Management of Upper Extremity |
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Lymphoedema with Microsurgical |
Lympho-Venous Anastomosis (LVA)
Corradino Campisi and Francesco Boccardo
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,theedemalaterextendedtotheforearmandhand(Fig.54.1).Inthemonths 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.
Initially, the edema had a rhizomelic distribution. It was hard to the touch and did not pit. There were no dystrophic or dyschromic skin lesions, except for signs of acute reticular erysipeloid lymphangitic attacks caused by Gram-positive Staphylococci. A lymphangioscintigram was performed, which showed features compatible with lymphatic impairment in the left arm (Fig. 54.2). This was followed by lymphangio-mag- netic resonance imaging (MRI) of the arm and hemithorax which showed no signs of loco-regional recurrence but confirmed lymph stasis, predominantly in the epifascial compartment. Dilated medial arm lymphatic collectors, interrupted at the proximal third of the arm, were also demonstrated. A Duplex of the left subclavian and axillary veins was normal. A diagnosis of chronic secondary lymphoedema was made.
Question 1
How would you classify lymphoedema?
A. Primary (congenital) and secondary (acquired)
B. Phlebo-lymphoedema and lipo-lymphoedema
C. Campisi ( )
Department of General Surgery, University Hospital, San Martino, Genoa, Italy
G. Geroulakos and B. Sumpio (eds.), Vascular Surgery, |
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DOI: 10.1007/978-1-84996-356-5_54, © Springer-Verlag London Limited 2011 |
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Fig. 54.1 Patient before treatment
Fig. 54.2 Lymphangio scintigram before microsurgery. Evident dermal back flow (arrows)
54 Management of Upper Extremity Lymphoedema with Microsurgical Lympho-Venous Anastomosis (LVA) |
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Question 2
Which of the following statements regarding the diagnosis of lymphoedema are correct?
A. Lymphangiography is currently the best diagnostic investigation for all types of lymphoedema.
B. Duplex has an important role in determining the correct treatment.
C. Lymphangioscintigraphy is the most popular non-invasive first-line investigation. D. It is difficult to diagnose early lymphoedema.
E. Lymphangio-MRI offers precise morphological imaging on edema distribution and topography of dilated lymphatic pathways, without requiring contrast.
The patient underwent microsurgical lymphatic-venous anastomoses in the proximal third of the volar surface of the arm using 8/0 nylon sutures (Fig. 54.3).
Question 3
Which of the following statements regarding the management of lymphoedema are correct?
A. Microsurgery can reduce edema in all patients, but the best outcome is seen in patients operated on in the second and third stages.
B. Elastic graded compression garments are an important adjunct to optimize long-term results.
Fig. 54.3 Lymphatic-venous anastomoses seen through the operating microscope (30x). Arrows indicate anastomoses and blue dye inside the vein (direct evidence of patency)
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Fig. 54.4 Long-term clinical outcome after microsurgery
C. Surgical intervention is not indicated in the advanced stages of lymphoedema.
D. Microsurgical lymphatic-venous anastomoses are used more frequently than reconstructive microsurgical methods.
E. Microsurgery cannot be applied in primary lymphoedema.
The postoperative recovery was uneventful. The patient was discharged home the fifth postoperative day. The incidence of lymphangitic attacks decreased significantly. A reduction of arm volume was seen within 3 days of the operation, and further improvements were observed at medium and longterm follow-up, particularly between the first and the fifth years after surgery. From the fifth year onwards, the clinical condition of the arm stabilized (Fig. 54.4). Lymphangioscintigraphy at 10 years demonstrated that the lym- phatic-venous anastomoses remained patent (Fig. 54.5).
Question 4
What are the long-term results of derivative and reconstructive microsurgery for lymphoedema?
A. Long term results are better in the early stages.
B. Long term results are better for derivative than reconstructive microsurgery. C. Long term results depend mainly on the surgical technique.