SURGICAL THERAPY
Surgical techniques used in the past for the treatment of lymphedema aimed to reduce the volume of the affected limbs by demolitive cutaneous exeresis (cutolipofascectomy, total superficial lymphangectomy). These procedures were a symptomatic solution that, by not removing the cause of the obstruction to the lymphatic flow, provided only a temporary reduction of edema with eventual subsequent recurrence, which was distributed in a non-homogeneous manner in the affected limb affected due to the presence of large and disfiguring surgical scars.
The advent of microsurgery stimulated the study and implementation of functional and therapeutic solutions for lymphedema, with the aim of draining the lymphatic flow or reconstructing the lymphatic pathways, where obstructed, missing or malfunctioning, through minute reparative techniques, intervening directly on the lymphatic structures themselves.
Indications for Lymphatic Microsurgery
Ideal indications:
- Initial stages (IB, IIA,) – considering the international staging (Consensus Document of the ISL) with 3 stages, which we modified in 2009 and also reported in the Guidelines of the Italian Society of Lymphangiology (Lymphology)
- Lymphoscintigraphy, demonstrating reduced proximal lymph node uptake and minimal or absent tracer passage beyond this lymph-glandular station
- Excellent patient compliance
- A reference lymphology center, to which the patient can be referred for any need, in addition to the Lymphatic Surgical Center where they had surgery.
Relative indications:
- Advanced stages (IIB, IIIA, IIIB)
- Lymphoscintigraphy, demonstrating an absent ascent of the tracer (“silent” lymphoscintigraphy)
- Poor “compliance” of the patient
Contraindications:
- Lymphatic-lymph node aplasia (extremely rare)
- Diffuse metastatic disease
- Very advanced stage of extreme elephantiasis (IIIB), with total disability and poorly responsive to conservative therapies
Microsurgical techniques have provided positive and long-lasting results both for the treatment of primary lymphedema, including those in the pediatric age, and also for lymphedema secondary to oncological interventions, which involve lymph node dissection in “critical” sites, such as the axilla and inguinal regions.
Lymphatic Microsurgery: derivative and reconstructive techniques
Microsurgical techniques for the “conservative and functional” surgical therapy of lymphedema are divided into derivative and reconstructive methods.
The derivative methods aim to restore lymphatic flow at the site of the obstruction through the creation of lymphatic-venous drainage with the use of lymph nodes or, better, directly using the lymphatic vessels anastomosed to a main satellite vein or, preferably, to its tributary branches:
- Lymph Node-Venous Anastomosis (LNVA)
- Lymphatic-Capsule-Venous Anastomosis (LCVA)
- Lymphatic-Venous End-to-End Anastomosis (EE-LVA)
- Lymphatic-Venous End-to-Side Anastomosis (ES-LVA)
The anastomosis of a lymph node by transverse or longitudinal section with a main vein of the superficial or deep venous circulation in the lymphedematous limb tends to occlude within a short time due to venous thrombosis in the anastomosis site or a re-endothelialization of the anastomotic surface of the lymph node. Lymphatic-capsule-venous anastomosis is preferably used in the treatment of lymphedema in pediatric age, in order to avoid excessive trauma to the small veins chosen for the anastomosis. This method consists of the anastomosis of the lymph node capsular segment, with the afferent lymphatic collectors, to the satellite vein. The end-to-end lymphatic-venous anastomoses are made with a telescopic technique, using a single U-shaped suture. In these cases, a continent collateral of the main vein is used for the end-to-end lymphatic-venous anastomosis (Fig. 2).
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Fig.1, A-B: Multiple end-to-end lymphatic-venous anastomosis with telescopic technique for the placement of the lymphatic collectors within the venous segment.
Fig.2: Lymphatic-venous microsurgery in the brachial region for the treatment of lymphedema of the upper limb (note the median nerve and the humeral artery).
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The end-to-side lymphatic-venous anastomosis is more easily accomplished by using a grooved needle-cannula of Degni. The lower border of the wall of the lymphatic segment is introduced, end-to-side, into the vein close to a valve, preventing the reflux of blood inside the lymphatic collector due to the valvular action. This technique was subsequently modified (Campisi, 1989) and realized, using, as a venous access for the lymphatic collectors, the orifice of a collateral vein of the main vein. This technical modification prevents the risk of stenosis of the anastomosis due to the particular arrangement of the smooth muscle cells of the venous wall at the point of entry of the lymphatic collectors.
