The Combination of Lymph Node Transfer and Excisional Procedures in Bilateral Lower Extremity Lymphedema: Clinical Outcomes and Quality of Life Assessment with Long-Term Follow-Up

Abstract

Background: Bilateral lower extremity lymphedema is a rare and invalidating condition that poses a great challenge to the scientific community, and deeply affects the quality of life (QoL) of affected patients. A combined protocol consisting of lymph node transfer and a reductive method have never been reported for the treatment of this condition, except for small case series with brief follow-up periods. Methods: This retrospective study analyzed data of 29 patients, mean age 51 ± 17.1 years, who had been diagnosed with bilateral lower extremity lymphedema. Gastroepiploic vascularized lymph node transfer was performed in all the patients, and an excisional procedure was associated according to the clinical stage. Clinical history, circumferential limb measurements, complications, episodes of cellulitis, and responses to the Lymphedema Quality of Life Questionnaire were analyzed. Results: The mean follow-up was 38.4 ± 11.8 months. A significant reduction in the episodes of cellulitis per year was observed (p < 0.001). In our series, BMI and duration of symptoms were significantly related to the development of cellulitis during the postoperative period, p = 0.006 and p = 0.020, respectively. The LYMQoL questionnaire showed a significant quality of life improvement from 3.4 ± 0.9 to 6.2 ± 0.8 (p < 0.05). Conclusions: An integrated approach is essential for the treatment of bilateral lower extremity lymphedema: reductive and reconstructive methods are complementary to achieve a successful outcome. Timely treatment and BMI reduction are relevant in order to decrease the number of episodes of cellulitis. An attentive follow-up is necessary to identify recurrence and treat affected patients in time.

Treatment of Early-Stage Gynecological Cancer-Related Lower Limb Lymphedema by Lymphaticovenular Anastomosis—The Triple Incision Approach

“…Among the available surgical techniques, supermicrosurgical LVA has gained widespread consensus worldwide due to its safety and efficacy in improving lymphedema symptoms, reducing swelling, attenuating disease progression, and decreasing the frequency of infections [ 43 , 44 , 45 ]. The anastomosis between lymphatic vessels and adjacent superficial venules allows redirecting lymph outflow to the venous system bypassing the obstruction and draining the excess fluids of the lymphedematous limb.…”

Surgical Treatment and Rehabilitation Strategies for Upper and Lower Extremity Lymphedema: A Comprehensive Review

“…Dayan et al have published very promising preliminary results using this method [ 71 ]. However, to the best of our knowledge, gastroepiploic lymph node transfer has never been associated with iatrogenic lymphedema; its main downside is the need for an abdominal surgeon for harvesting [ 4 , 72 ].…”

“…To eliminate these complications, the excisional procedure was combined with lymph node flap transfer. In bilateral cases, a team approach or staged procedures are mandatory [ 4 , 78 ].…”

“…The basis of this combined approach is that VLNT restores lymphatic fluid transit and immunocompetence, while liposuction reduces the chronic adipose deposition. Liposuction is not the only excisional procedure that can be safely combined with VLNT; indeed, RRPP and the Charles procedure were safely combined with VLNT with promising results [ 4 , 72 , 78 , 81 ]. From another point of view, adding excisional procedures to a physiologic approach helps reduce the lymphatic load, the rate of infection, limb volume, and improves the quality of life.…”

“…Lymphedema is usually not life-threatening, but due to the swelling of the affected limb, distress, pain, loss of function, and frequent infections may occur. Moreover, it has a very deleterious effect on self-esteem and causes impairments in body perception [ 4 , 5 , 6 ]. Primary lymphedema is the consequence of a progressive swelling without connection to any medical condition; it is caused by unusual development of the lymphatic system, and the onset could range from childhood to adult age [ 7 ].…”