Outcomes of Lymphovenous Anastomosis for Lower Extremity Lymphedema: A Systematic Review

Enhancing outcomes in severe lymphedema through combined treatment strategies

Lymphedema, particularly in its advanced stages, presents significant challenges in treatment, often necessitating a combination of therapies to manage symptoms effectively and improve patient outcomes. This article reviews the findings of Wang et al, regarding the use of lymphovenous anastomosis and complex decongestive therapy in treating severe, deformed stage III lymphedema with recurrent infections. The case report details the promising results achieved through this combined therapy, highlighting substantial reductions in limb volume and the complete resolution of recurrent lymphangitis. The patient experienced notable improvements in weight loss, physical function, and quality of life. Despite its strengths, the study has several limitations. It lacks specific details on the types of lymphovenous anastomoses performed and complex decongestive therapy protocols, such as frequency and adherence, making reproducibility difficult. The short follow-up period of six months limits understanding of long-term efficacy, and more consistent reporting of key metrics such as weight loss and body mass index would enhance outcome assessments. This article emphasizes the importance of integrating minimally invasive surgical techniques with conservative therapies to address both the symptoms and underlying causes of lymphedema. Further research is essential to standardize protocols and refine combined treatment strategies.

A systematic review of indocyanine green lymphography imaging for the diagnosis of primary lymphoedema

OBJECTIVES

This systematic review aims to evaluate the use of indocyanine green lymphography (ICGL) for the investigation of the lymphatics in the lower limbs of primary lymphoedema patients.

METHODS

MEDLINE and EMBASE articles from January 1, 2000 to September 1, 2023 were searched for. A total of 11 studies were included in the review after a two-stage screening process.

RESULTS

Data on patient demographics, ICG contrast injection technique, imaging protocols, and imaging outcomes were summarized and reviewed in detail. The review highlights the lack of commonality in protocols used. Factors important for good imaging are highly variable, particularly the number of injections, their location, and whether they are delivered intradermally or subcutaneously.

CONCLUSIONS

ICGL has strong potential to become a diagnostic tool to diagnose lymphoedema due to its non-ionizing nature and cost-effectiveness. However, due to the lack of thorough phenotyping and genotyping of patients included in the studies, uncertainty still exists as to the value of the described imaging features such as splash, starburst, and diffuse dermal rerouting patterns. Future studies, therefore, should aim to explore the diagnostic utility of ICGL for lymphoedema further through the imaging of primary lymphoedema patients with a confirmed genetic diagnosis and using standardized imaging protocols.

ADVANCES IN KNOWLEDGE

ICGL is a strong candidate for advancing the diagnosis and understanding of primary lymphoedema, and monitoring response to treatment, but protocol heterogeneity and a lack of consistency in reporting imaging details and patient phenotyping currently hold it back.

Prevalence of lower extremity edema following inguinal lymphadenectomy: A systematic review and meta-analysis

Background

Lower extremity lymphedema (LEL) can develop because of inguinal lymph node dissection in the treatment of gynecologic, genitourinary, and dermatological malignancies. To optimize patient counseling and patient selection for microsurgical interventions aimed at preventing or treating LEL, its prevalence and associated patient characteristics must be accurately documented. This systematic review and meta-analysis provides a comprehensive overview of literature on the reported prevalence of LEL in patients undergoing inguinal lymphadenectomy.

Methods

From Embase, PubMed, and Web of Science databases, 23 studies were identified that met the inclusion criteria. This review was conducted in accordance with the preferred reporting items for systematic reviews and meta-analyses guidelines. Risk of bias was assessed using the Risk of Bias in Non-randomized Studies-of Exposure tool.

Results

Random-effects meta-analyses of proportions estimated a 24% (95% confidence interval [CI]: 17-31) pooled prevalence of LEL with a high degree of heterogeneity between the studies (I2 =96%, p < 0.01). Subgroup analysis revealed significant differences in LEL prevalence based on the indications for inguinal lymphadenectomy. The pooled LEL prevalence was 25.75% (95% CI: 0.00-96.16) for patients who underwent lymphadenectomy for melanoma, 12.22% (95% CI: 1.03-23.40) for penile cancer, 30.96% (95% CI: 21.08-40.84) for vulvar cancer, and 13.62% (95% CI: 0.00-51.02) for miscellaneous indications.

Conclusion

The findings from this study emphasize the importance of considering malignancy etiology when assessing the risk of LEL following inguinal lymphadenectomy. This knowledge could aid physicians in informing patients about the risk of LEL, while also facilitating proper patient selection for microsurgical interventions.

