Review of Current Surgical Treatments for Lymphedema

Abstract

Background. The current mainstay of lymphedema therapy has been conservative nonsurgical treatment. However, surgical options for lymphedema have been reported for over a century. Early surgical procedures were often invasive and disfiguring, and they often had only limited long-term success. In contrast, contemporary surgical techniques are much less invasive and have been shown to be effective in reducing excess limb volume, the risk of cellulitis, and the need for compression garment use and lymphedema therapy. Microsurgical procedures such as lymphaticovenous anastomosis and vascularized lymph node transfer lymphaticolymphatic bypass can treat the excess fluid component of lymphedema swelling that presents as pitting edema. Suction-assisted protein lipectomy is a minimally invasive procedure that addresses the solid component of lymphedema swelling that typically occurs later in the disease process and presents as chronic nonpitting lymphedema. These surgical techniques are becoming increasingly popular and their success continues to be documented in the medical literature. We review the efficacy and limitations of these contemporary surgical procedures for lymphedema. Methods. A Medline literature review was performed of lymphedema surgery, vascularized lymph node transfer, lymphaticovenous anastomosis, lymphatic liposuction, and lymphaticolymphatic bypass with particular emphasis on developments within the past 10 years. A literature review of technique, indications, and outcomes of the surgical treatments for lymphedema was undertaken.Results. Surgical treatments have evolved to become less invasive and more effective. Conclusions. With proper diagnosis and the appropriate selection of procedure, surgical techniques can be used to treat lymphedema safely and effectively in many patients when combined with integrated lymphedema therapy.Lymphedema is a progressive and debilitating condition associated with dysfunction of the lymphatic system. While a small percentage of cases are congenital, most patients in developed countries present with lymphedema resulting from treatment of malignancy. The true incidence of lymphedema is difficult to determine as a result of significant differences in diagnostic criteria. However, lymphedema is reported to occur in up to 49 % of breast, 20 % of gynecologic, 16 % of melanoma, 10 % of genitourinary, and 6 % head and neck cancer patients after lymph node dissection and/or radiotherapy. Even among patients who undergo isolated axillary sentinel lymph node biopsy, up to 7 % have measurable arm differences, and up to 10 % have subjective symptoms of lymphedema.

An Effective System of Surgical Treatment of Lymphedema

“…LVA was preferred for lower extremity lymphedema and was performed by connecting peripheral lymphatics to adjacent venules by using techniques similar to those described by Koshima et al 17 Patients with volume excess primarily due to a nonpitting, solid lymphedema component were treated with SAPL, which was performed according to the protocol described by Brorson. 18 These procedures are described in more detail in our accompanying article. 19 …”

Surgical Treatment Modalities for Lymphedema

“…Hence, without the continued use of post-operative compression garments, relapse of lymphedema is inevitable [23,25]. However, when used complementarily with conservative treatment modalities or procedures improving lymphatic drainage (i.e., LVA or VLNT), the benefit from liposuction is maintained longterm [26,27]. Moreover, liposuction is surprisingly effective at preventing lymphedema associated cellulitis.…”

Lymphaticovenous Bypass Decreases Pathologic Skin Changes in Upper Extremity Breast Cancer-Related Lymphedema

“…3,4 Examples of these techniques include lymphaticovenous bypass (LVB) and vascularized lymph node transfer. [5][6][7][8][9][10] In these procedures, the primary aim is to bypass the obstructed lymphatics either by direct anastomoses of obstructed lymphatics to a regional vein or by transplantation of vascularized lymph nodes that promote lymphatic regeneration.…”