Post-operative care for patients following surgical treatment of lymphedema.

Surgical treatments are promising for the treatment of lymphedema. It is important for patients, healthcare providers, and lymphedema community to understand that surgical treatments currently are not a cure for lymphedema but have provided promising options for patients. Post-operative care for patients following surgical treatment of lymphedema is vital to optimize and sustain patient outcomes. This expert-consensus statement addresses current practice and research needs for standardized post-operative care, a core set of outcome measures, quality of care, and training of healthcare providers. Current research and clinical practice support non-surgical lymphedema therapy, also known as conservative therapy of lymphedema (e.g., compression therapy, or manual lymph drainage, or Complete Decongestive Therapy) as an essential part of post-operative care. Importantly, patient education should focus on patients' understanding that surgery is not a cure and the importance to adhere to post-operative care and life-long self-monitoring to sustain surgical results of limb volume reduction, relief of symptoms, and mitigate known or ongoing risk factors for recurrence of lymphedema. To optimize patient outcomes, it is crucial to have a multidisciplinary professional team consisting of well-qualified and credentialed healthcare providers participating in ongoing training and education. The essentials recommended by this expert-consensus are an initial and foundational step to build clinical standards for best practice and provide directions for future research.

Perforator-to-Perforator SCIP-Based Vascularized Lymphnode Transfer to Reduce Morbidity and Increase Efficacy in Lymphedema Surgery: Preliminary Results With 12 Cases.

BACKGROUND: Vascularized lymphnode transfer (VLNT) is one of the most common surgical treatments for moderate and severe lymphedema. Various techniques have been described for harvesting lymph nodes from different donor sites. However, a standardized harvest procedure is still lacking. The transplantation of inguinal lymph nodes using the perforator-to-perforator technique may represent a significant advancement in this context. This approach relies always on the same vascular pedicle, offers a lower morbidity, and allows for a more superficial inset at the recipient site. PATIENTS AND METHODS: Between 2019 and 2022, 12 patients received a perforator-to-perforator VLNT for the treatment of late stage (Late II) lymphedema, both primary and secondary. In all cases, the lymphnodes were harvested from the groin supplied by the superficial circumflex iliac artery perforator (SCIP) vessels. The average age was 62.2 years old (range 47-73 years old); nine patients were females and three were males. In 11 cases, the lower limb was affected, and in one case, the upper limb was affected. Eight patients received additional lymphovenous anastomosis. RESULTS: All the patients reported an improvement of the symptoms after surgery in terms of tissue quality (tenderness, lymphangiectasia, and pain), and no cases of recurrent cellulitis were reported. Postoperative lymphoscintigraphy was performed at 6 months, and in all cases, the function of transplanted lymphnodes was confirmed. No complications were encountered, neither at donor nor at recipient site. The follow-up was at least 12 months in all patients. CONCLUSIONS: Despite being more technically demanding, the systematic implementation of the perforator-to-perforator technique for the transfer of SCIP-based inguinal lymphnodes can be a valuable evolution of VLNT. The aim of this study is to present how this technical approach may become a standardized procedure for inguinal-based VLNT, offering a reduced donor and recipient site morbidity and potentially enhancing the lymph draining effects due to a more superficial inset.

Expert-consensus on lymphedema surgeries: candidacy, prehabilitation, and postoperative care.

For over 2 decades, the mainstay of lymphedema treatment has been complete decongestive therapy, however, surgical options are available when conservative treatment is not successful in reducing lymphedema. Standardized pre-surgical and post-surgical guidelines for candidates are not readily available. As part of the 2023 Lymphedema Summit that was sponsored by the American Cancer Society, and the Lymphology Association of North America, an expert consensus workgroup was formed and developed an expert consensus which affirms the importance of pre-surgical guidelines for candidates with lymphedema. The workgroup recommended that guidelines should be tailored to four major end-user groups: (1) patients, (2) referring physicians, (3) allied health professionals, and (4) surgeons.

The"Overlapping"Lymphaticovenous Anastomosis: an overlapped end-to-end anastomosis supermicrosurgical technique.

