The utility of surgical and conservative combination therapy for advanced stage lymphedema

Teaching of Microsurgery and Supermicrosurgery for Residents

On the basis of our numerous years of experience in teaching residents without microsurgery experience and assisting in the initiation of microsurgery in clinical practice, we herein describe the general procedures and crucial aspects to consider regarding microsurgery and supermicrosurgery training for residents. The description focuses on training methods, surgical skills, and training time and effort. The target audience of the training is residents who have never performed microsurgery. We believe that any person, regardless of operative experience, can acquire the technique for microsurgery and supermicrosurgery by performing 4 to 5 hours of training per day over a total of 30 days within this program setting. Considering individual differences in learning and experience, the training can be completed in a shorter period by performing additional daily training. It is relatively simple for a well-trained microsurgeon to master the uncommon supermicrosurgery techniques. We hope that this report will help as many residents as possible in learning the art of (super)microsurgery.

Surgical Treatment for Primary Lymphedema: A Systematic Review of the Literature

This is a retrospective review of surgical management for primary lymphedema. Data were extracted from 55 articles from PubMed MEDLINE, Web of Science, SCOPUS, and Cochrane Central Register of Controlled Trials between the database inception and December 2022 to evaluate the outcomes of lymphaticovenous anastomosis (LVA) and vascularized lymph node transfer (VLNT), and outcomes of soft tissue extirpative procedures such as suction-assisted lipectomy (SAL) and extensive soft tissue excision. Data from 485 patients were compiled; these were treated with LVA ( n  = 177), VLNT ( n  = 82), SAL ( n  = 102), and excisional procedures ( n  = 124). Improvement of the lower extremity lymphedema index, the quality of life (QoL), and lymphedema symptoms were reported in most studies. LVA and VLNT led to symptomatic relief and improved QoL, reaching up to 90 and 61% average circumference reduction, respectively. Cellulitis reduction was reported in 25 and 40% of LVA and VLNT papers, respectively. The extirpative procedures, used mainly in patients with advanced disease, also led to clinical improvement from the volume reduction, as well as reduced incidence of cellulitis, although with poor cosmetic results; 87.5% of these reports recommended postoperative compression garments. The overall complication rates were 1% for LVA, 13% for VLNT, 11% for SAL, and 46% for extirpative procedures. Altogether, only one paper lacked some kind of improvement. Primary lymphedema is amenable to surgical treatment; the currently performed procedures have effectively improved symptoms and QoL in this population. Complication rates are related to the invasiveness of the chosen procedure.

A Case of Severe Lower Extremity Lymphedema Caused by Postoperative Intraperitoneal Lymphatic Leakage Treatment

In the present study, we encountered a patient who developed intraabdominal lymphatic leakage after surgery for gastric cancer, underwent lymphangiography and lymphatic mass embolization, and developed severe lymphedema. The patient was a 55-year-old woman with gastric cancer with pancreatic invasion. Total gastrectomy and lymph node dissection were performed as conversion procedures. Six liters of ascites was detected postoperatively. Lymphangiography with Lipiodol injections into the bilateral inguinal lymph nodes was done three times, and Histoacryl embolization of the lymphatic leak was performed. However, edema of the lower extremities rapidly worsened. Lymphatic venous anastomosis was performed under general anesthesia. Anastomosis was performed at seven sites on the right and eight sites on the left. Postoperatively, the patient underwent compression therapy using the multilayer bandage method. The edema continued to improve further, and at 2 weeks postoperatively, the patient's weight had decreased by 21.4 kg from the preoperative weight, which was the same as that before the onset of edema. In this case, the patient's general condition was unstable due to cardiac insufficiency and other factors. Therefore, we aimed for an operation time of less than 3 hours. In addition, two surgeons performed the surgery to ensure an immediate therapeutic effect, and more anastomoses were performed than usual. After lymphatic venous anastomosis, not only the edema of both lower extremities but also the edema of the entire body improved promptly. One of the reasons for the improvement in general edema was thought to be due to increased intravascular protein and enhanced intravascular return of interstitial fluid.

Risk of congestive heart failure and mortality following lymphovenous anastomosis: a nationwide population-based retrospective cohort study

BACKGROUND

Lymphovenous anastomosis (LVA) enables lymphatic fluid to drain into the venous system. However, no study has investigated the association between LVA and heart failure (HF) caused by fluid overload in the blood circulating system. The purpose of our study was to determine whether LVA increases the risk of HF and mortality.

MATERIAL AND METHODS

This nationwide retrospective study evaluated a total of 1400 lymphedema patients who underwent LVA and two control cohorts with 28 000 lymphedema who did not undergo LVA and 70 000 age-matched and sex-matched participants from the Korean National Health Insurance database were included. Blood pressure, body mass index (BMI), glucose and cholesterol levels, smoking history, and comorbidities were obtained during National Health Insurance Service - Health Screening (NHIS-HealS). The incidence, adjusted risk for HF, and mortality were evaluated.

