Surgical Options for Treatment of Lymphoedema
Surgical options for treatment of lymphoedema including Lymphaticovenular Anastomosis, Lymph Node Transfer and Liposuction: The modern approach
By Mr. Sinclair Gore, Consultant Plastic Surgeon, Oxford Lymphoedema Practice
This article is taken from the Winter 2017 issue of LymphLine, the LSN’s quarterly newsletter available to all LSN members. For details of how to become a member, click here.
The history of surgery as applied to the treatment of lymphoedema is long-standing. For many years operations that removed the bulk of affected soft tissue were the only options available and these were radical in their approach. These operations were only suitable for advanced cases and included approaches such as the Charles procedure, where all the affected skin and subcutaneous fat affected by lymphoedema was removed and the limb was resurfaced with skin grafts. Whilst powerful from a volume reduction point of view, these were mutilating and destructive operations. The modern era of reconstructive lymphatic microsurgery was born in the 1970s in Australia and revived and popularised for the modern era in a small number of global centres including in Japan and Italy.
Lymphaticovenular anastomosis (LVA) surgery is an example of such a reconstructive approach. The principle underlying this surgery is to enable lymphatic fluid to flow from working lymphatic channels directly to the vascular system without having to pass through the usual lymph nodes in the axilla (armpit) or the groin. Such surgery is therefore most relevant in a secondary lymphoedema situation where lymph node (lymphadenectomy) surgery has been necessary for cancer treatment. The most common tumours requiring such lymph node removal include breast cancer, gynaecological malignancy (cervix, uterus, ovary), prostate cancer and malignant melanoma (skin cancer). In such cases it can be reasonably assumed that the lymphatic system was working well prior to oncological lymph node surgery taking place, and typically this can be shown in an unaffected opposite limb. Most cases of primary lymphoedema are caused by an intrinsic deterioration or progressive failure in the capacity of the lymphatic system to drain lymphatic fluid. This failure can be present from birth but more commonly appears in late childhood or in adulthood. The problematic drainage may occur at numerous levels within the lymphatic drainage system. It is uncommon for established cases of primary lymphoedema to have normally working deep lymphatic channels and as such it is a condition that is only uncommonly suitable for LVA surgery.
Normal lymphatic vessels act to pump fluid from our tissues back into our vascular system. In comparison to our veins, lymphatic vessels are smaller, have muscles within their walls to pump the fluid along and have valves within them. As a result they act as an effective one-way conduit for lymphatic fluid to return to the bloodstream. In secondary lymphoedema where the lymphatic outflow of the limb is blocked, there is a progressive pathological change of these lymphatic vessels from normally functioning lymphatics through to the vessels being dilated under pressure, then to sclerosis (progressive scarring) of lymphatic channels, and eventually to complete scarring and obliteration. Generally it is not understood why some patients’ intrinsic lymphatic function deteriorates more rapidly than others. This translates into patients developing the swelling of lymphoedema after a variable time from their lymph node surgery, in some cases progressing rapidly and in other cases following a more indolent course. It is thought that this may have a relation to underlying lymphatic drainage capacity and that there is a range of lymphatic capacity in any population. A lower lymphatic drainage capacity may predispose a patient to lymphoedema after any lymph node insult, whilst a high capacity means a patient may tolerate surgery, radiotherapy and other problems (such as post-operative infections) without going on to develop swelling at all. Screening for lymphoedema using ICG lymphography (see later) prior to swelling appearing may be of use for those who are anxious about its development.
Reconstructive surgery in the form of LVA surgery aims to improve the intrinsic lymphatic drainage that is possible within a limb. It is not typically suitable for lymphoedema affecting the trunk or breasts. Only rarely has it been used for lymphoedema of the head and neck following head and neck cancer treatment and there is little evidence of great success in this area. LVA surgery relies on a degree of intrinsic functioning lymphatic flow. This cannot be assessed by clinical examination alone although a significant degree of pitting oedema and response to massage and compression therapies suggests a persistent fluid element to the swelling rather than the more chronic deposition of fibrofatty tissue. The best way to assess the intrinsic functioning of the lymphatic system is using Indocyanine Green (ICG) lymphography. ICG is a dark green dye that is injected under the skin, is selectively taken up by lymphatic channels and can be visualised using a near-infra-red scanning camera. The specific patterns of lymphoedema include ‘dermal backflow’ and ‘dermal rerouting’. These patterns, combined with the speed with which dye travels up the limb (the Lymphatic Index), all combine to predict the degree of intrinsic remaining lymphatic function. This, in turn, classifies patients into those who would be very suitable, moderately suitable and not suitable for this type of surgery.
Normal lymphatic channels seen in ICG lymphography. At the bottom of the image a small dressing plaster is seen overlying the site of ICG dye injection. Lymph fluid is highlighted by ICG dye and looks white on this scan. Numerous lymphatic channels coalesce as they pass up a limb. When viewed in real time, spontaneous pumping of lymph can be seen, massage of the lymphatic channels away from the hand or foot moves fluid along, whilst massage towards the hand or foot fails to move dye retrogradely (because of intact valves preventing backwards flow).
A Starburst pattern of lymphoedema is shown in this case of lymphoedema of the leg. Multiple areas of lymphatic fluid pooling in the subcutaneous space results in high signal intensity where there should be darkness. Starburst pattern reflects a more advanced stage of lymphoedema and is correlated with greater limb swelling and less effective lymphatic transport.