Advances in surgical management of chronic lymphedema: current strategies and future directions

Lymphedema is a chronic condition caused by the accumulation of protein-rich fluid in the interstitial tissue, resulting in edema and a diminished quality of life. When first-line treatments like complete decongestive therapy (CDT) fail, surgical options are considered. These include physiological procedures like lymphaticovenous anastomosis (LVA) and vascularized lymph node transfer (VLNT), which aim to restore lymphatic function, as well as reductive procedures such as liposuction and excisional techniques, which reduce limb volume. Previous studies have evaluated these surgeries, but the literature remains scattered. This rapid review consolidates current research on surgical treatments for lymphedema. We reviewed the PubMed database and included systematic reviews, meta-analyses, randomized clinical trials, and literature reviews published between 2014 and 2024. Studies were selected if they reported outcomes such as objective volume reduction, patient-reported quality of life (QOL), or infection rates. Nineteen publications were selected for review. The most common procedures represented were LVA (N = 12) and VLNT (N = 10), though reductive operations such as liposuction and radical excision were also represented. Both LVA and VLNT, either alone or combined, demonstrated positive outcomes in terms of volume reduction, QOL, and infection prevention. Reductive surgeries were effective in reducing long-term volume but had less favorable cosmetic outcomes and variable infection rates. Overall, while surgical approaches have proven beneficial, the variability in outcome measures and inconsistent follow-up periods limit comparability across studies. Further research is needed to better guide patients in selecting the most appropriate surgical option based on their lymphedema characteristics and personal goals.

Long-Term Follow-Up of Single-Step Free Vascularized Lymph Node Transfer for the Management of Combined Genital and Lower Extremity Lymphedema: A Case Report

The occurrence of genital lymphedema with lower extremity involvement is rare. There is no standard approach in the management of combined genital and lower extremity lymphedema (CGLL). The limited literature available on the management of CGLL reveals the use of multiple procedures, including vascularized lymph node transfer (VLNT), lymphovenous anastomosis (LVA), and debulking. These approaches individually target the lower extremity or genital region. There is no single-step procedure for managing the CGLL, which involves two different anatomical regions. In this case report, we describe a single-step surgical approach for managing CGLL using a single free VLNT. A fifty-four-year-old male presented with CGLL due to filariasis, affecting the quality of life (QOL) predominantly due to genital involvement. He underwent supraclavicular lymph node transfer with an elliptical skin flap of size 5 × 3 cm, placed onto the inguinal region to target the primary lymphatic drainage of both genital and lower extremities. Venous congestion during the initial postoperative period was managed by anastomosing additional veins. The patient developed donor-site lymphorrhea, which was managed conservatively. At 5 years follow-up, the patient showed clinical improvement of both genital and lower extremity lymphedema with enhanced QOL. The functional status of the VLNT was confirmed by lower extremity lymphoscintigraphy with single-photon emission computed tomography (SPECT) and scrotal lymphangiogram with indocyanine green (ICG). This case report shows the placement of a single VLNT in the inguinal region as a useful single-step approach to improve functional outcomes in the management of CGLL.

Staging Approaches to Lymphatic Surgery: Techniques and Considerations

Lymphatic surgery has demonstrated promising outcomes for the treatment of lymphedema alongside nonsurgical techniques. Physiologic lymphatic surgeries including lymphovenous bypass and vascularized lymph node transplants address the fluid burden in lymphedema whereas reductive surgeries including suction lipectomy and excisional techniques address the fibroadipose component of the disease. Lymphedema patients often present with both fluid and fat components that may require different procedures for optimal results. In addition, the chronic, progressive nature of lymphedema can warrant the need for multiple procedures to address different anatomic areas as well as further improve outcomes. This paper reviews the current literature on staging different or repeated lymphatic procedures and proposes an algorithm to navigate physiologic and reductive lymphatic surgery when multiple procedures are needed to optimize surgical outcomes.

[Cost comparison of conservative vs. surgical treatment of chronic lymphedema]

BACKGROUND

Lymphedema is primarily treated conservatively using complex physical decongestion treatment (CDT). Lymphovenous anastomosis (LVA), vascularized lymph node transplantation (VLNT) and liposuction are available as surgical treatment methods; however, reimbursement in the diagnosis-related groups (DRG) system is sometimes inadequate or only possible following an individual application. The costs of these relatively new surgical procedures have not yet been set in relation to those of CDT.

METHOD

The costs of conservative treatment were determined in accordance with the guidelines. The costs for LVA, VLNT and liposuction of the upper and lower extremities were estimated on the basis of the DRG reimbursement per case and the expected reduction in conservative measures according to current knowledge. The annual treatment costs were then compared.

RESULTS

The annual treatment costs of LVA and VLNT are already lower than conservative treatment alone in the second postoperative year. Liposuction reaches this point in the 6th (upper extremity) or 47th postoperative year (lower extremity).

CONCLUSION

The evidence for the positive effects of lymphatic surgery is still limited; however, it is recognizable that the curative surgical approach can significantly reduce the treatment costs and improve the quality of life of lymphedema patients; however, there is a lack of adequate reflection of the surgical effort in the reimbursement.