RESULTS

Adjusted HRs for HF were 1.20 (confidence interval [CI], 1.03-1.40) and 1.30 (CI, 1.12-1.50), referenced by the general population control cohort and patients with lymphedema without LVA, respectively. In age, sex, BMI, and smoking status-stratified analyses, heightened risk of HF was evident across all sexes, spanning both young and old age groups, encompassing individuals with various smoking statuses, and those with a BMI of 18.5 or higher. Among these groups, the risk was notably greater in males compared to females, higher in younger individuals as opposed to older ones, and further elevated within the BMI range of 18.5-25.

CONCLUSIONS

LVA is associated with an increased HF risk, independent of cardiovascular risk factors and associated comorbidities. This association is prominent in participants aged <50 years, in males, and in the normal-to-obese (BMI ≥18.5 kg/m 2 ) group. Among patients with lymphedema, LVA did not significantly affect mortality.

Comparative study of conservative treatment and lymphaticovenular anastomosis with compression therapy for early-stage breast cancer-related lymphoedema

This single-centre retrospective cohort study aimed to clarify the superiority of treatment by comparing the outcomes of lymphaticovenular anastomosis with compression therapy and conservative treatment centred on compression therapy in the early stage of breast cancer-related lymphoedema. Data were collected from all patients treated for breast cancer-related lymphoedema between January 2015 and December 2022. The patients were classified into conservative treatment and surgical treatment groups. The upper extremity lymphoedema index value was calculated, based on five circumference values of the upper extremity and body mass index, to compare the 6-, 12-, 18- and 24-month outcomes between the groups. Of 101 patients with breast cancer-related lymphoedema, 81 (conservative treatment: 52; surgical treatment: 29) were included in the analysis. The therapeutic effect was significantly higher in the surgical treatment group than in the conservative treatment group, when comparing the rate of change in oedema at 6 (-6.6% ± 7.3% vs. 0.9% ± 7.5%; p < 0.001), 12 (-7.3% ± 6.2% vs. 2.9% ± 8.6%; p < 0.001), 18 (-7.6% ± 8.0% vs. 3.9% ± 9.2%; p < 0.001) and 24 (-5.6% ± 6.0% vs. 4.4% ± 10.7%; p < 0.001) months. The incidence of cellulitis increased in the conservative treatment group (from 9.6% to 15.4%), whereas it was suppressed in the surgical treatment group (from 13.8% to 0%). Conservative treatment centred on compression therapy increased oedema over time; however, lymphaticovenular anastomosis with compression therapy effectively reduced oedema.

Size adjustment suture technique for lymphaticovenular anastomosis

In this report, we describe a super microsurgical technique that enables rapid and accurate anastomosis while adjusting for caliber differences when anastomosing a small-caliber lymphatic vessel and a vein with a larger caliber, which is frequently encountered in surgeries such as lymphaticovenous anastomosis (LVA).  The suture size adjustment technique was performed in 30 anastomoses of lymphatic vessels and veins, whose diameter of lymph duct was at least two times smaller than that of the vein. The type of lymphedema, caliber of lymphatic vessels and veins anastomosed, caliber ratio, vein wall thickness, modified caliber ratio after vein wall thickness subtracted, presence of additional anastomosis, and anastomosis time were examined. On average, the lymphatic vessels had a diameter of 0.61 mm, while the veins were 1.43 mm in diameter. The mean caliber ratio of vein to lymphatic vessel was 2.3, while the modified caliber ratio of vein-to-lymphatic vessel was 1.5 on average. The average venous wall thickness was 0.51. The average anastomosis time was 9.1 min and no additional anastomosis due to leakage was necessary in any case. We successfully performed an anastomosis of lymphatic vessels and veins with different calibers, which can maintain long-term patency while adjusting the caliber difference and suppressing leakage at the anastomosis site. Finally, the caliber of the vein is commonly larger than that of the lymphatic vessel to be anastomosed in many cases of LVA surgery, indicating that the proposed anastomosis method could be of therapeutic use in many cases.

