Lymphaticovenous Anastomosis for Lower Extremity Lymphedema: A Systematic Review.

Background Lymphedema is an accumulation of protein-rich fluid in the interstitial spaces resulting from impairment in the lymphatic circulation that can impair quality of life and cause considerable morbidity. Lower extremity lymphedema (LEL) has an overall incidence rate of 20%. Conservative therapies are the first step in treatment of LEL; however, they do not provide a cure because they fail to address the underlying physiologic dysfunction of the lymphatic system. Among several surgical alternatives, lymphaticovenous anastomosis (LVA) has gained popularity due to its improved outcomes and less invasive approach. This study aims to review the published literature on LVA for LEL treatment and to analyze the surgical outcomes. Methods PubMed database was used to perform a comprehensive literature review of all articles describing LVA for treatment of LEL from Novemeber 1985 to June 2019. Search terms included "lymphovenous" OR "lymphaticovenous" AND "bypass" OR "anastomosis" OR "shunt" AND "lower extremity lymphedema." Results A total of 95 articles were identified in the initial query, out of which 58 individual articles were deemed eligible. The studies included in this review describe notable variations in surgical techniques, number of anastomoses, and supplementary interventions. All, except one study, reported positive outcomes based on limb circumference and volume changes or subjective clinical improvement. The largest reduction rate in limb circumference and volume was 63.8%. Conclusion LVA demonstrated a considerable reduction in limb volume and improvement in subjective findings of lymphedema in the majority of patients. The maintained effectiveness of this treatment modality in long-term follow-up suggests great efficacy of LVA in LEL treatment.

Axillary reverse mapping and lymphaticovenous bypass: Lymphedema prevention through enhanced lymphatic visualization and restoration of flow.

BACKGROUND: A lymphedema (LE) prevention surgery (LPS) paradigm for patients undergoing axillary lymphadenectomy (ALND) was developed to protect against LE through enhanced lymphatic visualization during axillary reverse mapping (ARM) and refinement in decision making during lymphaticovenous bypass (LVB). METHODS: A retrospective analysis of a prospective database was performed evaluating patients with breast cancer who underwent ALND, ARM, and LVB from September 2016 to December 2018. Patient and tumor characteristics, oncologic and reconstructive operative details, complications and LE development were analyzed. RESULTS: LPS was completed in 58 patients with a mean age of 51.7 years. An average of 14 lymph nodes (LN) were removed during ALND. An average of 2.1 blue lymphatic channels were visualized with an average of 1.4 LVBs performed per patient. End to end anastomosis was performed in 37 patients and a multiple lymphatic intussusception technique in 21. Patency was confirmed 96.5% of patients. Adjuvant radiation was administered to 89% of patients. Two patients developed LE with a median follow-up of 11.8 months. CONCLUSION: We report on our experience using a unique LPS technique. Refinements in ARM and a systematic approach to LVB allows for maximal preservation of lymphatic continuity, identification of transected lymphatics, and reestablishment of upper extremity lymphatic drainage pathways.

Patient characteristics may affect the lymphatic staining ability of Indocyanine green and Patent blue during lymphaticovenous anastomosis.

BACKGROUND: The use of dyes like Indocyanine green (ICG) and Patent blue facilitates the identification of lymphatic vessels during lymphaticovenous anastomosis (LVA) surgery. However, some patients experience "staining failure". In these cases, no stained lymphatic vessels can be detected, making supermicrosurgical LVA even more complex. OBJECTIVE: This study aims to investigate patient-related factors that may interfere with lymphatic vessel staining during LVA. METHODS: A retrospective study was conducted on 30 patient charts, focusing on patient characteristics and the staining quality of ICG and Patent blue dye. Statistical analyses were performed to identify correlations between variables. RESULTS: Significant correlations were found between higher age and secondary lymphedema, longer duration of lymphedema in male patients until surgery and reoccurring cellulitis and Patent blue staining. Notably, recurrent infections to the lymphatic system resulted in inferior staining ability during LVA surgery. CONCLUSIONS: Due to staining failure the detection of functional lymphatic vessels remains challenging in LVA surgery. A more extensive preoperative workup is recommended for patients with recurrent cellulitis to optimize surgical feasibility and procedure quality in LVA treatment for lymphedema.

ICG lymphographic findings following immediate lymphatic reconstruction in breast cancer patients.