Lymphovenous Bypass as an Alternative Strategy for Managing Phleboedema and Venous Leg Ulcers: Preliminary Results

Background

Chronic venous leg ulcers (VLUs) are a common manifestation of chronic venous insufficiency, accounting for up to 70% of all chronic leg ulcers. Patients sustained refractory ulcers and persistent phleboedema even with a combination of different treatment methods. Lymphovenous bypass (LVB) has shown promising results in patients with lymphedema. We hypothesize that LVB could potentially alleviate VLUs and phleboedema, given their symptom similarities with lymphedema.

Methods

From May 2021 to June 2023, we prospectively deployed LVB in patients with nonhealing stasis ulcers after 4-week traditional care, or in those with persistent phleboedema despite prior surgery for vein etiologies. Demographics, healing course and recurrence, lymphoscintigraphy, and VLU quality of life (QoL) questionnaires were collected.

Results

Thirty-one patients were treated with LVB and additional skin grafting as necessary. Their mean age was 62.6 ± 14.7 years, with male predominance (20, 64.5%), and most patients sustained clinical, etiologic, anatomic, pathophysiologic classification C6 (25, 80.6%). Postoperatively, wound healing and phleboedema decongestion were observed mostly within 2 months. The VLU QoL questionnaire (39.3% response rate) showed improvement in QoL in activities, and psychological and symptom distress aspects.

Conclusions

Using LVB for chronic venous insufficiency showed an increase in the success rate of ulcer healing and decompression of the swollen limbs with durable results. Patient-reported outcome measures disclosed the potential benefits of LVB. Large-scale randomized controlled trials and pathophysiological studies are warranted to elucidate its efficacy.

Effects of Lymphaticovenous Anastomosis on Quality of Life, Body Image, and Spiritual Health in Lymphedema Patients: A Prospective Cohort Study

BACKGROUND

Lymphedema is a debilitating condition that significantly affects quality of life due to its chronic nature and visible symptoms. Lymphaticovenous anastomosis (LVA) has emerged as a promising surgical intervention, yet its effects on body image and spiritual health alongside physical symptoms have not been thoroughly examined. This study evaluates the efficacy of LVA in improving symptoms, quality of life (QOL), body image, and spiritual well-being in lymphedema patients.

METHODS

A prospective cohort study was conducted at Kaohsiung Chang Gung Memorial Hospital, Taiwan, involving 44 patients with lymphedema undergoing LVA surgery. Evaluations were made pre-surgery, one month post-surgery, and six months post-surgery using the 36-Item Short Form Health Survey (SF-36), Multidimensional Body-Self Relations Questionnaire-Appearance Scales (MBSRQ-AS), and a spiritual health scale. Statistical analysis was performed using one-way repeated measures ANOVA.

RESULTS

Significant improvements were observed in lymphedema symptoms and QOL measures at six months post-operation. SF-36 results showed enhanced scores in nearly all domains, particularly in physical functioning and role-physical. The appearance orientation scores from the MBSRQ-AS significantly increased, indicating improved perceptions in some dimensions of body image.

CONCLUSIONS

LVA surgery significantly enhances physical and psychological outcomes in patients with lymphedema, with marked improvements in symptoms, QOL, and body image perceptions. The findings suggest that while LVA is effective in addressing the physical and psychological aspects of lymphedema, it does not impact spiritual dimensions. This underscores the need for holistic approaches in the management of lymphedema to address all facets of patient well-being.

Supermicrosurgical lymphovenous anastomosis

Lymphedema impairs patients' function and quality of life. Currently, supermicrosurgical lymphovenous anastomosis (LVA) is regarded as a significant and effective treatment for lymphedema. This article aims to review recent literature on this procedure, serving as a reference for future research and surgical advancements. Evolving since the last century, LVA has emerged as a pivotal domain within modern microsurgery. It plays a crucial role in treating lymphatic disorders. Recent literature discusses clinical imaging, surgical techniques, postoperative care, and efficacy. Combining advanced tools, precise imaging, and surgical skills, LVA provides a safer and more effective treatment option for lymphedema patients, significantly enhancing their quality of life. This procedure also presents new challenges and opportunities in the realm of microsurgery.

The N-LVA Study: effectiveness and cost-effectiveness of lymphaticovenous anastomosis (LVA) for patients with cancer who suffer from chronic peripheral lymphoedema - study protocol of a multicentre, randomised sham-controlled trial

INTRODUCTION

Cancer-related lymphoedema is one of the most debilitating side-effects of cancer treatment with an overall incidence of 15.5%. Patients may suffer from a variety of symptoms, possibly resulting in a diminished health-related quality of life (HRQoL). A microsurgical technique known as lymphaticovenous anastomosis (LVA) might be a promising treatment option. The objective of this study is to evaluate whether LVA is effective and cost-effective compared with sham surgery in improving the HRQoL.