Efficacy of Lymphaticovenular Anastomosis for Secondary Upper Extremity Lymphedema: Treatment Strategies with Effects of Compression Therapy Discontinuation and Site-Specific Evaluation of the Upper Extremity

Background: Lymphaticovenular anastomosis (LVA) has recently become a mainstream surgical treatment for lymphedema and is a useful treatment option in addition to conservative therapies such as compression therapy, exercise therapy, and lymphatic drainage. We performed LVA with the goal of stopping compression therapy and report the effect of LVA on secondary lymphedema of the upper extremities. Methods and Results: The participants were 20 patients with secondary lymphedema of the upper extremities categorized as stage 2 or 3 according to the International Society of Lymphology classification. We measured and compared the upper limb circumference at six locations before and 6 months after LVA. Significant decreases in circumference after surgery were observed at 8 cm proximal to the elbow, the elbow joint, 5 cm distal to the elbow, and the wrist joints, but not at 2 cm distal to the axilla or the dorsum of the hand. At more than 6 months postoperatively, eight patients who had been wearing compression gloves were no longer required to wear them, and three patients who had been wearing both sleeves and gloves were no longer required to wear them. Conclusions: LVA is effective in the treatment of secondary lymphedema of the upper extremities, particularly in improving elbow circumference, and is one of the treatments that contributes significantly to the improvement of quality of life. For severe cases with limited range of motion of the elbow joint, LVA should be performed first. Based on these results, we present an algorithm for upper extremity lymphedema treatment.

Outcomes after microsurgical treatment of lymphedema: a systematic review and meta-analysis

BACKGROUND

Microsurgical treatment options for lymphedema consist mainly of lymphovenous anastomosis (LVA) and vascularized lymph node transfers (VLNTs). There are no standard measurements of the effectiveness of these interventions and reported outcomes vary among studies.

METHODS

A systematic review and meta-analysis were performed based on a structured search in Embase, Medline, PubMed, Cinahl, Cochrane, and ProQuest in October 2020, with an update in February 2022. Firstly, a qualitative summary of the main reported outcomes was performed, followed by a pooled meta-analysis of the three most frequently reported outcomes using a random effects model. Randomized controlled trials, prospective cohorts, retrospective cohorts, and cross-sectional and case-control studies that documented outcomes following microsurgery in adult patients were included. Studies of other surgical treatments (liposuction, radical excision, lymphatic vessel transplantation) or without reported outcomes were excluded. The study protocol was registered on PROSPERO (International Prospective Register of Systematic Reviews) (ID: CRD42020202417). No external funding was received for this review.

RESULTS

One hundred fifty studies, including 6496 patients, were included in the systematic review. The qualitative analysis highlighted the three most frequently reported outcomes: change in circumference, change in volume, and change in the number of infectious episodes per year. The overall pooled change in excess circumference across 29 studies, including 1002 patients, was -35.6% [95% CI: -30.8 to -40.3]. The overall pooled change in excess volume across 12 studies including 587 patients was -32.7% [95% CI: -19.8 to -45.6], and the overall pooled change in the number of cutaneous infections episodes per year across 8 studies including 248 patients was -1.9 [95% CI: -1.4 to -2.3]. The vast majority of the studies included were case series and cohorts, which were intrinsically exposed to a risk of selection bias.

CONCLUSION

The currently available evidence supports LVA and vascularized lymph node transfers as effective treatments to reduce the severity of secondary lymphedema. Standardization of staging method, outcomes measurements, and reporting is paramount in future research in order to allow comparability across studies and pooling of results.

Super-microsurgery technique for lymphaticovenular anastomosis

BACKGROUND

In super-microsurgery, such as lymphaticovenular anastomosis (LVA), the diameter of the target vessel can be small and difficult to manage, and the basic surgical technique of microsurgery, such as inserting a forceps into the lumen and applying countertraction, can be difficult. In addition, it can be difficult to confirm the success or failure of the postoperative anastomosis, unlike with normal free-flap transfer, or to learn the technique by reviewing the results.

METHODS

We have described a safe, quick, and accurate technique for LVA based on our experience performing several hundred such cases at our institution.

RESULTS

Before LVA, the location of the significant lymphatic vessels and veins proximal to the lymphatic vessels should be marked using indocyanine green fluorescence angiography and a vein viewer to help determine the skin incision site. We used super-microsurgical titanium needles and surgical scissors and an end-to-end anastomosis. The lymphatic vessels should be dissected as far as possible from the skin incision to the center, and the veins should be dissected as far as possible from the periphery. First, a stay suture should be applied to the upper and lower ends of the anastomosis at 180°. Next, the anterior wall should be sutured. In some cases, countertraction can be applied by inserting the tip of a forceps into the vascular vessel. However, because its insertion could damage the lymphatic vessel wall, it would be more appropriate to perform the anastomosis using the involved stitch technique. After anastomosis of the anterior wall, the vessel should be inverted and the posterior wall anastomosed using the same technique.

CONCLUSIONS

We have reported the key points necessary to perform LVA quickly and accurately and the precautions necessary to maintain long-term patency. This sophisticated LVA technique can be applied to improve the outcomes for patients with lymphedema.

Outcomes of Lymphovenous Anastomosis for Lower Extremity Lymphedema: A Systematic Review

Lymphovenous anastomosis (LVA) is a microsurgical treatment for lymphedema of the lower extremity (LEL). This study systematically reviews the most recent data on outcomes of various LVA techniques for LEL in diverse patients.

