The Contemporary Surgical Treatment of Lymphedema. A popular topic for discussion.

The Contemporary Surgical Treatment of Lymphedema A popular topic for discussion

By Janice Cormier and Kate Cromwell

Thesurgical treatment of lymphedema has become a popular topic for discussion among both patients and healthcare providers. While surgical interventions offer promise for patients with lymphedema that is unresponsive to traditional treatments, such as Complete Decongestive Therapy (CDT), patients often fail to realize that the surgical treatment rarely provides a cure and most patients must continue with compression garments for the rest of their lives.

lymphedema, which summarized the reported risks and benefits, as well as the post-treatment measurements, techniques and associated volume reduction (Table 1). Various types of tissue, including omentum, muscle flaps, and lymph nodes, have been used to try to enhance lymphatic drainage.

investigators reported that 60 percent of patients had demonstrable changes in their lymphatic function at the site of tissue harvest, but none had manifested changes in limb circumference during the follow-up period (range: 8-56 months). Five lymph node transplant procedures are

Each surgical procedure has been documented to have associated benefits and risks, and the range of volume reduction reported with each type of procedure varies widely in the literature.

Asreported in the International Lymphoedema Framework’s recently released position document, the American Lymphedema Framework Project (ALFP) conducted a systematic review of 11 major medical indices of the peer-reviewed literature on the surgical treatment of

The surgical treatment of lymphedema which can broadly be divided into four broad categories of procedures including excisional, liposuction, lymphatic reconstruction and tissue transfer, has become a popular topic for discussion.

Excisional procedures

The most widely reported techniques harvest healthy lymph nodes from a nonlymphedematous region and transplant them into the region of swelling. An update to the systematic review identified eight studies of tissue transfer with reported volume reduction of 81 percent to an increase of limb volume of 13 percent following surgery. In a recent study, in which donor site limb function was examined using lymphoscintigraphy and limb circumference measurements, the

Janice N. Cormier, MD, MPH, FACS is a Professor in the Department of Surgical Oncology at the University of Texas MD Anderson Cancer Center. Dr. Cormier’s combined expertise in clinical oncology, lymphedema, and outcomes research are internationally recognized.

Kate D. Cromwell, MS provides research support to Dr. Cormier at the University of Texas MD Anderson Cancer Center.

still under investigation, and similar to other surgical treatments for lymphedema, have not been studied in randomized controlled studies with other surgical or non-surgical (CDT) treatments for lymphedema. Potential complications for lymph node transplant procedures include lymphedema at the donor site and recurrent lymphedema of the affected site. Excisional or debulking surgical options are the most extensive lymphedema surgical option. First described in 1918 by Walter Sistrunk, these operations remove the bulk of subcutaneous tissue and skin in the enlarged limbs with subsequent skin grafting of large areas. More recently the procedures have evolved to spare skin flaps on the lymphedematous limb in order to maintain blood flow to reduce the area of exposed tissue and promote healing.

Table 1

Summary of the Surgical Treatment of Lymphedema

Type ofNo. No.Range inMeasurement Techniques

ProcedureStudiesPatientsReduction (%)

Excision1028516-21 Circumference, volumetry, subjective

Liposuction715218 - 118Circumference, water displacement

Lymphatic920702 - 56 Circumference, Reconstruction water displacement

Tissue Transfer811113% increaseCircumference, to 81% decreasewater displacement

A total of 10 peer-reviewed publications on excisional procedures reported postsurgical limb volume reduction to be between 16-21 percent.1 A number of post-operative complications have been documented following debulking procedures including infection, delayed wound healing, deep vein thrombosis, poor cosmetic appearance, destruction of remaining lymphatics, loss of limb function, and recurrence of swelling.

Liposuction

While considered a specific type of debulking, liposuction has also been used to reduce limb volume in patients with chronic lymphedema of the upper and lower extremity. The contemporary technique for liposuction was pioneered in Sweden by Dr. Brorson.2 Patients who are candidates for liposuction are first treated with CDT until there is no evidence of pitting edema. Liposuction is performed by making 15-20 small incisions and removing subcutaneous fat. At the conclusion of the operation, custom compression garments, measured preoperatively to fit the non-affected limb, are applied as a dressing and then changed postoperatively and replaced every three months. A total of seven articles were included in the systematic review which reported limb volume reduction of 18-118 percent. The morbidity associated with liposuction includes bleeding, infection, skin loss, and paresthesias (burning or numbness of the skin). Brorson and colleagues emphasize that following liposuction, patients are

expected to continue wearing compression garments for the rest of their lives.