METHODS AND ANALYSIS

A multicentre, double-blind, randomised sham-controlled trial conducted in three university hospitals in the Netherlands. The study population comprises 110 patients over the age of 18 years with unilateral, peripheral cancer-related lymphoedema, including 70 patients with upper limb lymphoedema and 40 patients with lower limb lymphoedema. A total of 55 patients will undergo the LVA operation, while the remaining 55 will undergo sham surgery. The follow-up will be at least 24 months. Patients are encouraged to complete the follow-up by explaining the importance of the study. Furthermore, patients may benefit from regular monitoring moments for their lymphoedema. The primary outcome is the HRQoL. The secondary outcomes are the limb circumference, excess limb volume, changes in conservative therapy, postoperative complications, patency of the LVA and incremental cost-effectiveness.

ETHICS AND DISSEMINATION

The study was approved by the Medical Ethical Committee of Maastricht University Medical Center on 20 September 2023 (NL84169.068.23). The results will be presented at scientific conferences and published in peer-reviewed medical journals.

TRIAL REGISTRATION NUMBER

NCT06082349.

Risk of congestive heart failure and mortality following lymphovenous anastomosis: a nationwide population-based retrospective cohort study

BACKGROUND

Lymphovenous anastomosis (LVA) enables lymphatic fluid to drain into the venous system. However, no study has investigated the association between LVA and heart failure (HF) caused by fluid overload in the blood circulating system. The purpose of our study was to determine whether LVA increases the risk of HF and mortality.

MATERIAL AND METHODS

This nationwide retrospective study evaluated a total of 1400 lymphedema patients who underwent LVA and two control cohorts with 28 000 lymphedema who did not undergo LVA and 70 000 age-matched and sex-matched participants from the Korean National Health Insurance database were included. Blood pressure, body mass index (BMI), glucose and cholesterol levels, smoking history, and comorbidities were obtained during National Health Insurance Service - Health Screening (NHIS-HealS). The incidence, adjusted risk for HF, and mortality were evaluated.

RESULTS

Adjusted HRs for HF were 1.20 (confidence interval [CI], 1.03-1.40) and 1.30 (CI, 1.12-1.50), referenced by the general population control cohort and patients with lymphedema without LVA, respectively. In age, sex, BMI, and smoking status-stratified analyses, heightened risk of HF was evident across all sexes, spanning both young and old age groups, encompassing individuals with various smoking statuses, and those with a BMI of 18.5 or higher. Among these groups, the risk was notably greater in males compared to females, higher in younger individuals as opposed to older ones, and further elevated within the BMI range of 18.5-25.

CONCLUSIONS

LVA is associated with an increased HF risk, independent of cardiovascular risk factors and associated comorbidities. This association is prominent in participants aged <50 years, in males, and in the normal-to-obese (BMI ≥18.5 kg/m 2 ) group. Among patients with lymphedema, LVA did not significantly affect mortality.

Conservative treatment versus lymphaticovenular anastomosis for early-stage lower extremity lymphedema

OBJECTIVE

Several options for the treatment of lower extremity lymphedema (LEL) can be broadly classified into conservative treatment, such as compression garments and decongestive lymphatic therapy, and surgical treatment, such as lymphaticovenular anastomosis (LVA). The purpose of our study was to clarify the superiority of these treatments by comparing the outcomes of LVA with those of conservative treatment for early-stage LEL.

METHODS

We performed a single-center, retrospective cohort study. The patients with LEL who presented to our department between January 2015 and December 2022 were identified and classified into two groups: conservative treatment and surgical treatment. The LEL indexes, calculated from the four lower extremity circumferences and the body mass index, were compared at the 6-, 12-, and 24-month follow-up between the two groups.

RESULTS

Of the 101 patients with LEL, 53 with 72 affected limbs (conservative treatment, 39 patients and 53 affected limbs; surgical treatment, 15 patients and 19 affected limbs) were included in the present analysis. The therapeutic effect for reducing edema, as determined by comparing the corrected LEL index at 12 months (103.7 ± 12.7 vs 91.9 ± 10.7; P = .005) and 24 months (103.1 ± 12.9 vs 83.8 ± 7.2; P < .001), was significantly higher in the surgical treatment group than that in the conservative treatment group. The conservative treatment group showed little change in the corrected LEL index at ≤24 months of follow-up (+3.1%; P = .299). In contrast, the surgical treatment group showed a significant reduction in edema at 24 months according to the corrected LEL index (-16.2%; P = .019).

CONCLUSIONS

In early-stage LEL, conservative treatment centered on compression therapy alone only maintained edema (ie, edema did not worsen or improve). In contrast, LVA with compression therapy reduced edema.