METHODS

A comprehensive literature search was conducted in the Ovid MEDLINE, Ovid EMBASE, and Scopus databases to extract articles published through June 2021. Studies reporting data on objective postoperative improvement in lymphedema and/or subjective improvement in quality of life for patients with LEL were included. Extracted data comprised demographics, number of patients and lower limbs, duration of symptoms before LVA, surgical technique, duration of follow-up, and objective and subjective outcomes.

RESULTS

A total of 303 articles were identified and evaluated, of which 74 were ultimately deemed eligible for inclusion in this study, representing 6260 patients and 2554 lower limbs. The average patient age ranged from 22.6 to 76.14 years. The duration of lymphedema before LVA ranged from 12 months to 11.4 years. Objective rates of improvement in lymphedema ranged from 23.3% to 100%, with the greatest degree of improvement seen in patients with early-stage LEL.

CONCLUSIONS

LVA is a safe and effective technique for the treatment of LEL of all stages. Several emerging techniques and variations may lead to improved patient outcomes.

Relationship Between Lymphaticovenular Anastomosis Outcomes and The Number and Types of Anastomoses

BACKGROUND

Lymphaticovenular anastomosis (LVA) is the first-line treatment for lymphedema in many hospitals. However, many aspects of its effects remain unclear. This study aimed to analyze problems with regard to the relationship between lymphaticovenular anastomosis and outcomes of surgery for lymphedema in the upper and lower extremities.

METHODS

Eighteen articles were selected for review. The following information was extracted from these articles as factors associated with LVA for lymphedema in the upper and lower extremities: number of cases, average patient age, mean number of bypasses, lymphedema stage, duration and type of lymphedema, anastomotic technique, follow-up period, type of scale, and treatment outcomes.

RESULTS

Upper extremity lymphedema: The average age of patients was 54.2 (range: 41.3-60.1) years. The mean number of anastomoses was 3.91 (range: 1.0-7.2). Six of nine articles provided data for volume change, and the mean volume change was 29% (-5%-50%). Lower extremity lymphedema: The average age of patients was 50.3 (range: 34-64 years). The mean number of anastomoses was 4.6 (range: 2.1-9.3). Comparison was difficult as different methods were used for postoperative evaluation (lower extremity lymphedema index in three patients, limb circumference in one, volume change in two, and restaging in three).

CONCLUSIONS

We obtained useful information with regard to the effects of LVA in this review. An increased number of anastomoses between the lymphatic ducts and veins did not seem to improve the effectiveness of LVA. With regard to the stage of lymphedema, LVA may be useful for both early and advanced stages.

Vascularized lymph node transfer for surgical treatments of upper versus lower extremity lymphedema

OBJECTIVE

The purpose of this study was to compare clinical outcomes after vascularized lymph node transfer (VLNT) for the treatment of lymphedema performed on the upper and lower extremities.

METHODS

Between April 2015 and January 2020, 71 patients with advanced-stage lymphedema, categorized as International Society of Lymphology late stage 2 or 3, who underwent VLNT in upper and lower extremities were included in this study. Thirty-seven and 34 patients underwent VLNT in upper and lower extremities, respectively. The circumference of the affected and unaffected extremities was measured at baseline, follow-up visits, and at the last visit. The circumference was measured in six places on the extremities, and the circumference and volume percent differences between the affected and unaffected extremities were calculated. First, we compared preoperative and postoperative extremity circumferences in the overall, upper, and lower extremity groups. Second, we compared circumference and volume percent differences between the affected and unaffected extremities calculated at the last visit to identify the degree of improvement by VLNT in the upper and lower extremity groups.

RESULTS

The results of the comparative analysis between the preoperative and postoperative extremity circumferences showed that all postoperative extremity circumferences measured at the last visit were decreased compared with the preoperative values in the overall, upper, and lower extremity groups. In the upper extremity group, the circumference percent difference measured at the elbow was 23.1% before surgery and decreased to 13.4% at the last visit (P < .001). In the lower extremity group, the circumference percent difference measured at the knee was 24.4% before surgery and decreased to 17.4% at the last visit (P = .003). In the results of comparative analysis between the upper and lower extremity groups, there was a statistically significant difference in the postoperative circumference percent differences at the elbow/knee calculated at the last visit (P = .048). Similarly, there were statistically significant differences in circumference percent differences in two of six measurement sites at the last visit between the upper and lower extremity groups. However, there was no statistically significant difference in the volume percent difference calculated at the last visit between the upper and lower extremity groups.

CONCLUSIONS

These results demonstrate that VLNT may be effective in treating patients with advanced-stage lymphedema. However, patients with upper extremity lymphedema demonstrate superior outcomes compared with those with lower extremity lymphedema.