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41 Lymphatic-Venous Derivative and Reconstructive Microsurgery
Pre-op
Post-op
After >15 years
349
Fig. 41.6 Bilateral lower limb primary lymphedema before and after 15 years from microsurgical
derivative operation at the groin. The technique of lymphatic–venous anastomoses, if performed in
the proper manner, represents a physiological, long-lasting repair of the lymphatic drainage of the
extremity
The optimal indications for lymphatic microsurgery are represented by: early
stages (Ib, II, early III); lymphoscintigraphy showing a low inguinal or axillary
lymph nodal uptake and minimal or absent passage of the tracer beyond this proximal nodal area; excellent patient compliance; and a well-organized lymphedema
center where the patient can be easily referred for additional care to a Center of
Lymphatic Surgery to receive this specialized surgery.
At later stages (advanced III, IV, and V), with absent visualization of lymphatic
channels and regional lymph nodes, it is necessary to reduce the stage of the lymphedema by non-operative methods before microsurgery. After the operation, it is
particularly important for these patients to be kept under close follow-up with the
regimen of complete lymphedema functional therapy – CLyFT8; such an approach
is essential to improve the clinical outcome and maintain the short-term operative
results for the long term (Fig. 41.11). In the case of poor patient compliance, the
results may be unsatisfactory. Relative contraindications to lymphatic microsurgery
are represented by cases of lymphatic–lymph nodal aplasia (extremely rare), diffuse
metastatic disease, and advanced stage (V) not responsive to conservative therapy.
350 C. Campisi and F. Boccardo
Pre-op Post-op
Fig. 41.7 Right lower limb lymphedema treated with derivative lymphatic–venous anastomoses
at the inguino-crural region. These techniques allow the compression garments to be used irregularly thanks to the formation of preferential lymphatic pathways and to the positive lymphatic–
venous pressure gradient
Traditional debulking operations are presently less frequently utilized to treat
lymphedema except in cases of late-stage lymphedema to reduce skin folds after
marked edema reduction obtained by conservative physical and microsurgical methods; in body regions relatively inaccessible to effective compression such as the
genitalia; in advanced lymphatic filariasis at times combined with lymphatic–venous
or nodal–venous anastomosis in the setting of widely dilated lymphatic channels;
and in localized lipolymphedema associated with massive obesity and forced
immobility.
In recent years, both primary and secondary peripheral lymphedemas have
become better understood and more manageable problems, with increased aware-
9-13
ness and early detection.
Nonetheless, apparent non-operative measures are
aimed at minimizing morbidity without removing the cause of the underlying disturbance.
14,15
Microsurgical derivative and reconstructive operations can restore
41 Lymphatic-Venous Derivative and Reconstructive Microsurgery
Pre Post
351
Fig. 41.8 Bilateral primary lower limb lymphedema with associated important venous dysfunction. In this case, reconstructive lymphatic–venous anastomoses was used bilaterally with a good
long-term result. This technique can also be used in bilateral lymphedemas and does not determine
any risk of secondary lymphedema at the harvesting site
Fig. 41.9 Lymphoscintigraphic follow-up of an upper limb secondary lymphedema treated by
derivative lymphatic microsurgery. Post-operatively, preferential lymphatic ways are evident and
the tracer disappears at the site of anastomosis because of passage into the blood stream
352 C. Campisi and F. Boccardo
Pre Post
Fig. 41.10 Lymphoscintigraphy before and after reconstructive microsurgical lymphatic–venous
technique performed in a bilateral lower limb lymphedema. Post-operatively, venous grafts are
visualized in between lymphatic pathways below and above the inguinal region
lymphatic drainage, both in the short and long term, and the best results are obtained
when these surgical procedures are combined with physical rehabilitative methods.
Finally, we recently proposed the use of lymphatic–venous anastomoses for primary prevention of arm lymphedema, performing anastomoses at the same time as
axillary lymph nodal dissection for breast cancer treatment (the lymphatic microsurgical preventive healing approach – LyMPHA).
16
This technique was also used
for preventing lower limb secondary lymphedema with vulvar carcinoma and melanoma of the trunk.
41 Lymphatic-Venous Derivative and Reconstructive Microsurgery
CLyFT (Boccardo – Campisi)
Complete lymphedema functional therapy
3 phases
Treatment/Time
1
st
ph
2
nd
ph
3
rd
ph
Edema
Complex physical therapy (6– 12 months)
Microsurgery (1 week)
Rehabilitative treatment (post-op
follow-up: 3–5 ys)
Fig. 41.11 Scheme of the complete lymphedema functional therapy (CLyFT) proposed for the
combined non-operative and microsurgical treatment of lymphedema. This therapeutic association
proved to supply the best and longest lasting results, combining the efficacy of non-operative
methods with the results of microsurgical procedures and giving the patient the possibility of wearing compression garments irregularly at the beginning, and also to avoid the use of stockings and
sleeves in the long run
References
1. Olszewski WL. The treatment of lymphedema of the extremities with microsurgical lympho-
venous anastomoses. Int Angiol. 1988;7(4):312-321.