OBJECTIVE: Lymphaticovenular anastomosis (LVA) is increasingly utilized in the treatment of lymphedema. This study aims to assess the efficacy and safety of the "Overlapping" LVA technique, which addresses the size mismatch between lymphatic and venous vessels in lymphedema treatment. METHODS: Between August 2022 and April 2023, seventeen patients diagnosed with lymphedema were enrolled in this study. The severity of lymphedema in these patients was classified according to the International Society of Lymphology (ISL) staging system.All patient underwent LVA procedures, anastomosis techniques including the Overlapping, end-to-end and octopus anastomosis. The techniques of anastomosis, anastomosis time, patency rate, and volume of limb lymphedema were evaluated. RESULTS: Our study enrolled 17 lymphedema patients who underwent the LVA procedure. All patients showed significant postoperative improvement in limb edema. The mean drainage volume was 472.29 ml. The Overlapping technique demonstrated a 100% success rate as assessed by clinical observation and intraoperative Indocyanine Green (ICG) lymphography. The average anastomosis time was 5.3 min, reducing operative time compared to traditional methods. CONCLUSIONS: These findings suggest that the Overlapping technique could serve as a valuable addition to the current LVA technique. This Overlapping anastomosis technique provides a wide range of applications for lymphatic anastomosis treatment and prevention of lymphedema.

Donor-site safety in microvascular lymph node transfer for breast cancer-related lymphedema using reverse lymphatic mapping-A prospective study.

BACKGROUND: Vascularized lymph node transfer (VLNT) is one option among other surgical treatments in the management of breast cancer-related lymphedema (BCRL). The cause of concern regarding VLNT harvested from the groin has been the potential development of secondary lower-extremity lymphedema. This study explored the risks associated with donor-site morbidity following groin VLNT, with or without concomitant breast reconstruction. METHOD: The cohort comprised data from the Lymfactin® Phase I and II trials, conducted from 2016 to 2019, that used perioperative reverse lymphatic mapping. The volume of the lower extremities was measured preoperatively and at 3, 6, and 12 months postoperative, and the adverse events were documented during study visits. RESULTS: Altogether, 51 women with a mean age of 55.5 years were recruited. The mean duration of BCRL was 31.8 months. Among these, 25 (49%) underwent VLNT (VLNT-group) and 26 (51%) underwent VLNT in combination with breast reconstruction (VLNT-BR group). The groups were similar in terms of age, (p = 0.766), BMI (p = 0.316), and duration of BCRL (p = 0.994). Across a period of one year, the volume difference between the lower extremities changed by 22.6 ml (range: -813 to 860.2 ml) (p = 0.067). None of the patients had lower-extremity volume difference exceeding 10% at the 12-month follow-up visit. The most frequent adverse events were postoperative pain (17.7%), wound healing issues (11.8%), and seroma formation (11.8%). Most adverse events (64.6%) were classified as minor. CONCLUSIONS: This prospective study demonstrated that groin VLNT with reverse lymphatic mapping appears safe and does not increase the risk of secondary donor-site lymphedema within one year postoperatively.

Morel-Lavallee associated lymphedema treated with lymphovenous anastomosis: A case report.

Morel-Lavallee Lesions lead to disruption of lymphatic anatomy that require early identification and may necessitate lymphatic reconstruction. We present the case of a 59-year-old male with lower extremity lymphedema resulting after a severe Morel-Lavallee lesion and treated using lymphovenous anastomoses. He was initially managed with multiple aspirations followed by repeat incision and drainage. At 10 months following his injury, he continued to have swelling of his upper thigh and developed a large festoon medially, with lower leg pitting edema. He was diagnosed with lymphedema via lymphoscintigraphy. His superficial lymphatic anatomy was visualized using indocyanine green (ICG) lymphography and showed diffuse dermal backflow across his thigh, with signs of altered lymphatic anatomy distally. We preformed two lymphovenous anastomoses at the level of his mid-thigh to bypass the lymphatic disruption and restore drainage to his lower leg. After rerouting lymphatic flow from the lower extremity, the patient had overall improvement of his symptoms and reduced swelling with continued therapy. At 5 months postoperatively, his volumetric lower extremity measurements showed a decrease by 314 mL and he began walking again in 20-minute intervals. Lymphedema may be an important consideration following severe Morel-Lavallee lesions. Using modern diagnostic and supermicrosurgical techniques, plastic surgeons can help treat this long-term morbidity.