Like many operations, the outcomes of surgery cannot be absolutely guaranteed but for those who are deemed to be suitable, a benefit can be expected in over 85% of patients. Results data at the Oxford Lymphoedema Practice is grouped by the starting volume discrepancy (as measured by digital perometry) into low, medium and high volume groups. Low volume groups will have a lesser benefit in terms of absolute volume reduction (because their volume discrepancy is low to start with) but surgery may bring benefits with reduction in garment requirement and in reduction of lymphoedema deterioration in the longer term. Medium and larger volume discrepancy patients typically benefit from a reduction in limb volume discrepancy and in how tense or tight the limb feels. Reduction of limb volume discrepancy by 50% would be not uncommon and depending on the approach of the patient, a reduction in requirement to wear compressive garments may result from this. There is good scientific data demonstrating a reduction in incidence of post-operative cellulitis after LVA surgery. Whilst strong evidence exists for this surgery in general, for any given individual it is impossible to predict their degree of response as this will rely largely on the actual nature of their lymphatic channels at the time of surgery. (For this reason it is important to counsel patients carefully about their potential chance of benefitting from undergoing surgery. Expectation management by the treating surgeon(s) is an important part of assessment and it is important that such discussion is undertaken in detail.)
Lymphatic channels of this sort are located very superficially and the surgery is very suitable for this approach. LVA surgery is technically very demanding, requiring high-powered microscopes and a finely-tuned microsurgical skill set. However, unusually for microsurgery of this sort, this surgery can typically be carried out on a day case basis. In addition, such surgery can be typically carried out under local anaesthetic. The risks of this surgery are low. A small number of scars (typically 4-6cm long) may be made within a limb and may extend as high as the axilla or groin. The chances of making lymphoedema worse are low. Post-operative infection and leakage of lymph fluid from the wounds (lymphorrhoea) is a risk but is uncommonly a problem. Given the higher risk of infection in a lymphoedematous limb, prophylactic peri-operative oral antibiotics are given as a routine.
In LVA surgery deep lymphatic channels are found and connected to small veins. The stitches used are a fifth of the diameter of human hair. When a join (an anastomosis) is complete, lymphatic fluid can be seen passing from the lymphatic system directly to the bloodstream. In this case the lymphatic fluid appears light blue due to the use of blue.
After the anastomosis is complete seamless passage of lymphatic fluid may be seen to the bloodstream. In a typical LVA procedure the number of anastomoses undertaken can range from 6 to 16, depending on the quality and make-up of lymphatics and veins available to anastomose.
This surgery is not currently available on the NHS in England or Scotland. A trial is currently underway in Wales for patients with certain ranges of limb volume discrepancy, a defined frequency of cellulitis skin infections and, of course, exists principally for Welsh patients. Efforts to have this surgery funded by the NHS in England have so far been unsuccessful despite numerous efforts to address this by surgeons and patients alike. It is my impression that the NHS is already struggling with its finances to such a great degree that funding new services requiring costly equipment and significant time and staff resource is not a priority for most local funding groups. Many conditions are in this category currently and it is unfortunate that lymphoedema does not attract the degree of NHS surgical support that it could.
Other reconstructive surgical approaches include lymph-node transfer (LNT). This also aims to maximise the degree of intrinsic lymphatic drainage from within a limb, but the procedure involved is quite different. In this operation, a section of lymph node-containing tissue is taken from a remote part of the body and transferred as a microvascular free flap (with arterial blood supply and venous blood drainage) to the affected limb. Typically tissue is taken from under the armpit to treat a lymphoedematous leg, whilst a lymphoedematous arm may be treated by transfer of tissue from the groin. Great effort must be taken to minimise the risk of inducing lymphoedema at the site where lymphatic tissue is harvested. Lymphatic mapping techniques may be helpful in this regard. Numerous technical variations of this procedure exist. The physiology by which the procedure works is unclear but many hypotheses exist. Interestingly a randomised controlled trial published in 2016 demonstrated some benefit from this surgery when combined with standard compression compared to standard compression alone. This represents how many approaches to enhance lymphatic drainage can have benefit and how not only one approach should be considered.
The differing profiles of LVA and LNT surgery are based on the adequacy of residual lymphatic function and side-effect profile of the operation. For that reason, in the hands of those who are technically capable, treatment typically includes LVA surgery initially, as the risk of downsides from the surgery are low. Should it prove unsuccessful LNT may be offered as an alternative approach. This sequence of procedures would be considered relatively standard in Japan, one of the world leaders in this type of surgery.
Departing from reconstructive surgery, the modern era of tissue removal surgery rests with liposuction. This is a significantly greater degree of surgical insult to a patient than LVA surgery and requires general anaesthesia and a short period of inpatient stay with intensive bandaging. For limbs that have poor intrinsic lymphatic function and significant volume discrepancy this is a very powerful technique but one that must be considered carefully because it typically comes with a likelihood of increased garment dependency in the long-term. It is reasonable to assume that the act of intensive liposuction could damage any residual lymphatic drainage capacity. For that reason it is important to stress that whilst liposuction can powerfully reduce limb volume excess it may require wearing of compression garments night and day long-term.
In summary, reconstructive lymphatic surgery for lymphoedema is an important part of the modern treatment of this chronic condition. Different patients respond differently to different non-surgical approaches, and similarly a surgical approach must be tailored to a patient’s desires, lifestyle and current lymphatic status. There is no doubt that surgery has a role to play in the management of lymphoedema but this must be combined with good-quality non-surgical management with compression-based therapies. As surgical techniques evolve there may be a greater hope in the future of yet better treatment outcomes and a scientific approach to data collection and surgical management is a vital part of this.