Microsurgical treatment of lymphoedema

Chronic lymphoedema following treatment for breast cancer is a common complication that can be treated using conservative methods as well as surgical methods such as liposuction or microsurgical therapies. The following is an overview of microsurgical treatment options such as lymphovenous anastomoses (LVA) or vascularised lymph node transfers (VLNT).

Lymphoedema is a chronic, progressive and potentially disabling condition. It is an accumulation of protein-rich interstitial fluid in the tissue caused by an insufficiency of the lymphatic drainage system. There are various reasons for this lymphatic drainage disorder. It can either be primary, i.e. congenital, or secondary, for example following cancer treatment. As breast cancer is the most common cancer in women, breast cancer-associated lymphoedema is a common complication that can occur in particular after lymph node dissection of the axilla or radiotherapy. Breast cancer-associated lymphoedema occurs in one third of patients after surgical treatment of breast cancer within 2 years (1). This incidence can even increase to up to 50% of patients if a lymph node dissection of the axilla has been performed (2). Lymphoedema can lead to swelling, redness and a feeling of heaviness in the extremities, which is very distressing for patients. In addition, long-term lymphoedema can lead to irreversible fibrosis of the tissue, which can result in restricted mobility (3). It is therefore crucial to initiate treatment for lymphoedema at an early stage. In early or mild stages, conservative treatment with compression bandages and manual lymphatic drainage can be started initially. However, conservative therapy does not treat the causal causes of lymphoedema, so the idea of surgical therapy is to restore functional lymph drainage.

Lymphovenous anastomosis

Lymphovenous anastomosis (LVA)is a connection between compromised lymphatic channels and a vein, which improves lymph drainage. In order to identify the areas of restricted lymphatic drainage, the lymphatic channels are visualised preoperatively using indocyanine green (ICG). The areas of lymph congestion are marked and the skin incision for the corresponding LVA is made at the same location.

In LVA, several anastomoses of lymph vessels to veins are often performed directly. These can be anastomised end-to-end or end-to-side. Intraoperative monitoring of the improved lymphatic drainage is also carried out using ICG (see Fig. 1).

Fig. 1: Intraoperative photo of an LVA with end-to-end anastomosis and direct monitoring of lymphatic drainage using ICG.

Vascularised lymph node transfer

In advanced cases or in cases of long-standing lymphoedema where fibrosis of the tissue has already occurred, LVA alone is no longer sufficient. In this case, an additional transfer of tissue containing lymph nodes is required, which is connected vascularly by microsurgery. Various areas of the body such as axillary, inguinal, supraclavicular, submental or omental donor sites can be used for this vascularised lymph node transfer (VLNT) (4). In addition, LVA is usually performed to optimise lymphatic drainage.

Summary

Lymphoedema is a common complication in patients with status post breast cancer therapy, which can be treated causally exclusively by either an LVA or a VLNT, also in combination with an LVA. These microsurgical operations are very efficient and, compared to other lymphatic surgical procedures such as debulking operations, much less invasive. We therefore believe that LVA and VLNT play a crucial role in the treatment of lymphoedema and will be the gold standard as the only causal treatment options in the future.

Author:
Prof Dr med Mario F. Scaglioni
FMH Specialist in Plastic, Reconstructive and Aesthetic Surgery
Hand surgery and lymphatic surgery | Co-chief physician

In collaboration with:
Dr Caroline Sophie Fritz
FMH Specialist in Plastic, Reconstructive and Aesthetic Surgery

References:
1. Zou L et al: The incidence and risk factors of related lymphedema for breast cancer survivors post-operation: a 2-year follow-up prospective cohort study. Breast Cancer. 2018; 25(3): 309-314.
2 Rönkä R et al: Breast lymphedema after breast conserving treatment. Acta Oncol. 2004; 43(6): 551-557.
3 Warren AG et al: Lymphedema: a comprehensive review. Ann Plast Surg. 2007; 59(4): 464-472.
4 Garza R et al: A comprehensive overview on the surgical management of secondary lymphedema of the upper and lower extremities related to prior oncologic therapies. BMC Cancer. 2017; 17(1): 468.

All illustrations: ©Scaglioni