Resources on lymphedema surgery: How effective are they for patients?

Online patient education materials (PEMs) on lymphedema surgery were assessed for quality, readability, and content. A total of 37 PEMs were identified, primarily authored by academic/medical organizations. Readability scores indicated materials were difficult to read, with an average Flesch-Kincaid Grade Level of 10.4. PEM Assessment Tools showed acceptable understandability (72.3%) but poor actionability (28.5%). PEMs often lacked information on surgical risks, postoperative care, and long-term follow-up. Simplifying language and adding visual aids could improve PEM effectiveness.

Chronic Wound Caused by Lymphorrhea after Skin Abscess Drainage on Lower Extremity: A Case Report.

ABSTRACT: Surgical operations such as lymph node dissection may inadvertently damage the lymphatic system and lead to lymphorrhea. Excessive lymphatic exudation can cause a chronic wound. However, for surgery that does not involve the lymphatic system, lymphorrhea is a rare postoperative complication. This case report describes a 38-year-old patient who presented with lymphatic cutaneous leakage after incision and drainage of a skin abscess on the lower extremity. Persistent lymphorrhea increased the amount of wound exudation, which affected wound healing. After treatment of the lymphorrhea, the lower extremity wound healed completely within 4 weeks and did not result in lymphedema. Ligation of lymphatic vessels is a simple and easily performed treatment method for lymphatic leakage.

History of surgical treatment of lymphatic drainage at the Department of Plastic and Aesthetic Surgery, St. Anne's University Hospital in Brno.

The Department of Plastic and Aesthetic Surgery, St. Anne's University Hospital in Brno, and Faculty of Medicine of Masaryk University, Brno, has a long history of surgical treatment of lymphedema and elephantiasis, which started in 1970s. There were many types of surgeries described and performed at our department - starting with prof. Barinka's radical operation of elephantiasis, then lower limb end-to-side lymphovenous anastomosis pulled through the wall to the great saphenous vein, and genital lymphedema reduction. We call this era "the first period" of surgical lymphedema treatment. "The second period" started in 2016 by using free flaps with lymph nodes or vascularized lymph nodes and using microsurgical techniques of end-to-end, end-to-side and side-to-end lymphovenous anastomoses to the subcutaneous veins of a small calibre, which then drain the lymph into the blood stream. "The third period" started 2 years ago after the visit of prof. Yang from Taiwan - we started to use the method of single stitch end-to-side anastomosis to big subcutaneous veins like the great saphenous vein or the cephalic vein.

Tissue-engineered cellulose tubes for microvascular and lymphatic reconstruction: A translational and feasibility study.

BACKGROUND: Lymphedema microsurgery is an emerging treatment modality, with dissimilar long-term outcomes. One of the main technical challenges in lymphatic microsurgery is the identification and availability of suitable donor vessels for anastomosis. Tissue engineering using biomaterials has demonstrated promise in addressing vessel quality issues in other fields, but its application in microsurgery is still limited. METHODS: Decellularized cellulose tubes were developed and bioengineered by decellularizing stems of Taraxacum-Ruderalia. The microscopic structure, mechanical properties, and residual DNA content of the cellulose tubes were evaluated. Human and murine skin fibroblasts and dermal lymphatic endothelial cells were isolated and cultured for recellularization studies. Biocompatibility, proliferative capacity, and ex-vivo endothelialization of the cellulose tubes were assessed as potential interposition grafts. Finally, the engineered cellulose tubes were assessed as interposing xenografts for lymphovenous anastomoses (LVA) in an ex-vivo swine limb model. RESULTS: The decellularized cellulose tubes exhibited a suitable microscopic structure, mechanical properties, and low residual DNA content. The tubes showed adequate biocompatibility, supported cell proliferation, and facilitated spontaneous ex-vivo endothelialization of lymphatic endothelial cells. In the swine limb model, LVA using the engineered cellulose tubes was successfully performed. CONCLUSION: This translational study presents the use of decellularized cellulose tubes as an adjunct for micro and supermicrosurgical reconstruction. The developed tubes demonstrated favorable structural, mechanical, and biocompatible properties, making them a potential candidate for improving long-term outcomes in lymphedema surgical treatment. The next translational step would be trialing the obtained tubes in a microsurgical in-vivo model.

