Staged surgical treatment of extremity lymphedema with dual gastroepiploic vascularized lymph node transfers followed by suction-assisted lipectomy—A prospective study
Mouchammed Agko, Pedro Ciudad, Hung-Chi Chen. J Surg Oncol. 2018;1–9
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Staged surgical treatment of extremity lymphedema with dual gastroepiploic vascularized lymph node transfers followed by suction-assisted lipectomy—A prospective study
Mouchammed Agko, Pedro Ciudad, Hung-Chi Chen. J Surg Oncol. 2018;1–9
Background: Both physiologic and excisional procedures have been described for the treatment of lymphedema. However, there exist few reports that combine these procedures.The objective of this study was to evaluate the effectiveness of combining vascularized lymph node transfer (VLNT) with suction-assisted lipectomy (SAL) in a staged manner for the treatment of extremity lymphedema.
Methods: Patients with unilateral late stage II lymphedema (International Society of Lymphology), who consented to staged surgical treatment, were evaluated prospectively. Between 2014 and 2015, 12 female patients with upper (n=6) or lower (n=6) extremity lymphedema completed the treatment protocol. Primary outcomes evaluated included limb size and number of infectious episodes. In addition, compression garment usage was analyzed.
Results: The overall circumference reduction rate was on average 37.9% after VLNT and increased to 96.4% after SAL. While all patients had experienced at least one infectious episode prior to surgical treatment, only one patient did so after VLNT and none after SAL. All patients were able to eventually discontinue compression therapy.
Conclusion: VLNT followed by SAL can allow patients with late Stage II lymphedema achieve near normal limb size and eradication of infectious episodes. At follow-up, these desirable outcomes were maintained well after discontinuation of compression therapy.
Main findings
- Small sample size of 12 upper limb and 12 lower limb.
- Stage 1 vascularized lymph node transfer (VLNT). At 1 month post op the patient was provided with instructions of usage of custom made compression garments until the liposuction. There were no details about the custom made garments.
- Stage 2 was the suction assisted liposuction (SAL) which occurred 6-8 months after the VLNT. Prior to discharge, the patient was provided with compression garments and instructed to use them continuously. The patient was further instructed to discontinue compression 2 days prior to the 3-month follow up. If there was significant oedema re-accumulation, continuous compression was continued for another 3 months. Otherwise, the patient was transitioned to daytime compression only for 3 more months. If limb size was maintained for 3 months with daytime compression only, the patient was allowed to discontinue compression therapy. Instructions were given for prompt resumption of therapy and return to the clinic, if oedema would recur.
- Both LVA and VLNT allow diversion of the lymphatic fluid into the venous system. A transplanted lymph node acts as a “lymph pump” by the virtue of natural lymphovenous drainage within the node itself.
- The optimum sequence and time interval between the two procedures are yet to be determined. Another controversy is whether a single level VLNT followed by SAL would provide similar results.
- In patients with late stage II lymphedema, staged surgical treatment with VLNT followed by SAL allowed reduction of limb size to near normal levels and elimination of infectious episodes. These beneficial outcomes were observed despite discontinuation of compressive therapy in the postoperative period. These findings have potentially important implications for the surgical treatment of extremity lymphedema.
