inconsistent outcomes is the steep learning curve associated with these procedures. Many surgeons are still overcoming their individual learning curves. All too frequently, I saw surgeons who were starting out getting discouraged by suboptimal outcomes, who then suffered a second hit when they realized they/hospitals did not get paid.
What we can do to help is to make training for supermicrosurgical lymphatic surgery more accessible to surgeons who are passionate about helping lymphedema patients. Doing so will help them more consistently achieve favorable outcomes, which should, over time, improve insurance coverage.
Adapted LYMPHA procedure at the Cleveland Clinic
Classic LYMPHA, the preventive supermicrosurgical procedure performed by most and originally proposed by Professor Campisi, is performed in the arm pit at the time of axillary lymph node dissection. However my preferred way of performing this prophylactic procedure to prevent symptomatic lymphedema, is at the location of the elbow. It’s also not performed at the time of injury, but performed later. As you know, lymphedema doesn’t develop overnight, so what is the rush? There are multiple reasons.
a lymph node dissection and radiation, that this procedure be followed.
Long-term outcomes
I suggest that surgeons track their LYMPHA studies by ICG lymphographic findings, rather than volume and circumference. Tracking and observing the degree of limb swelling can be misleading.
We conduct a baseline ICG study before the surgery to see the extent of injury. Then post-surgery we perform follow-up ICG at various points. We look to see if the injury is resolving2. That is what we consider a surgical success. If the patient is not having swelling but we’re seeing this injury worsening, to me, that surgery failed, because this patient will likely eventually develop lymphedema.
We call this “delayed distally-based prophylactic LVA” 1. And as the title suggests, we hypothesized that it improves functionality, feasibility and oncologic safety. We have concerns in routing lymph flow in lymph vessels, which used to drain to cancer-containing lymph nodes, into the systemic circulation. Are we going to contribute to the spread of cancer? We don’t know. That’s the first concern.
The second concern is we frequently would run into unfavorable pressure gradients in the axilla due to the veins being much larger than the lymph vessels, resulting in vein to lymph vessel flow and ineffective lympho-venous connections.
Thirdly, the majority of these patients will undergo postoperative radiation. Given what we know about LVA, I think the prognosis of these LVAs is not good. If you blast them with radiation, they most likely will shut down. In fact, they probably have shut down already just from the unfavorable pressure gradients.
I withhold some of the yet unpublished data, but can share with you that the outcome of our technical approach is highly favorable. It’s so favorable that I recommend universally to all patients who are undergoing
Patients post-surgery who are not experiencing swelling in two, three, four, or even five years—it doesn’t mean the patient is out of the woods. In one particular patient of ours, lymphedema developed following cervical cancer 30 years later.
Standardized methodology
My suggestion regarding nearly all of the lymphedema-related outcome studies is not to use volume as the outcome, because that method is so insensitive and inaccurate. If we measure three times, we get three different numbers. How reliable do you think that outcome is? So as a result, all of the circumference-based outcomes need to be an average. People would measure three times or five times to get an average because it’s so inaccurate. And then even worse would be those who take circumference measurements and then use the truncated cone formula to get a calculated volume. You’re basically compounding your error.
Another reason why the outcomes of any lymphedema treatment, surgical or non-surgical, are all over the place is because the methodology is flawed, not consistent and not standardized. Anyone can easily see why using circumference measurement is bad, but it is understandable why it is continuing to be used. It is easy, accessible, and many of
I suggest that surgeons track their LYMPHA studies by ICG lymphographic findings, rather than volume and circumference. Tracking and observing the degree of limb swelling can be misleading.
the clinicians have no access to more advanced technologies. My take on this is that—we should insist on doing the right thing and not compromise on something we know is inaccurate.
Funding challenges
A fundamental problem for surgical treatment is finance. If the insurance coverage situation for surgery (in the USA) doesn’t improve, the current increased enthusiasm from surgeons’ communities will eventually die out. Many major academic centers in the U.S. have already been forced to stop performing lymphatic surgery because they could not financially sustain their lymphedema surgery. We need to do something about this quickly. We need your help! LP
References
1. Chen, Wei F., and Rebecca Knackstedt. “Delayed Distally Based Prophylactic Lymphaticovenular Anastomosis: Improved Functionality, Feasibility, and Oncologic Safety?” Journal of Reconstructive Microsurgery 36.09 (2020): e1-e2.)
2. (Chen, Wei F., et al. “Indocyanine green lymphographic evidence of surgical efficacy following microsurgical and supermicrosurgical lymphedema reconstructions.” Journal of Reconstructive Microsurgery 32.09 (2016): 688-698.
Editor’s Note: Canada has a publicly funded healthcare system with governments that are only just starting to show a willingness to fund surgery, if it can be shown that procedures will prevent lymphedema (like LYMPHA type surgery) and improve quality of life. We look forward to seeing how lymphatic surgery evolves among all the provincial jurisdictions as the limited availability of Canadian surgical expertise improves.
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