Reconstructive microsurgical techniques allow the restoration of a continuity of flow of the lymphatic circulation, overcoming the site of the blockage with the implantation of autologous lymphatic or venous segments between the collectors, upstream and downstream to the obstacle:
- Lymphatic-Lymphatic Anastomosis (LLA)
- Segmental Lymphatic AutoTransplantation (SLAT)
- Lymphatic-Venous-Lymphatic-Plasty or Lymphatic-Venous-Lymphatic Anastomosis (LVLA).
- Free Lymphatic-Lymph-node Flaps (FLF)
Lymphatic-lymphatic anastomosis is rarely used because often the “gap” between the afferent and efferent collectors is too large and prevents direct anastomosis, therefore requiring the interposition of a segment of lymphatic vessels or vein. The lymphatic collector autotransplantation is an experimental technique, which allows the reconstruction of only 1 or 2 lymphatic pathways in the affected limb and can be used exclusively for the treatment of unilateral lymphedema, as the lymphatic segment is taken from the healthy side through a surgical incision. However, this incision is relatively wide and carries the risk of the appearance of a iatrogenic lymphedema in the donor anatomical site.
In contrast, interposition of autologous venous grafts between the lymphatic collectors, upstream and downstream of the obstacle in lymphatic flow, represents a method, alternative to derivative techniques, that is easy to perform (Campisi, 1982). The venous grafts are readily taken from the same site as the microsurgery, from the volar surface of the arm or the lower limb (in this case, collateral branches of the saphenous vein) for a length ranging from 7 to 25 cm. and a diameter of 1.5-5.0 mm. This method is used, above all, for the lower limb and the surgical site is between the supra- and the sub-inguinal regions, using a telescopic anastomosis to insert, with a 8/0 U-shaped suture in non-absorbable material, nylon, or monofilament, the lymphatic vessels into the vein mouth. Lymphatic-Venous-Lymphatic-Plasty (LVLA) has an average duration of 2.5 hours in the OR and is used when there is also pre-existing venous disease (e.g., venous hypertension, valvular insufficiency) that can not be surgically corrected (Fig.3).
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Fig.3, A-C: Schematic drawing and intraoperative phases of lymphatic-venous-lymphatic reconstructive microsurgery, with the interposition of an autologous venous segment between the lymphatic collectors upstream and downstream to the obstacle.
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In very rare cases of lymphatic-lymph node hypoplasia, lymphatic-lymph node flaps may represent an advantageous solution, which provide free microvascular autotransplantation of lymphatic-lymph node tissue in the axillary or inguinal site of the affected limb.
The use of microsurgical techniques for the treatment of lymph stasis allows us to achieve positive results, with reduction in edema consistency and volume of the affected limb ranging from 50% to 75%, up to 100% compared to the conditions prior to treatment, depending on the pre-surgical stage of the disease: the earlier the surgery, the greater the percentage of edema regression. In the “follow-up” of patients treated with lymphatic microsurgery for limb lymphedema, even after more than 20 years after surgery, these results have proved to be stable and long-lasting. The evaluation criteria of the results include water volume displacement and lymphoscintigraphy performed before the treatment and at a variable distance from the surgery.
Evaluation of results in the medium and long term
Water volume displacement and lymphoscintigraphy were used to evaluate the results of the microsurgery. With regards to the volumetric measurements of the affected limb, a water volume displacement method is used, consisting of placing the affected limb(s) into a cylinder of known surface size, filled with water, communicating with a column of transparent graduated material. The volumetric variations of the limb are measured based upon the volume of water displaced by the limb. In cases of unilateral pathology, these measurements are compared to the volume of the healthy contralateral limb. Alternatively, it is possible to use the formula of the truncated cone and measure the volumetry by calculating the circumferences of the limb measured at various points along the limb.