BACKGROUND: Immediate lymphatic reconstruction (ILR), performed at the time of axillary lymph node dissection (ALND), has demonstrated promising reductions in breast cancer-associated lymphedema. However, questions remain over the effects of adjuvant therapies on the continued patency of the lymphaticovenous anastomosis. Our study aimed to assess lymphographic outcomes, including ICG pattern and LVB patency, in patients at high risk for breast cancer-associated lymphedema following axillary ILR. METHODS: Baseline ICG lymphography studies performed during ILR of 15 patients were compared to repeat ICG studies obtained during second-stage breast reconstructive procedures to assess for changes in lymphatic flow patterns through the at-risk arm and transit into the axilla. RESULTS: All 15 patients in this study demonstrated linear lymphatic flow in baseline lymphography. Repeat lymphographic studies showed linear lymphatic transit in 12/15 patients. Of these 12 patients, 10 received chemotherapy, and all 12 received post-mastectomy radiation (PMRT). Dermal backflow patterns were recorded in 3/15 patients. All 3 patients received chemotherapy and 2/3 underwent PMRT. Additionally, repeat ICG studies of 7/12 lymphedema-free patients demonstrated clear visualization of linear ICG flow from the lymphatics of the arm into the axilla. CONCLUSION: We have demonstrated that ICG lymphography can be implemented as a postoperative tool to assess lymphatic function in patients who have undergone ILR in the axilla. Repeat ICG studies in the majority of patients demonstrated linear ICG flow similar to baseline studies. Additionally, ICG flow patterns through the axilla in repeat lymphography provided visual evidence supporting sustained LVB patency, despite axillary irradiation.

Lymphaticovenular Anastomosis for Advanced-Stage Peripheral Lymphedema: Expanding Indication and Introducing the Hand/Foot Sign.

BACKGROUND: Effective lymphaticovenular anastomosis (LVA) requires identification of functioning lymphatics, which are not always visible with contrast-based imaging in advanced-stage lymphedema patients. Ultrasound (US) allows to identify preoperatively functioning lymphatic vessels even in limbs severely affected by lymphedema. Moreover, in our experience, we observed an interesting clinical sentry in advanced-stage lymphedema patients, the hand/foot sign that is analyzed in this paper. PATIENTS AND METHODS: From January 2016 to January 2019, 76 consecutive advanced-stage secondary lymphedema patients underwent LVA. Preoperative planning included lymphoscintigraphy, indocyanine-green lymphography (ICG-L) and US. Patients' features, the hand/foot sign (preservation of more normal skin on the dorsum of the hand or foot), lymphatic degeneration, quantitative, qualitative, and composite outcomes at 1-year follow-up were evaluated. RESULTS: An average number of 3±0.1 LVA was performed in upper limb lymphedema (ULL) (range 2-5, 47 patients) and of 4±1.08 LVAs in lower limb lymphedema (LLL) cases (range 4-7, 29 patients). The composite outcome was positive in 45 cases (59.7%). The "negative" hand /foot sign was significantly associated with presence of functioning lymphatic channels. The incidence of adverse outcomes was significantly higher in patients with positive hand/foot sign. CONCLUSION: Patients with no functioning lymphatic vessels detectable by lymphoscintigraphy and ICG-L may still have functioning lymphatic channels that can be identified preoperatively by ultra-high-frequency ultrasound and salvaged by LVA. The "hand/foot sign" is a simple clinical sentry that appears to be correlated with higher probability of being able to localize functional lymphatics for potential lymphovenous bypass surgery.

Current Concepts in Surgical Management of Lymphedema.

The decision on whom to offer surgical interventions for lymphedema requires collaboration and input from all involved specialists and should address patients' expectations, invasiveness of procedures, and disease severity. There is no consensus on what constitutes success or failure of complex decongestive therapy and when to pursue surgical intervention. Surgery has the potential to fundamentally affect the pathophysiology of the disease state and can be a powerful tool when used correctly. The dogma of which surgery to offer for a given clinical situation has been undergoing revision and is an area of ongoing research.

Advances and current concepts in reconstructive surgery for breast cancer.

In this article, we report on recent advancements in reconstructive care of the breast cancer patient. New developments in sensate breast reconstruction to help address the problem of numbness after mastectomy have emerged and show promise. Methods to restore lymphatic physiologic flow after axillary lymphadenectomy using supermicrosurgical techniques have begun to show benefit by reducing the short-term incidence of breast cancer related lymphedema (BRCL). Breast implant safety has received significant recent attention and we explore the emergence of BIA-ALCL (Breast Implant Associated Anaplastic Large Cell Lymphoma) and its implications for the breast cancer patient and their multidisciplinary care team.

Effect of Lymphaticovenous Anastomosis in Breast Cancer-Related Lymphedema: A Review of the Literature.

BACKGROUND: Lymphedema affects ∼15% of all patients after breast cancer treatment. The aim of this review was to assess the clinical effects (improvement in arm circumference and quality of life) of lymphaticovenous anastomosis (LVA) in treating breast cancer-related lymphedema (BCRL). METHODS AND RESULTS: A systematic literature search was conducted in Medline, Embase and the Cochrane Library in July 2017, to identify all studies on LVA for the treatment of BCRL. The primary outcome was limb volume or circumference reduction and the secondary outcome was the improvement of quality of life. The search yielded 686 results, of which 15 articles were included in this review. All studies reported on BCRL in terms of volume or circumference reduction. Thirteen out of the included studies reported a positive surgical effect on reduction in volume or circumference. Twelve articles mentioned qualitative measures, being symptom improvement and improvement in quality of life. The number of patients who experienced symptoms relief ranged from 50% to 100% in the studies. CONCLUSIONS: The current review showed that the effects of LVA for the treatment of BCRL are variable among studies, although overall LVA seems effective in early stage BCRL. Higher quality studies are needed to confirm the effectiveness of LVA.