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ecancer 2 / 10.3332/ecancer.2008.LTR152

Is there a role for surgery in the management of lymphoedema?

Alex Munnoch

Consultant Plastic Surgeon
Department of Plastic Surgery, Ninewells Hospital, Dundee, United Kingdom

Prior to the development of suitable pressure garments and the various decongestive therapy techniques, the only option for patients with large lymphoedematous limbs was surgery. A variety of techniques were described in the early 20th century, with some still in use today (Charles & Homan’s procedures).

The draw back of these surgical excision procedures is the significant and unacceptable degree of scarring and cosmetic deformity which can result.

The Charles procedure (excision of lymphoedematous tissue and skin grafting) is still used in the treatment of genital lymphoedema, where it can improve physical appearance, ambulation, hygiene, micturition & sexual function 1.

Since the 1990’s an alternative form of surgical debulking has been described for lymphoedematous limbs – liposuction. Dr Brorson in Sweden has really pioneered this work, producing detailed research of the involved limbs, demonstrating that the excess tissue, in the absence of pitting oedema, is hypertrophied fat. This can be removed with liposuction through multiple small incisions, with the excess skin simply shrinking and redraping on the limb, thus avoiding the significant scarring of the older debulking techniques and resulting in excellent cosmesis.

Providing patients are compliant with the need to wear pressure garments continuously, then it is possible to maintain, or exceed, 100% volume reduction. Studies have shown that skin circulation is improved, lymphatic function is not adversely affected, patients have a better quality of life and have fewer episodes of cellulitis. He has recently published an article 2 describing successful outcomes up to 14years postoperatively in arms, and for the past 4 years has also treated legs, with similar results. 3,4,5,6,7,8 My experience providing a service in Dundee following the Swedish protocol has, so far, been very similar to that of Dr Brorson.

Microvascular reconstruction of lymphatic drainage pathways was first described in the 1970’s. Several techniques and variations have been described, but over the years they have had a mixed reception, with variable results being reported.

These techniques are technically demanding, require a high degree of microvascular experience, and careful choice of patients to ensure optimal results. The reported results from many centres have been negative, possibly due to poor patient selection and lack of surgical experience.

These techniques are performed regularly in some very specialized centres in Europe by experienced lymphoedema surgeons reporting good results.

Lymphaticovenous anastamoses involve joining lymphatic vessels onto a functioning vein, to allow drainage of lymph and works best in patients with early lymphoedema (up to stage 3).

Professor Campisi in Genoa has demonstrated significant improvement in over 1500 patients treated with this technique over the past 30 years. He joins lymphatics to veins in the proximal arm or leg, and has reported over 75% volume reduction in 83% of patients followed up for over 10 years, with many being able to dispense with pressure garments altogether 9,10.

Dr Koshima in Japan, however, prefers to perform supermicrosurgical anastamoses at multiple points within a limb through small incisions, often under local anaesthetic. He has demonstrated an average limb circumference reduction of 41% in over 82% of patients 11,12.

Instead of joining lymphatic vessels to veins, Professor Baumeister in Munich has performed lymphatic grafting or transplantation for over 20years. For lower limb oedema, this involves the pedicled transfer of lymphatics from the normal limb to the abnormal, with microlymphatic anastamoses. For upper limb cases, a segment of functioning lymphatics is harvested from the thigh and anastomosed to lymphatics in the limb and neck. He has demonstrated significant improvement in limb volumes, to the extent that some patients can discard their garments. In a few patients he has subsequently performed liposuction to remove any residual excess fat to bring the limb volume right down to equal the normal side. He has confirmed patency and function of these grafts with lymphoscintigraphy. Long-term, he has found it more difficult to maintain the volume reduction in the lower limb cases. He does not report any increase in volume of the limb used as the lymphatic donor 13-16.

Most recently, microsurgical lymph node transplantation has been described. This involves harvesting lymph nodes from the lateral groin with their blood vessels, which are then anastomosed to blood vessels in the axilla – no lymphatic anastomosis is performed.

Professor Becker, from Paris, has described her experience in treating 22 patients - 10 patients were cured, and a further 12 had improvement in lymphoedema. In 5 out of 16 cases the effectiveness of the procedure was demonstrated by lymphoscintigraphy, with tracer flowing through the lymph nodes. 17 This technique may have even more promise in the future as laboratory based researchers in Finland and Australia are currently looking at stimulation of lymphatic vessel growth in transplanted lymph nodes using growth factors. 18

In summary, although surgical management of lymphoedema has fallen out of favour due to previously poor outcomes, there is some hope for the future. If the correct technique is performed by a suitably experienced surgeon on the appropriate patient, then it is possible to treat the lymphoedema and its associated problems (cellulitis, fat hypertrophy) thus improving the quality of life and functional outcome for the patient, which is the aim of everyone involved in the management of patients with lymphoedema.

