Lymphedema is often diagnosed by its characteristic clinical presentation. In some cases, however, instrumental investigations are necessary to establish the diagnosis, particularly in early stages of the disease. One of the primary problems for microsurgery in treating lymphedema consists of the discrepancy between the excellent technical possibilities and the insufficient results in reduction of lymphedematous tissue fibrosis and sclerosis. Long-term results indicate that microsurgical operations have a valuable place in the treatment of obstructive lymphedema (primary or secondary) and should be the treatment of choice in these patients. Improved results can be expected with earlier microsurgical operations because patients referred earlier usually have less lymphatic disruption and fibrotic tissue. Advanced diagnostic methods and improvements in operation techniques have modified indications for surgical therapy of lymphedema. This article systematically reviews the published literature on the microsurgical treatment of lymphedema to the present.
Our clinical observations in 64 patients affected by chronic obstructive lymphedema (either arm or leg) undergoing interposition autologous lymphatic-venous-lymphatic (LVL) anastomoses are reported. This microsurgical technique is an alternative to other lymphatic shunting methods, especially when venous dysfunction coexists in the same limb and, therefore, when direct lymphatic-venous anastomosis is accordingly inadequate. Preoperative diagnostic evaluation (including lymphatic and venous isotopic scintigraphy, Doppler venous flowmetrics, and pressure manometry) plays an essential role in assessing the conditions of both the lymphatic and venous systems and in establishing which microsurgical procedure, if any, is indicated. Our microsurgical technique consists of inserting suitably large and lengthy autologous venous grafts between lymphatic collectors above and below the site of obstruction to lymph flow. The data show that, using this technique, both limb function and edema improved, and in all patients followed up for over 5 years edema regression was permanent.
The secondary lymphedema of the upper limb (post-mastectomy lymphedema) has an incidence, in patients who underwent axillary lymphadenectomy for breast cancer, between 5 to 25%, up to 40% after radiotherapic treatment. We studied 50 patients treated for breast cancer. The patients were divided in two groups of 25 each, comparable for age, sex, pathology and treatment and followed up to 5 years after operation for breast. One group of 25 patients was controlled only clinically (physical examination, water volumetry) at 1-3-6 months and 1-3-5 years from breast cancer treatment. The other group of 25 patients was followed also by lymphatic scintigraphy performed pre-operatively and after 1-3-6 months and 1-3-5 years from operation. In the first group, followed only clinically, lymphedema appeared in 9 patients after a period variable from 1 week to 2 years, with highest incidence between 3 and 6 months. In the second group of 25 patients, the preventive therapeutic protocol allowed to have a clinically evident arm lymphedema only in 2 patients. The comparison of the two groups of 25 patients proved a statistically significant difference in the appearance of arm secondary lymphedema (p = 0.01, using Fisher's exact test). The diagnostic and therapeutic preventive procedures allow to reduce the incidence rate of lymphedema significantly, in comparison with patients who did not undergo this protocol of prevention.
Lymphovenous anastomosis (LVA) has been described as an effective treatment for early stages of lymphedema (LE). The aim of this study was to deepen the evaluation of the effectiveness of LVA by performing a meta-analysis to provide information about its utility in specific anatomical sites, clinical stages, duration of lymphedema, and surgical technique. A systematic literature search using PubMed/Medline, Google Scholar, and Cochrane Database was performed in November 2019. Only original studies in which exclusively LVA was performed for primary and/or secondary lymphedema in humans were eligible for data extraction. A meta-analysis was performed on articles with a well-defined endpoint and a subgroup analysis was conducted in relation to surgical technique, duration of lymphedema, stage of pathology. Forty-eight studies, including 6 clinical trials and 42 low-risk bias observational studies were included in our meta-analysis. 1,281 subjects were included and the majority of articles reported a pre-post analysis. Lymphaticovenular anastomosis appears to result effectively in treatment of lymphedema with an odds ratio of 0.07 (CI: 0.04, 0.13, p<0.001). All subgroup meta-analyses were statistically significant for LVAs specifically with regard to anatomical site, clinical stage, duration of LE, or type of microsurgical procedure (p<0.05). Our meta-analysis confirmed the efficacy of LVAs for the treatment of lymphedema, even when subgroup analysis was performed for clinical stage, duration of pathology, anatomical site of lymphedema, or type of microsurgical procedure. Further prospective trials with a common clearly defined outcome measure are warranted for an unbiased evaluation.
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