Corradino Campisi

Surgical prevention of Lymphedema following lymph node dissection: LY.M.P.H.A. technique.

Background A side-effect of axillary lymph node excision and radiotherapy for breast cancer is arm lymphedema in about 25% patients (ranging from 13 to 52%). Sentinel lymph node (SLN) biopsy has reduced the severity of swelling to nearly 6% patients (from 2 to 7%) and, in case of positive SLN, complete axillary dissection (AD) is still required. That is why Axillary Reverse Mapping method (ARM) was developed aiming at identifying and preserve lymphatics draining the arm. Leaving in place lymph nodes related to arm lymphatic drainage would decrease the risk of arm lymphedema, but not retrieving all nodes, the main risk is to leave metastatic disease in the axilla. Based on long term experience in lymphatic-venous anastomoses (LVA) for lymphedema treatment, Authors conceived and carried out preventive LVA during nodal dissection (Lymphatic Microsurgical Preventing Healing Approach LY.M.P.H.A. technique). Methods 78 patients underwent axillary nodal dissection for breast cancer treatment and in 74 of them LY.M.P.H.A. procedure was performed. Indications to LY.M.P.H.A. technique were based on clinical and lymphoscintigraphic parameters. All blue nodes were resected and 2 to 4 main afferent lymphatics from the arm could be prepared and used for anastomoses. Lymphatics were introduced inside the vein cut-end by a U-shaped stitch. Volumetry was performed preoperatively in all patients and after 1, 6, 12 months and once a year. Lymphoscintigraphy was performed in 45 patients preoperatively and in 30 also postoperatively after at least over 1 year. Results Seventy-one patients had no sign of lymphedema. In 3 patients, lymphedema occurred after 8-12 months postoperatively. The incidence of secondary arm lymphedema after LY.M.P.H.A. technique was therefore 4.05%. Conclusion LVA proved not only to prevent lymphedema but also to reduce early lymphatic complications (i.e. lymphorrhea, lymphocele). LY.M.P.H.A. technique is also useful in patients with melanoma of the trunk and vulvar cancer, in whom it is possible to perform preventive LVA simultaneously with inguinal lymphadenectomy. Lymphedema is a consequence of cancer treatment. The use of the blue dye and of LVA helps to solve the problem of preventing secondary arm and leg lymphedema. LY.M.P.H.A. represents a rational approach to the prevention of lymphedema following axillary and groin surgery in the therapy of breast cancer, melanoma, vulvar cancer and other tumors.

Lymphatic Truncular Malformations of the Limbs: Surgical Treatment

The majority of the clinical conditions that are considered to be primary lymphedema are due to truncular lymphatic malformations that arise during the final stages of the lymphangiogenesis when there is the formation of the lymphatic trunks, vessels, and nodes. These malformations result in hypoplasia, hyperplasia, or aplasia of the lymphatic vessels and/or the lymph nodes and may clinically manifest as obstruction or dilatation. When the malformations result in the absence or defectiveness of the endoluminal valves, reflux of lymph is the main clinical manifestation; e.g. primary lymphedema. Lymphatic microsurgery represents a means to restore lymphatic drainage in lymphedema by bypassing the obstruction in the lymphatic pathway and directing the flow of lymph into the veins (MLVA) or, in the case of an associated venous pathology, by using an autologous vein graft to bridge the gap in the lymphatic collectors around the obstruction (MLVLA). Lymphatic microsurgery offers excellent outcomes when applied early in the disease process where a complete resumption of lymphatic flow in the long-term is possible.

Thoracic Duct Dysplasias and Chylous Reflux

Complex clinical pictures can develop in patients with thoracic duct and lymphatic dysplasias, due to duct anomalies and malformations of the lymphatic, cisterna chili, and chyliferous collectors, with parietal-valvular insufficiency and related chylous reflux syndromes. Adequate diagnosis of the nature and sites of the chylous obstruction and/or leakage is essential to a successful long-term outcome. Various surgical procedures, made after a proper metabolic control by TPN and MCT dietary regimen, may include: (1) identification of the sites of obstruction, leakage, and chylous reflux; (2) drainage of the chylothorax: the thoracic duct can be ligated, repaired, or diverted by means of appropriate microsurgical procedures, with possible additional pleurodesis, through a minimally invasive video-thoracoscopic approach; (3) removal of chylolymphocele, chylous cysts, and/or chylomas with, when possible, wide resection of chylolymphangiodysplasic, and chylolymphangiectasic tissues, if present, can be very effective, together with “spaced-out” anti-gravitational ligatures of dilated and incompetent chylolymphatic collectors; (4) the optional use of CO2 LASER; and (5) the microsurgical derivative multiple lymphatic-venous anastomoses (LVA) or reconstructive lymphatic-venous-lymphatic autologous interpositioned shunts offer a functional repair of the chylolymphatic pathways, if performable.

Management of Upper Extremity Lymphoedema with Microsurgical Lympho-Venous Anastomosis (LVA)

A 59 year old woman presented with an 8 year history of edema of the left arm. Initially, the edema appeared in the upper arm. The patient was treated with combined decongestive physiotherapy (manual and mechanical lymphatic drainage), bandaging and exercises three to four times over a 12 month period. Despite these measures, the edema later extended to the forearm and hand (Fig. 54.1). In the months preceding her admission she developed several episodes of erysipeloid lymphangitis and pain. There were no warts or wounds on the skin. Her past medical history included lumpectomy with axillary lymphadenectomy and radiotherapy for left breast cancer. There was no suggestion of local recurrence on routine follow-up.