2. Campisi C, Boccardo F. Lymphedema and microsurgery (Invited Review). Microsurgery.
2002;22:74-80.
3. Campisi C, Boccardo F. Microsurgical techniques for lymphedema treatment: derivative lym-
phatic-venous microsurgery. World J Surg. 2004;28(6):609-613.
4. Papendieck CM. The big angiodysplastic syndromes in pediatrics with the participation of the
lymphatic system. Lymphology. 1998;31(suppl):390-392.
5. Dellachà A, Boccardo F, Zilli A, Napoli F, Fulcheri E, Campisi C. Unexpected histopathologi-
cal findings in peripheral lymphedema. Lymphology. 2000;33:62-64.
6. Campisi C, Eretta C, Pertile D, et al. Microsurgery for treatment of peripheral lymphedema:
long-term outcome and future perspectives. Microsurgery. 2007;27(4):333-338.
7. Campisi C, Boccardo F, Tacchella M. Reconstructive microsurgery of lymph vessels: the per-
sonal method of lymphatic-venous-lymphatic (LVL) interpositioned grafted shunt. Microsurgery.
1995;16(3):161-166.
8. Campisi C, Boccardo F. Terapia Funzionale Completa del Linfedema (CLyFT: Complete
Lymphedema Functional Therapy): efficace strategia terapeutica in 3 fasi. Linfologia. 2008;1:20-23.
9. Bellini C, Boccardo F, Taddei G, et al. Diagnostic protocol for lymphoscintigraphy in new-
borns. Lymphology. 2005;38(1):9-15.
10. Bourgeois P, Leduc O, Leduc A. Imaging techniques in the management and prevention of
posttherapeutic upper limb edemas. Cancer. 1998;83(12 suppl American):2805-2813.
11. Mariani G, Campisi C, Taddei G, Boccardo F. The current role of lymphoscintigraphy in the
diagnostic evaluation of patients with peripheral lymphedema. Lymphology. 1998;31(S):316.
12. Pecking AP, Gougeon-Bertrand FJ, Floiras JL. Lymphoscintigraphy. Overview of its use in the
13. Witte C, McNeill G, Witte M. Whole-body lymphangioscintigraphy: making the invisible eas-
lymphatic system. Lymphology. 1998;31(S):343.
ily visible. In: Mitsumas N, Uchino S, Yabuki S, eds. Progress in Lymphology XII. Amsterdam/
London/Tokyo: Elsevier; 1989:123.
353
354 C. Campisi and F. Boccardo
14. Campisi C. Use of autologous interposition vein graft in management of lymphedema: pre-
liminary experimental and clinical observations. Lymphology. 1991;24(2):71-76.
15. Campisi C. Rational approach in the management of lymphedema. Lymphology. 1991;24:
48-53.
16. Boccardo F, Casabona F, De Cian F, et al. Lymphedema microsurgical preventive healing
approach: a new technique for primary prevention of arm lymphedema after mastectomy. Ann
Surg Oncol. 2009;16(3):703-708.
Chapter 42
Lymphatic-Lymphatic Reconstructive
Microsurgery
Ruediger G.H. Baumeister
Introduction
A direct approach to the lymphatic vessels was considered unthinkable for a long
time. However, on the basis of high-power operating microscopes and increasing
ability to anastomose small arteries and veins, the lymphatic vessels also became
possibly suturable vessels.
Lympholymphatic anastomoses and microsurgically performed lymphovenous
anastomoses using grafts were described by Cordeiro et al.
In extensive experimental studies the use of lymphatic grafts for reconstruction
purposes within the lymphatic vascular system and their patency could be demonstrated as well.
2
Subsequently, lymphatic grafting was introduced into the treatment protocol for
the patients with localized lymphatic interruptions, and was performed for the first
time in June 1980 in Munich.
3
1
Correlation With the Pathophysiology of Lymphedemas
The origin of the development of lymphedemas can be described as an imbalance
between the lymphatic load and the lymphatic transport capacity.
tries, most jeopardized lymph transport capacity is due to surgical and/or radiation
injuries. Therefore, the obstruction of the lymphatic system is limited to a localized
area, mostly at the root of an extremity, e.g., in the axilla or the groin.
