Combined Surgical Treatment for Chronic Upper Extremity Lymphedema Patients

Abstract

Background Upper limb lymphedema is a common problem after axillary lymph node dissection. Lymphatic drainage can be improved by microvascular lymph node transfer, whereas liposuction can be used to reduce arm volume and excess of adipose tissue. We present the results of chronic lymphedema patients who have undergone lymph node transfer and liposuction simultaneously in 1 operation and compare the results with patients who have undergone lymph node transfer without liposuction. Methods During May 2007 to February 2015, 20 postmastectomy patients and 1 Hodgkin's lymphoma patient presenting with chronic nonpitting lymphedema (age between 37 and 74 years, average 56.7 years) were operated using the combined technique and 27 postmastectomy patients presenting with early-stage lymphedema (age between 31 and 68 years, average age 50.2 years) were operated using only the lymph node transfer. Compression therapy was started immediately after the operation and the patients used compression 24 h/d at least 6 months postoperatively. Changes in clinical parameters (number of erysipelas infections, pain), arm volume, transport indexes calculated form lymphoscintigraphy images, and daily usage of compression garments were compared preoperatively and postoperatively and between groups (combined technique vs lymph node transfer). The study was a retrospective observational study. Results In the combined technique group, the average arm volume excess decreased postoperatively 87.7%, and in 7 of 10 patients, the edema volume did not increase even without compression. Seventeen of 21 patients were able to reduce the use of compression garment. Lymphoscintigraphy results were improved in 12 of 15 patients and the improvement was significantly greater in the combined technique group than in the lymph node transfer group (P = 0.01). The number of erysipelas infections was decreased in 7 of 10 patients and the decrease was significantly greater in the combined technique group than in the lymph node transfer group (P = 0.02). In the lymph node transfer group, the average excess volume decreased postoperatively 27.5%. Fourteen of 27 patients were able to reduce the use of compression garments. Lymphoscintigraphy results were improved in 8 of 19 patients, and the number of erysipelas infections was decreased in 1 of 3 patients. Conclusions Liposuction can safely be performed with lymph node transfer in 1 operation to achieve optimal results in patients with chronic lymphedema. The combined technique provides immediate volume reduction and further regenerative effects on the lymphatic circulation. The significantly greater reduction in lymphoscintigraphy values and erysipelas infections suggests that the combined technique might be better for late-stage lymphedema patients than lymph node transfer alone.

Lipoaspiration and Lymph Node Transfer for Treatment of Breast Cancer-related Lymphedema: A Systematic Review

“…Most of the studies evaluating the use of both procedures were observational, without a control group. Leppapuska et al were the first to compare the outcomes of lymphedema patients treated with lymph node transfer and lipoaspiration with those of patients only receiving lymph node transfer [1]. They found a volume reduction of 87.7% in the group treated with both procedures, without any additional increase after a seven-day stop of use of compression garments in approximately 20 months of follow-up.…”

“…Lipoaspiration or lymph node transfer was offered after conservative treatment in all studies. Lymphedema developed after breast cancer in almost all patients, except one whose lymphedema was secondary to Hodgkin's lymphoma [1,[10][11][12][13]. Surgical procedures were applied in patients with stage II or III of lymphedema.…”

“…Surgical procedures were applied in patients with stage II or III of lymphedema. The sequence between procedures varied in all studies; two considered lipoaspiration as the first procedure followed by lymph node transfer, two described lymph node transfer as the first step followed by lipoaspiration, and one reported performing both procedures at the same surgery [1,[10][11][12][13]. The time between lipoaspiration and lymph node transfer when performed at different times ranged from 1 to 11 months.…”

“…Breast cancer-related lymphedema incidence varies from 9% to 41% in patients who undergo axillary lymph node dissection [1]. No cure for this condition exists; however, the current management of this disease is focused on decreasing symptoms and morbidity and improving the quality of life of these patients [2].…”

“…Although lipoaspiration and lymph node transfer are usually performed as a unique surgical treatment without any agreement regarding timing, the use of both combined procedures to treat chronic lymphedema has been suggested to improve outcomes between these patients [1].…”