Current and Future Implications of Lymphedema Surgery in Head and Neck Reconstruction.

In this study, the authors shed light on the underappreciated realm of head and neck lymphedema (HNL) amid the backdrop of significant advancements in extremity lymphedema management. Despite its prevalence and impact, HNL has long been overlooked, attributed to its subtle symptom presentation and lack of awareness among primary care providers. The study delves into the unique challenges associated with diagnosing and treating HNL, emphasizing the predominance of internal swelling over external manifestations. The authors advocate for the refinement and standardization of outcome measures and the integration of innovative techniques such as indocyanine green lymphography and patient-reported outcomes.

Impact of sentinel node use in lymphedema formation among gynecologic cancer patients.

PURPOSE OF REVIEW: The most common surgical procedure associated with lymphedema formation is the regional lymphadenectomy. One of the advantages of sentinel node biopsy is the reduction of the risk of lymphedema formation. The purpose of this review is to collect and analyze the most relevant and recent evidence of the use of sentinel node biopsy and its implication on the development of postoperative lymphedema in gynecological cancer. RECENT FINDINGS: The current evidence of the use of sentinel node biopsy in cervical cancer to reduce lymphedema is heterogeneous and more data is needed to establish its role.Sentinel lymph node biopsy in endometrial cancer is a staging procedure with lower surgical complications, as well as lymphedema formation; while the results of prospective trials evaluating its impact on quality of life are still lacking.Sentinel lymph node biopsy in vulvar cancer minimizes the need for extensive dissection and reduces the incidence of complications associated with overharvesting of lymph nodes such as lymphedema without compromising oncological outcomes. SUMMARY: The prevalence of lymphedema in gynecological cancer varies based on the surgical treatment or additional therapies applied. Over the past years, one of the most important surgical modifications to decrease lymphedema formation has been implementation of sentinel lymph node technique mainly in vulvar cancer patients.

Analysis of different outcome parameters and quality of life after different techniques of free vascularized lymph node transfer.

OBJECTIVE: Vascularized lymph node transfer (VLNT) has become an important surgical technique in the treatment of lymphedema. Considering the different available regions available for flap harvest, we aimed to analyze different donor sites for VLNT with respect to donor site morbidity, impact on limb volume, and patient-reported outcome measurements (PROMs). METHODS: A single-center prospective study of all patients undergoing VLNT at the Department of Plastic Surgery and Hand Surgery of the University Hospital Zurich between September 2016 and 2023 was conducted. Lymph nodes were harvested either from the omentum (gastroepiploic [GE]-VLNT), the lateral thoracic wall (LTW), or the superficial inguinal region (SI-VLNT). Volume measurements and PROMs were assessed preoperatively and at different postoperative intervals. RESULTS: Overall, 70 patients with upper limb lymphedema (21%) or lower limb lymphedema (79%) with different lymphedema stages were included. There were 49 patients who underwent GE-VLNT, followed by LTW-VLNT (n = 16) and SI-VLNT (n = 5). Lymph node harvest from the SI was associated with a significantly higher frequency of seroma development. The average percentage volume loss related in comparison to the preoperative volume of the affected limb was 9% after GE-VLNT, 10% after LTW-VLNT, and 5% after SI-VLNT without a significant difference between the groups. PROMs revealed significant improvements for physical functioning, symptoms and psychological well-being, with no differences between the VLNT techniques. CONCLUSIONS: VLNT leads to a significant improvement of quality of life and can decrease limb volume effectively, regardless of the selection of donor site. GE-VLNT has become our flap of choice owing to its low donor site morbidity and its properties that allow a double transplantation while avoiding a second donor site.