R.G.H. Baumeister
Professor of Surgery, the Ludwig Maximilians University, Munich, Germany
Consultant of Lymphology,
Chirurgische Klinik Muenchen Bogenhausen
Drozzaweg 6, D 81375 Muenchen, Bavaria, Germany
e-mail: baumeister@lymphtransplant.com
B.-B. Lee et al. (eds.), Lymphedema,
DOI 10.1007/978-0-85729-567-5_42, © Springer-Verlag London Limited 2011
4,5
In western coun-
355
356 R.G.H. Baumeister
For such limited interruption of the lymphatic vessels, a bypass has been considered as an option that could lead to full recovery of the reduced transport capacity
because the bypass surgery has been well accepted as a viable treatment in other
vascular systems with obstruction.
However, especially in advanced lymphedemas, secondary tissue damages/
changes have a serious impact on the outcome of the therapy. Therefore, preferably at an early stage, after maximum conservative treatment, a reconstruction
should be offered to the patient as an optional treatment to provide further
improvement of the condition. Because edemas also can subside spontaneously
within approximately 6 months, this time period should be used for this kind of
treatment.
If the early interventional option was missed and the lymphedema accompanied
heavy tissue change with fat and connective tissue deposits, an improvement in the
transport capacity by reconstruction of the lymphatic interruption should be
attempted first. Thereafter, further treatment to restore the original volume and
shape of the extremity may be added with various invasive methods/resection
including the suctioning out of the surplus tissue when indicated.
However, a great concern regarding suction is the potential risk of lymphatic tissue damage, and, therefore, it should be performed with great care to spare the
lymphatics as much as possible.6 In addition, lymphedematous tissue is quite different from normal fatty tissue, which can be sucked out in aesthetic indications.
Therefore, this procedure should be named properly, with consideration of the
underlying lymphatic problem, and should not be called just liposuction7 but rather
“lipo-lymphosuction” at best.
In this way, the surgical procedure follows the pathophysiology. The reconstruction of the interrupted lymphatic system is attempted first, and thereafter the sequelae of the primary cause are dealt with, the deposit of fat and connective tissue when
indicated.
Experimental Basis
Reconstruction of lymphatics is based on extensive experimental investigations.
Anastomosing procedures were tested in the rat model at the abdominal thoracic duct.
Lymphatic vessels are relatively resistant against longitudinal traction, but most
fragile under oblique tension. Therefore, the “tension-free anastomosing technique”
was developed. The ends of the lymphatic vessel remain in place to maintain a
tension-free condition. First, the corner stitch opposite the surgeon is performed.
Then, for the back wall stitches, the vessel is minimally lifted as necessary to handle
the needle. The second corner stitch and the front wall are made subsequently without moving the vessel. In small lymphatic vessels, only three stitches can be applied
in the same manner (Figs. 42.1–42.3).
Absorbable suture material seemed to be of advantage. Histological studies
showed within several weeks almost no foreign body reactions using this material,
2,3
42 Lymphatic-Lymphatic Reconstructive Microsurgery
Fig. 42.1 Lympho-lymphatic end-to-end anastomoses under tension-free anastomosing technique
without turning the vessel
357
Fig. 42.2 Lympho-lymphatic end-to-end anastomoses between the graft with a thin wall and the
lymph vessel with long-standing lymphedema with heavy fibrosis using three stitches
whereas non-absorbable suture material remained long after the intervention with a
remarkable foreign body reaction close to the small lymphatic vessels. Therefore,
we prefer absorbable suture material for the anastomoses, even though it is available
only in a larger size compared with non-absorbable material.
358 R.G.H. Baumeister
Fig. 42.3 Lympho-lymphatic
end-to-side anastomoses
The patency of the lympho-lymphatic anastomoses has been proved by surgical
reinterventions, direct lymphographies, patent-blue injections, and electron
microscopy.
The rate of patency reached 100% checked by histological examinations, which
indirectly reflects that the lymphatic collectors are able to help to maintain patency
following microsurgery. The findings of the Danese et al., who only approximated
lymphatic vessels and found spontaneous communication, also support this
impression.
8
The patency and effect of lymphatic transplants were checked in the rat as
well as in the dog model using surgical reinterventions, direct lymphography,
dye injections, isotopic tracers, volume estimations, and intralymphatic pressure
measurements. Thereby, high patency rates and high functional benefits could
be demonstrated. After removal of the lymphatic transplant, as a control study,
the opposite effect was seen. The volume of the affected extremity immediately
increased again.
By measuring the intralymphatic pressure, we investigated the effect of low
molecular dextran as well. We documented an increase in the pressure and assumed
it to be an effect of flushing through the newly created anastomoses. Therefore, we
also administer this or similar drugs to the patients for several days after the intervention to keep increased lymph flow through the anastomoses.
Also, we compared different materials like autogenic veins, allogeneic lymphatics, small PTFE grafts, together with autogenous lymphatic grafts. This showed the
clear superiority of autologous lymphatic grafts. This was confirmed in a study of
the canine model by Yuwono.
9