Lymphoscintigraphy (Fig. 4), carried out at varying intervals of time from the surgery, allows the demonstration of the patency of the derivative or reconstructive microsurgical anastomoses through: 1) a reduction in “dermal backflow”, 2) the “disappearance” of the tracer at the level of the microanastomoses due to the passage into the bloodstream, 3) the early hepatic “uptake” of the tracer indicative of a more rapid passage of the radioisotope in the systemic blood circulation, 4) restoration of preferential lymphatic pathways of tracer ascent and 5 ) visualization of the interposed venous segment.
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Fig. 4: Lymphoscintigraphy before and after the lymphatic-venous derivative microsurgery at the upper-middle third of the arm. Note the appearance of a preferential lymphatic drainage pathway, the reduction of the dermal back flow, and the early liver uptake of the tracer.
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Microsurgical techniques are effective, especially in the earliest stages of the disease, where the microsurgery, thanks to the restoration of preferential lymphatic drainage pathways in the affected limb, gives results that can also reach complete healing (Fig. 5- 8). Even in the most advanced stages of disease, microsurgical techniques still allow a rapid and significant reduction of edema (in correspondence to the liquid component of the swelling; however, some fibrotic-adipose tissue contributing to the swelling will remain). The results are maintained over time and improved through medical-physical procedures designed to optimize the surgically-reconstructed pathways of lymphatic drainage. However, in these more advanced stages, the partial result of the Multiple Lymphatic-Venous Derivative / Reconstructive Microsurgery (MLVA) can be significantly and steadily improved by using the recent method we have developed: selective Fibro-Lipo-Lymph Aspiration, with a “Lymph Vessel Sparing” procedure (FLLA-LVSP), under the guidance of a Fluorescent Microlymphography using Indocyanine Green dye
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Fig. 5: Lymphedema of the right upper limb (stage IIB) secondary to the treatment of breast cancer, before and after microsurgical treatment.
Fig. 6: Primary lymphedema of the left lower limb, stage IIB, before and after lymphatic-venous derivative microsurgery.
Fig. 7: Congenital lymphedema of the lower limbs with gravitational reflux, stage IIIA before, and one week after, bilateral lymphatic-venous microsurgery in the inguino-crural region.
Fig. 8: Secondary lymphedema of the right upper limb, stage IIA treated by lymphatic-venous derivative microsurgery.
Fig.9: Secondary lymphedema of the left lower limb at stage IIA treated by lymphatic-venous derivative lymphatic microsurgery.
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Figure 10: Secondary lymphedema of the left lower limb stage IIA associated to significant hypertension of the deep veins, treated by reconstructive microsurgery with lymphatic-venous-lymphatic-plasty at the left inguino-crural site.
Figure 11: A-B: Lymphedema of the right lower limb, stage IIB, treated with multiple lymphatic-venous microsurgery.
Figure 12: Primary lymphedema of the left lower limb, stage IIIA, before and after lymphatic-venous microsurgery (MLVA).
Figure 13: Elephantiasis of the lower limbs in an obese patient (advanced stage IIIA), treated with obesity therapy, CPT, and multiple lymphatic-venous anastomoses derivative microsurgery (MLVA).
Figure 14: Voluminous inguinal lymphocele and lymphedema of the right lower limb, before and after the “en bloc” removal of the lymphoncele, combined with lymphatic-venous microsurgery (MLVA).
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Rationale of an integrated therapeutic protocol:
- By-pass of the obstruction site with lymphatic-venous drainage upstream to the obstacle or by using a venous “bridge” between the lymphatics upstream and downstream to the blockage
- The initial treatment always includes combined physiotherapy, conducted at specialized centers by competent staff in the lymphology sector if possible
- Surgical timing: application of microsurgical techniques occurs when conservative therapies, after having obtained a more or less significant reduction of edema, no longer achieve further improvements in the clinical picture or for the control of eventual episodes of acute lymphangitis.
At this point, microsurgery allows us to further improve the results obtained with conservative treatment methods, which, when also applied after the surgery, stabilize the surgical results, improving them over time. Microsurgery can be applied to both secondary and primary lymphedema. Primary lymphedema almost always is a result of a congenital obstructive cause, represented by proximal lymph-nodal fibrosclerosis (axillary or inguinal), with afferant lymphatic collectors, which are working well but are often dilated and hypertrophied from trying to overcome the obstacle.
