Surgical Management of Lower Extremity Lymphedema: A Comprehensive Review

Abstract

Lymphedema refers to the accumulation of protein-rich fluid in the interstitial spaces. This can occur secondary to congenital malformation of the lymphatic channels or nodes or as a result of an insult that damages appropriately formed channels and nodes. Stagnant, protein-rich lymph initiates an inflammatory response that leads to adipocyte proliferation, fibrous tissue deposition, and increased susceptibility to infections. The end result is permanent disfigurement and dermal changes. Early and accurate diagnosis is essential, since lymphedema is a chronic and progressive problem. When lymphedema affects the lower extremity, it is important to manage it in a way that preserves function and mobility. Early diagnosis also allows for a proactive rather than reactive approach to treatment and utilization of novel physiologic procedures, such as lymphovenous anastomosis and vascularized lymph node transfer. Such interventions slow down disease progression and reduce morbidity by allowing the surgeon to salvage the remaining functional lymphatic channels. When physiologic procedures fail or when faced with a delayed presentation, the addition of excisional procedures can provide a more comprehensive treatment of this debilitating disease. The aim of this article is to review the most current concepts in the surgical management of lower extremity lymphedema.

Lymphaticovenous Anastomosis for Lower Extremity Lymphedema: A Systematic Review

“…43 Compression therapy should be initiated one month postsurgery and patients should be follow up each 3 months postoperatively to assess volume reduction until maintenance of limb size is achieved with daytime therapy for 3 consecutive months. 94 Our systematic review found that the largest reduction rates achieved after LVA for LEL ranged between 51.1 and 63.8%, with better results presented in early stages of lymphedema, and that almost all studies reported a decrease in episodes of infection. Patients' satisfaction after LVA has been also evaluated.…”

Noncontrast MR Lymphography in Secondary Lower Limb Lymphedema:

“…However, there is new evidence that early diagnosis allows proactive management of the disorder, using Lymphatic Venous Anastomosis and Vascularized Lymph Node Transfer. These surgical interventions can slow disease progression and improve the lymph drainage through the preservation of the residual functioning lymphatics 22,27 . VLNT is utilized for hypoplastic LE, 23,28 and LVA is the technique of choice in patients with hyperplastic lymphatic pattern and dilated lymphatic vessels 17 .…”

“…The following MR findings were recorded for each patient, regardless of the number of limbs involved: laterality of the swelling (unilateral/bilateral) and its symmetry, the presence of the honeycomb pattern 17,21 visible as trabecular/reticular structures with enlarged fat pockets in the subcutaneous fat (Fig. 2); thickening of the dermis (dermis thickness >2 mm); abnormalities in the muscle compartment, such as impaired trophism or altered signal; the number of inguinal lymph nodes; the appearance of iliac lymphatic trunks 22,23 classified as hypoplastic, if <3 lymphatic trunks were recognizable, normal, when 3–6 lymphatic trunks were visible, or hyperplastic, if >6 lymphatic trunks were present or if their caliber was >3 mm; and dilatation of distal lymphatic vessels (diameter >2 mm) 17,18 …”

Fluid Shifts Induced by Physical Therapy in Lower Limb Lymphedema Patients

“…The amount of fluid accumulated can reach up to 5–15 L [ 7 ]. It requires continuous treatment including meticulous care on behalf of the patient, non-invasive therapy options, such as physical therapy, and surgery [ 8 , 9 ]. However, no definite cure is currently available.…”