Sara Dessalvi

Lymphatic microsurgery to treat lymphedema: techniques and indications for better results.

AbstractThis study aimed to report new clinical approaches to the treatment of lymphatic disorders by microsurgical techniques based on histological and immunohistochemical findings. The authors’ wide clinical experience in the treatment of patients with peripheral lymphedema by microsurgical techniques is reported. Microsurgical methods included derivative lymphatic-venous anastomoses and lymphatic reconstruction by interpositioned vein grafted shunts. In all patients, lymphatic and lymph nodal tissues were sent for histological assessment, together with specimen of the interstitial matrix. Diagnostic investigations consisted in venous duplex scan and lymphoscintigraphy. Results were assessed clinically by volumetry performed preoperatively and postoperatively at 3 to 6 months and at 1, 3, and 5 years. The outcome obtained in treating lymphedemas at different stages was analyzed for volume reduction, stability of results with time, reduction of dermatolymphangioadenitis attacks, necessity of wearing elastic supports, and use of conservative measures postoperatively. Microsurgical lymphatic derivative and reconstructive techniques allow bringing about positive results in the treatment of peripheral lymphedema, above all in early stages when tissular changes are slight and allow almost a complete restore of lymphatic drainage.

Lymphatic complications in surgery: Possibility of prevention and therapeutic options

The problem of prevention of lymphatic complications in surgery is extremely important if we think about the frequency of both early complications such as lymphorrhea, lymphocele, wound dehiscence and infections and late complications such as lymphangitis and lymphedema. Nowadays, it is possible to identify risk patients and prevent these lesions or treat them at an early stage. This report helps to demonstrate how it is important to integrate diagnostic and clinical findings to better understand how to properly identify risk patients for lymphatic injuries and, therefore, when it is useful and proper to do prevention. Authors report their experiences in the prevention and treatment of lymphatic injuries after surgical operations and trauma. After an accurate diagnostic approach, prevention is based on different technical procedures among which microsurgical procedures. It is very important to follow-up the patient not only clinically but also by lymphoscintigraphy. A protocol of prevention of secondary limb lymphedema was proposed and it includes, from the diagnostic point of view, lymphoscintigraphy and, as concerns therapy, it recognizes also a role to early microsurgery. It is necessary to accurately follow-up the patient who has undergone an operation at risk for the appearance of lymphatic complications and, even better, to assess clinically and by lymphoscintigraphy the patient before surgical operation.

LYMPHA Technique to Prevent Secondary Lower Limb Lymphedema

BackgroundInguinofemoral lymphadenectomy carries a high risk of lower limb lymphedema. This report describes the feasibility of performing multiple lymphatic-venous anastomoses (MLVA) after inguinofemoral lymph node completion (LYMPHA technique) and the possible benefit of LYMPHA for preventing lymphedema.MethodsBetween February, 2011 and October, 2014, 11 patients with vulvar cancer and 16 patients with melanoma of the trunk requiring inguinofemoral lymphadenectomy underwent lymph node dissection and the LYMPHA technique. Blue dye was injected into the thigh 10 min before surgery. Lymphatics afferent to the blue nodes were used to perform MLVA using a collateral branch of the great saphenous vein.ResultsThe mean age of patients in the vulvar cancer group was 52 years (range, 48–75 years). The melanoma group comprised seven men and nine women with a mean age of 41 years (range, 37–56 years). Of the 16 patients, 5 with vulvar cancer underwent bilateral inguinofemoral lymphadenectomy, whereas the remaining 6 patients with vulvar cancer and all 16 patients with melanoma of the trunk had unilateral node dissection. All the patients were treated by the LYMPHA technique. No lymphocele or infectious complications occurred. Transient lower-extremity edema occurred for one melanoma patient (6.25 %), which resolved after 2 months, and permanent lower-extremity edema occurred for one patient (9 %) with vulvar cancer.ConclusionsThe LYMPHA technique appears to be feasible, safe, and effective for the prevention of lower limb lymphedema, thereby improving the patient’s quality of life and decreasing health care costs.

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.