Comparing Different Donor Sites After Vascularized Lymph Node Transfer to the Lymphedematous Upper Limb: A Systematic Review and Meta-analysis of Clinical Outcomes.

BACKGROUND: Vascularized lymph node transfer (VLNT) involves the microvascular transplantation of functional lymph nodes from a donor site into a limb affected by lymphedema to restore the normal flow of lymphatic fluid. Despite the increasing clinical experience with VLNT, there remains insufficient data to support its routine use in clinical practice. Here, we aim to evaluate the effectiveness and safety of VLNTs for upper limb lymphedema and compare clinical outcomes when using different donor sites. METHODS: We carried out a systematic search of the literature through PubMed and Scopus databases for studies on VLNT for upper limb lymphedema. Primary and secondary outcomes included circumference reduction rate (CRR) and infection reduction rate by postoperative cellulitis episodes for the efficacy and safety of VLNT. Pooled analysis was performed using the inverse variance weighting meta-analysis of single means using the meta package in R software. Subgroup analyses were performed for donor and recipient sites, age groups, follow-ups, and symptom durations. Quality assessment was performed using the Newcastle-Ottawa Scale for nonrandomized studies. RESULTS: A total of 1089 studies were retrieved from the literature, and 15 studies with 448 upper limb lymphedema patients who underwent VLNT were included after eligibility assessment. The mean CRR was 34.6 (18.8) and the mean postoperative cellulitis episodes per year was 0.71 (0.7). The pooled analysis of CRR was 28.4% (95% confidence interval, 19.7-41.1) and postoperative cellulitis episodes showed a mean of 0.59 (95% confidence interval, 0.36-0.95) using the random-effect model. Subgroup analyses showed significant group differences in recipient site for CRR and postoperative cellulitis episodes with the wrist comprising the highest weights, and patients younger than 50 years showing a lower postoperative infection. CONCLUSIONS: Vascularized lymph node transfer using gastroepiploic flaps at the wrists has shown a significant difference in reductions of limb circumference and cellulitis episodes in upper limb lymphedema patients when compared with other donor sites. However, further prospective studies are needed to consolidate this finding.

Lymphaticovenous anastomosis map established using lymphatic ultrasound and multi-lymphosome indocyanine green lymphography.

BACKGROUND: Although the usefulness of lymphaticovenous anasotmosis (LVA) for lymphedema has been reported, it is difficult to determine where the LVA is to be performed, especially for inexperienced surgeons. This study aimed to establish a map of the LVA site. METHOD: A total of 105 limbs from 64 patients who underwent lower limb LVA were retrospectively reviewed. Multi-lymphosome indocyanine green (ICG) lymphography (in 35 patients) and lymphatic ultrasound (in all patients) were performed preoperatively and the incision site was determined where dilated lymph vessels and appropriate veins were located in close proximity. The LVA location was identified using a post-operative photograph. Additionally, the degree of lymphatic degeneration at the LVA site was recorded based on the normal, ectasis, contraction, and sclerosis type (NECST) classification. RESULT: A total of 206 skin incisions were analyzed. Among them, 161 (75.9%) were medial and 45 (21.2%) were lateral. Among the 85 sites on the calf, 52 (61.2%) were medial and 33 (38.8%) were lateral. Among the 117 sites on the thigh, 106 (90.6%) were medial and 11 (9.4%) were lateral. As the severity of lymphedema progressed, the probability of performing LVA on the lateral calf increased. Among the 202 locations where LVA was performed on the thigh and lower leg, ectasis type was found in 164 sites (81.2%). CONCLUSION: We established an LVA map of the legs based on multi-lymphosome ICG lymphography and lymphatic ultrasound data. Using this LVA map, surgeons can easily predict the location of lymph vessels, thereby improving the success rate of LVA.

The Impact of Obesity on Success of Immediate Lymphatic Reconstruction for Prevention of Breast Cancer-Related Lymphedema.

