Emerging Strategies in the Surgical Treatment of Lymphedema

Lymphedema is a chronic and debilitating condition due to damage or obstruction of the lymphatic system that results in the build-up of protein-rich lymphatic fluid within the interstitium of affected tissues.  Most common in the upper or lower extremity, patients report discomfort, pain, and the sensation of limb heaviness.  Affected tissues swell due to a mismatch of fluid deposition in the setting of significantly reduced outflow, potentially leading to pathologic increases in limb volume, induration, fibrosis, cellulitis, and irreversible skin changes.  In the United States and other developed nations, the most common cause of lymphedema is malignancy and associated treatments such as surgical extirpation, lymph node dissection, and radiotherapy.  Alongside improved cancer screening and early detection methods – resulting in increased diagnosis before metastatic spread -  is improved efficacy of locoregional treatment options (i.e., surgery and radiotherapy).  As a result, the prevalence of lymphedema has also risen in recent years. In addition to significant morbidity and reduced quality of life scores associated with lymphedema, it is also associated with substantial healthcare spending and financial costs that must be borne by patients.

The mainstay of lymphedema treatment consists of non-operative approaches, including physical therapy, manual lymphatic drainage, compression, and lymphatic massage.  Given the relatively minimal benefit for many patients with conservative approaches, surgeons historically turned to excisional techniques such as debulking, direct tissue excision, and liposuction.  These methods, however, similarly had limited benefit or were prohibitively morbid. In light of inadequate or unacceptable treatment options for lymphedema, novel surgical approaches that rely on reconstructive microsurgical principles are under investigation. The two most effective methods include lymphovenous anastomosis (LVA) and vascularized lymph node transfer (VLNT). These extremely complex techniques require significant technical expertise, expensive surgical equipment (e.g., high-power microscopes), and a hospital infrastructure capable of appropriate post-operative management.  Nevertheless, early results have demonstrated that these surgeries are highly effective when used in appropriately selected patients.

LVA facilitates bypass of an obstructed lymphatic system via the anastomosis of functional superficial lymphatics to nearby venules in the extremity. In effect, lymphatics in the distal part of the extremity are connected to veins in order to reroute lymphatic fluid into the venous system prior to a proximal site of obstruction.  In contrast, VLNT involves the transfer of healthy lymph nodes and lymphatic tissue from one area of the body into the affected site.  Common donor sites include the omental, thoracic, groin, supraclavicular, and submental areas.  The donor tissue is microsurgically revascularized at the recipient site (i.e., the site of lymphatic obstruction) by anastomosing a recipient artery and vein to an artery and vein associated with the harvested donor tissue. This facilitates reperfusion of the transferred tissue, thereby enabling its survival.  VLNT likely improves lymphedema by promoting lymphangiogenesis, absorbing excess lymphatic fluid and transferring it into the venous system (similar to LVA), and reducing scar tissue formation.  Although further investigation is required of the outcomes, indications, and limitations associated with these physiologic techniques, initial data suggests that they are highly effective.

“In light of inadequate or unacceptable treatment options for lymphedema, novel surgical approaches that rely on reconstructive microsurgical principles are under investigation. The two most effective methods include lymphovenous anastomosis (LVA) and vascularized lymph node transfer (VLNT).”

An even more recent technique that few surgeons in the lymphedema community offer is immediate lymphatic reconstruction (ILR). While traditional treatment of lymphedema (i.e., LVA, VLNT) are employed only after a patient has developed lymphedema, ILR is offered as a strategy to prevent it.  During ILR, lymphatics that have been divided during the extirpative portion of surgery (e.g., during axillary or pelvic lymph node dissection) are identified and microsurgically repaired to a nearby vein in the surgical site. This allows lymphatic channels that would have otherwise become non-functional, thereby resulting in lymphatic obstruction, to remain patent and facilitate lymphatic drainage into the venous system.  Like LVA and VLNT, ILR requires significant expertise and resource investment.  Early outcomes of ILR have shown that it results in significantly reduced rates of lymphedema development as well as a notable reduction in patient expenses and healthcare expenditures associated with lymphedema.

At present, an ideal treatment or prevention strategy for lymphedema does not exist.  However, recent emerging physiologic surgical techniques have demonstrated significant improvement in our ability to improve lymphedema, and thus the lives of patients suffering from its effects.  Continued investigation into these and other techniques will lead to an improved understanding of the pathophysiologic processes that underlie lymphedemaas well as comprehensively characterize the advantages, disadvantages, and utility of their use. Notably, optimizing patient selection (i.e., which patients are likely to benefit from one or more of these techniques) will provide for a tailored and more individualized approach to patient care.  To that end, continued innovation will be paramount in surgical lymphedema treatment advances. For example, we recently employed the da Vinci Single-Port (SP) surgical robot system to facilitate donor site harvest during vascularized omental lymphatic transplant. This novel application of the robot platform led to reduced donor site morbidity relative to current methods, thereby further enhancing patient outcomes in lymphedema treatment.  This highlights the importance of continued innovation and investigation.

Indeed, compared to years prior, the landscape is bright for the lymphedema community.  In addition to an ongoing examination of potential treatment options, a critical factor in accelerating treatment for a greater number of patients afflicted with lymphedema will be increased surgeon awareness, training, and experience with emerging techniques.