Say Goodbye to Compression Garments after Dr. Cheng’s Lymphedema Microsurgery
The lower extremity lymphedema has a 10-49% occurrence in patients who suffer from gynecological cancers with pelvic lymph node dissection and radiation. Higher body mass index, a greater number of pelvic lymph node removal, and radiation are the top risk factors for lower extremity lymphedema caused by parasite infection (Filariasis). Primary lymphedema patients with unknown etiology for symptoms and signs are categorized by their ages of onset as congenital (less than 2 years), lymphedema praecox (2- 35 years), and lymphedema tadar (older than 35 years). The incidence is higher after cancer resection and lymph node dissection in vulva cancer followed by cervical and ovarian cancer. Recently, sentinel lymph node biopsy was selectively applied in gynecological cancer surgery to reduce the lower limb lymphedema.
Lymphedema then presents as chronic changes and swelling of the tissue and is often associated with adipogenesis or fibrotic changes in the lower limb as well. Severe fibrosis occurs with long-standing lymphedema due to the accumulation of protein-rich fluid in the interstitial spaces coupled with inflammation repeated bouts of cellulitis. It is common for lymphedema patients to experience depression, due to the physical discomfort, emotional distress and lowered quality of life.
Dr. Ming-Huei Cheng developed a Cheng’s Lymphedema Grading tool to assess the severity of extremity lymphedema. Cheng Lymphedema Grading System is currently the most common used measurement, it is based on not only subjective criteria and clear objective findings that could facilitate discussions and meaningful comparison of the treatment proposed. The circumferential measurement is an objective analysis tool to assess the severity of lymphedema commonly by comparing the circumferential differences between the lymphedematous limb and the normal limb. Lymphoscintigraphy, computed tomography (CT), indocyanine green (ICG) lymphography, and magnetic resonance imaging (MRI) are other key diagnostic devices to determine the severity of lymphedema. The lymphoscintigraphy has been reported as the most effective indicator with 96% sensitive and 100% specific conclusion for diagnosing extremity lymphedema. The Taiwan Lymphoscintigraphy Staging systems was published in 2018 at Annals of Surgery.
Treatments of lymphedema are aimed to control infection, to reduce the swelling of the extremity and to improve the quality of life. Basic treatments of lymphedema start with conservative physical therapy, including manual lymphatic drainage and compression bandage-centered decongestive lymphatic therapy. The efficacy of conservative physical therapy presents only when the patients are compliant with the treatment program. However, it also carries risks of intravascular cancer metastasis and thrombosis formation. Surgical treatments are indicated when first line conservative measures fail and when patients present with late stage disease. There are two main categories of surgical treatment: excisional and physiologic procedures. Excisional procedures are essentially a surgical reduction of excess fibro-adipose tissue in the affected limb while physiologic procedures reconstruct the lymphatic system to improve physiologic drainage. Surgical treatments are also “be cure and control”, the goals of treatment are similarly preventing progression of disease and reducing morbidities.
Debulky surgery and circumferential suction-assisted lipectomy can be performed to reduce the severely, non-pitting lymphedematous extremity. More technical demanding surgeries, such as lymphaticovenous anastomosis and Free vascularized lymph node transfer The basic physiologic mechanism of the vascularized lymph node flap is that lymph is absorbed by the transferred lymph nodes and drained into a donor vein through natural lymphaticovenous connections inside a flap. The arterial flow from the recipient artery to the vascularized lymph node flap provides the driving force for venous return and hence, continuous lymph drainage. We report the transfer of a vascularized submental lymph node flap to the ankle is a novel approach for the effective treatment of lower extremity lymphedema. There was no donor site morbidity. At a mean follow-up of 8.7 ± 4.2 months, the mean reduction of the leg circumfer- ence was 64±11.5% above the knee, 63.7±34.3% below the knee and 67.3±19.2% above the ankle. All of the patients did not use compression garments post-operatively!