BACKGROUND: Breast cancer-related lymphedema (BRCL) is a potential sequela of high-risk breast cancer treatment. Preventive treatment with immediate lymphatic reconstruction (ILR) at the time of axillary lymph node dissection (ALND) has emerged as the standard of care; however, there is relatively little known about factors that may contribute to procedural failure. METHODS: A retrospectively maintained, institutional review board-approved study followed patients who underwent ILR at the time of ALND at our tertiary care center between May 2018 and May 2023. Patients who presented for at least one follow-up visit in our multidisciplinary lymphedema clinic met the criteria for inclusion. Patients who developed lymphedema despite ILR and potential contributing factors were further explored. RESULTS: 349 patients underwent ILR at our institution between May 2018 and May 2023. 341 of these patients have presented for follow-up in our multidisciplinary lymphedema clinic. 32 (9.4%) patients developed lymphedema despite ILR. This cohort was significantly more likely to be obese (56% vs 35%, P = 0.04). Multivariate logistic regression demonstrates increased odds of procedural failure in patients with a body mass index (BMI) ≥30 kg/m2 (odds ratio 2.6 [1.2-5.5], P = 0.01). CONCLUSION: These data comment upon our institutions outcomes following ILR. Patients who develop lymphedema despite ILR tend to have a higher BMI, with a significantly increased risk in patients with a BMI of 30 or greater. Consideration of these data is critical for preprocedural counseling and may support a BMI cutoff when considering candidacy for ILR going forward, as well as when optimizing failures for secondary lymphedema procedures.

[Research progress of breast reconstruction in the prevention and treatment of breast cancer-related lymphedema].

Advances in the diagnosis and treatment of breast cancer have significantly improved survival rates. Breast cancer-related lymphedema is the most common mid-and long-term complication after breast cancer surgery, which seriously affects the quality of life. Breast reconstruction can not only restore the shape of the breasts after mastectomy, but also reduce the occurrence of lymphedema to some extent. Immediate autologous breast reconstruction combined with lymphatic venous anastomosis (LVA) or vascularized lymph node transfer (VLNT) can effectively prevent lymphedema. Delayed breast reconstruction combined with LVA or VLNT can achieve the dual benefits of restoring the appearance and treating lymphedema at the same time. The autologous tissue flap can function as a bridge to promote lymphatic drainage, thus enhancing the treatment of lymphedema. The advances mentioned above in surgical techniques have provided a basis for decision making in breast reconstruction and the prevention and treatment of breast cancer-related lymphedema, and have also brought hope for improving the quality of life of patients.

Primary Lymphovenous Anastomosis After Extended Soft Tissue Resection in the Medial Thigh for Reduction of Lymphocele and Lymphedema.

INTRODUCTION: Postoperative chronic lymphocele and lymphedema represent severe burdens for soft tissue sarcoma patients who are already physically handicapped after an extensive surgery and a long recovery time. Incidences are high in the upper medial thigh. We have shifted our focus to lymphedema and lymphocele risk reduction with immediate lymphovenous anastomosis (LVA) after sarcoma resection. METHODS: We performed immediate lymphatic reconstruction in 11 patients after soft tissue sarcoma resection in the upper medial thigh. The postoperative course was followed up closely, and postoperative occurrence of lymphocele and lymphedema was clinically assessed. A literature search outlining the latest clinical data, current treatment strategy landscape, and their application into clinical practice was added to the investigation. RESULTS: A total of 19 LVA and 2 lympho-lymphatic anastomoses were performed in 11 patients immediately after tumor resection in an end-to-end manner. We found a postoperative lymphedema rate of 36% and a postoperative lymphocele rate of 27%. Mean follow-up time was 17 months. Average tumor volume was 749 cc. Our literature search yielded 27 articles reporting on immediate LVA in cancer patients. Incidences of secondary lymphedema after LVA for lymphedema prevention vary between 0% and 31.1%. Lymphocele prevention with LVA is poorly studied in sarcoma patients. CONCLUSION: Immediate lymphatic reconstruction improved the overall postoperative course of our patients. The current literature does not serve with high-quality studies about primary LVA preventing lymphedema and lymphocele formation. We conclude that this technique should be seen as an additional concept to achieve overall better postoperative outcomes in these challenging surgical settings. We strongly recommend to either anastomose or ligate severed lymphatics under the microscope primarily after sarcoma resection in the upper medial thigh area.