Lymphatic reconstruction

Lymphatic reconstruction occurs when new connections are created between the damaged lymphatics and other lymphatic channels. The goal of the surgery is to create new connections which allow for

While surgical interventions offer promise for some patients with lymphedema, the surgical treatment rarely provides a cure and most patients continue with compression garments for the rest of their lives.

the drainage of lymphatic fluid into the lymphatic system. The most commonly used technique for lymphatic reconstruction is lymphatico-venular bypass which creates microsurgical (0.8mm) connections from normal or dilated lymphatic channels to veins.3 These surgical techniques are highly specialized, require training in microvascular surgery and are most commonly performed by physicians trained in plastic surgery. A total of nine studies were identified which reported on the use of lymphatic reconstruction with a resultant range of volume reduction of 2-52 percent. The

associated complications included early failure (occlusion/scarring) of the connections and recurrence of lymphedema. More recently lymphatic imaging with indocyanine green dye has been used in conjunction with this procedure to assist with the visualization of lymphatic channels. A study has recently been published by Boccardo et al., in which lymphaticovenular bypasses were created at the time of axillary node dissection for the treatment of breast cancer to try to prevent the onset of lymphedema.4

Tissue transfer

Various types of tissue, including omentum, muscle flaps, and lymph nodes, have been used to try to enhance lymphatic drainage. The most widely reported techniques harvest healthy lymph nodes from a non-lymphedematous region and transplant them into the region of swelling. An update to the systematic review identified eight studies of tissue transfer with reported volume reduction of 81 percent to an increase of limb volume of 13 percent following surgery. In a recent study, in which donor site limb function was examined using lymphoscintigraphy and limb circumference measurements, the investigators reported that 60 percent of patients had demonstrable changes in their lymphatic function at the site of tissue harvest, but none had manifested changes in limb circumference during the follow-up period (range: 8-56 months).5 Lymph node transplant procedures are still under investigation, and similar to other surgical treatments for lymphedema, have not been studied in randomized controlled studies with other surgical or non-surgical (CDT) treatments for lymphedema. Potential complications for lymph node transplant procedures include lymphedema at the donor site and recurrent lymphedema of the affected site.

Discussion

In summary, a number of surgical procedures have been proposed for the surgical treatment of lymphedema. Many of these surgical procedures have demonstrated promising results in select groups of patients; the majority of studies have reported a significant reduction in limb volume. Few studies have reported on the incidence of

associated complications. Ongoing use of compression garments is generally recommended following the surgical treatment of lymphedema. The efficacy of these surgical procedures has not been examined in the context of randomized controlled trials and the long-term results have not been examined in large cohorts of patients. There is significant variability in the volume

reduction reported and aside from liposuction, the optimal patient populations for each of the procedures have not been defined. The surgical treatment of lymphedema is likely to be most successful if integrated into a comprehensive lymphedema care program which includes traditional treatment.

Editor’s Note:

Surgical procedures for lymphedema are evolving in various parts of Canada with many centres just beginning start up programs. The assessment and outcomes of these procedures are important and trials may be necessary before they become adopted as standards of care. Accessibility is limited to 1) local expertise and 2) eligibility on a case-by-case basis, with strict criteria for patient selection.

References

1. Cormier JN, Askew RL, Mungovan KS, Xing Y, Ross MI, Armer JM. Lymphedema beyond breast cancer: a systematic review and meta-analysis of cancer-related secondary lymphedema. Cancer. Nov 15 2010; 116(22):5138-5149.

2. Brorson H. Liposuction gives complete reduction of chronic large arm lymphedema after breast cancer. Acta Oncol. 2000; 39(3):407-420.

3. Chang DW. Lymphaticovenular bypass for lymphedema management in breast cancer patients: a prospective study. Plastic and reconstructive surgery Sep 2010; 126(3):752-758.

4. Boccardo FM, Casabona F, Friedman D, et al. Surgical prevention of arm lymphedema after breast cancer treatment. Annals of surgical oncology Sep 2011; 18(9):2500-2505.

5. Viitanen TP, Maki MT, Seppanen MP, Suominen EA, Saaristo AM. Donor site lymphatic function after microvascular lymph node transfer. Plastic and reconstructive surgery. Aug 8 2012.