References:

1. Modolin M, Mitre A.I., da Silva J.C.F., intra, W., uagliano A.P., rap S, & Ferreira M.C. (2006) Surgical Treatment of lymphedema of the penis and scrotum. Clinics 61[4] 289-294

2. Brorson, H., Ohlin, K., & Svensson, H. (2008) The facts about liposuction as a treatment for lymphoedema. J of Lymphoedema 3[1] 38-47 

3. Bagheri, S., Ohlin, K., Olsson, G., & Brorson, H. (2005) Tissue tonometry before and after liposuction of arm lymphedema following breast cancer Lymphat.Res.Biol 3 2 66-80.

4. Brorson, H., Svensson, H., Norrgren, K., & Thorsson, O. (1998) Liposuction reduces arm lymphedema without significantly altering the already impaired lymph transport Lymphology 31 4 156-172

5. Brorson, H., Ohlin, K., Olsson, G., & Nilsson, M. (2006b) Adipose tissue dominates chronic arm lymphedema following breast cancer: an analysis using volume rendered CT images, Lymphat.Res.Biol 4 4 199-210

6.Brorson, H., Ohlin, K., Olsson, G., Langstrom, G., Wiklund, I., & Svensson, H. (2006a) Quality of life following liposuction and conservative treatment of arm lymphedema Lymphology 39 1 8-25.

7. Brorson, H. & Svensson, H. (1997b) "Skin blood flow of the lymphedematous arm before and after liposuction", Lymphology, 30 4 165-172

8. Brorson, H. & Svensson, H. 1997a, "Complete reduction of lymphoedema of the arm by liposuction after breast cancer", Scand.J.Plast.Reconstr.Surg.Hand Surg., vol. 31, no. 2, pp. 137-143.

9. Campisi, C., Eretta, C., Pertile, D., da, R. E., Campisi, C., Maccio, A., Campisi, M., Accogli,S., Bellini, C., Bonioli, E., & Boccardo, F. 2007, "Microsurgery for treatment of peripheral lymphedema: long-term outcome and future perspectives", Microsurgery, vol. 27, no. 4, pp. 333-338.

10. Campisi, C. & Boccardo, F. 1998, "Frontiers in lymphatic microsurgery", Microsurgery, vol.18, no. 8, pp. 462-471.

11. Koshima, I., Nanba, Y., Tsutsui, T., Takahashi, Y., Itoh, S., & Fujitsu, M. 2004, "Minimal invasive lymphaticovenular anastomosis under local anesthesia for leg lymphedema: is it effective for stage III and IV?", Ann.Plast.Surg., vol. 53, no. 3, pp. 261-266.

12. Nagase, T., Gonda, K., Inoue, K., Higashino, T., Fukuda, N., Gorai, K., Mihara, M., Nakanishi, M., & Koshima, I. 2005, "Treatment of lymphedema with lymphaticovenular anastomoses", Int.J.Clin.Oncol., vol. 10, no. 5, pp. 304-310.

13. Baumeister, R. G. & Frick, A. 2003, "[The microsurgical lymph vessel transplantation]", Handchir.Mikrochir.Plast.Chir, vol. 35, no. 4, pp. 202-209.

14. Baumeister, R. G. & Siuda, S. Treatment of lymphedemas by microsurgical lymphatic grafting: what is proved? Plast.Reconstr.Surg. 85[1], 64. 1990. Ref Type: Generic

15. Weiss, M., Baumeister, R. G. H., & Hahn, K. 2002, "Post-therapeutic lymphedema: scintigraphy before and after autologous lymph vessel transplantation 8 years of long-term follow-up", Clinical Nuclear Medicine, vol. 27, no. 11, pp. 788-792.

16. Weiss, M., Baumeister, R. G. H., & Hahn, K. 2003, "Dynamic lymph flow imaging in patients with oedema of the lower limb for evaluation of the functional outcome after autologous lymph vessel transplantation: an 8-year follow up study.", Eur.J.Nucl.Med., vol. 30, no. 2, pp. 202-206.

17. Becker, C., Assouad, J., Riquet, M., & Hidden, G. 2006, "Postmastectomy lymphedema. Long-term results following microsurgical lymph node transplantation.", Ann.Surg., vol. 243, no. 3, pp. 313-315.

18. Tammela T, Saaristo A, Holopainen T, Lyytikka J, Kotronen A, Pitkonnen M, Abo-Ramadan U, Yla-Herttuala S, Petrova TV, & Alitalo K. Therapeutic differentiation and maturation of lymphatic vessels after lymph node dissection and transplantation. Nature Medicine 13, 1458-1466. 2007.



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