The microsurgical techniques divert the obstructed lymphatic flow on a congenital or acquired basis into the venous circulation, when the latter is intact, or through reconstructive methods if there are concomittant venous problems. Connection is made between the lymphatic collectors downstream and upstream of the ‘obstacle’, through the interposition of lymphatic segments or, better, an autologous venous segment (lymphatic-venous-lymphatic plasty). Finally, microsurgical techniques play an important role in the prevention of secondary lymphedema, as well as in preventing the worsening of the pathology and its complications (lymphangitis, lymphorrhea, lymphostatic verrucosis, and the possible evolution towards a lymphangiosarcoma in the most advanced stages). Complementary and alternative therapies, with regards to lymphedema, are to be identified with the current possibilities of prevention of the disease, in particular, lymphedema of the upper limb secondary to surgery and / or radiotherapy for breast cancer. Prevention is based on the possibility offered to us today, above all, by lymphoscintigraphy, to study, prior to any surgery to the breast and the axillary cavity, or immediately after, the anatomical-functional structure of the lymphatic circulation of the ipsilateral upper limb. It would thus be possible to identify, in the female population affected by breast cancer and candidate for surgical and / or radiotherapy cancer treatment, categories of patients at risk (low, medium, and high) for the appearance of secondary lymphedema. Thus, these patients could be suitably immediately treated (not at a later time), with therapeutic measures considered most appropriate according to the case, depending on the extent of the damage to the lymphatic circulation identified.
MULTIPLE LYMPHATIC VENOUS ANASTOMOSIS (MLVA)
MULTIPLE LYMPHATIC VENOUS ANASTOMOSIS (MLVA) IN INGUINO-CRURAL OR BRACHIAL REGION (SINGLE-SITE SURGERY) FOR LOWER/UPPER LIMB LYMPHEDEMA TREATMENT
The reconstructive techniques proposed for the treatment of limb lymphedema are many. These include lymphatic-venous derivative microsurgery and autologous lymph node transplantation. Scientific literature has highlighted how, to date, the technique that presents the best long-term results is represented by the Multiple Lymphatic-Venous Anastomoses derivative / reconstructive microsurgery (MLVA). This approach allows, with a single surgical incision, in the groin for the lower limbs or brachial for the upper limbs, to successfully treat lymphedema. In particular, this microsurgical technique allows the superficial and/or deep lymphatic structures of the diseased limb to be used. In fact, in order to obtain a good result after surgery, the superficial and deep lymphatic system must be adequately studied.
The reconstructive techniques proposed for the treatment of limb lymphedema are many. These include lymphatic-venous derivative microsurgery and autologous lymph node transplantation. Scientific literature has highlighted how, to date, the technique that presents the best long-term results is represented by the Multiple Lymphatic-Venous Anastomoses derivative / reconstructive microsurgery (MLVA). This approach, with a single surgical incision, in the groin for the lower limbs or brachial for the upper limbs, successfully treats lymphedema. In particular, this microsurgical technique, uses both the superficial and/or deep lymphatic structures of the diseased limb. In fact, in order to obtain a good result after surgery, the superficial and deep lymphatic system must be adequately examined prior to surgery.
Proper surgical planning is completed by lymphoscintigraphic examination, thanks to which the surgeon can understand which lymphatic system to repair. In a study recently developed by our research group, analyzing the outcomes of approximately 250 lymphoscintigraphy exams, it was found that in less than 13% of cases only the superficial lymphatic system is pathological, meanwhile both the superficial and deep lymphatic system are altered in a percentage higher than 97% of cases, depending on the limb affected. It is possible to understand how we need to intervene with both the superficial and deep lymphatic systems in order to obtain the best results.
Techniques proposed by other groups have anatomical and pathophysiological limits. They are often experimental without being supported by statistically significant long-term results, unlike the Multiple Lymphatic-Venous Anastomoses (MLVA), used as part of our Genovese treatment protocol (Complete Lymphedema Functional Therapy – CLyFT).