Manual lymphatic drainage (MLD) – based complex decongestive therapy

(CDT)

7,8

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simple phenomenon of accumulation of lymph fluid eventually becomes a disabling and distressing limb condition affecting the entire surrounding soft tissue beyond the lymphatic system.

reviewed in other chapters.

Reconstructive surgery is most effective when performed in the earlier stage of lymphedema, when residual lymphatic vessels remain functionally intact with the ability to relieve lymphatic obstruction and lymph stasis after successful lymphatic reconstruction.

sole treatment option in the ideal situation or as a supplemental therapy to boost CDT-based physical therapy among its poor responders.

In reality, many medical centers only offer reconstructive surgery to patients who are poor to non-responders to conventional CDT-based treatment. CDT-based treat­ment is often effective in the majority of chronic lymphedema patients. The Institutional Review Board, therefore, encourages delaying surgical therapy until CDT-based therapy has been completely exhausted with no further improvement. Reconstructive surgery is often recommended by a multidisciplinary care team only after properly documenting that the patient has failed extensive CDT, and is then determined to have “treatment failure” and in addition, has experienced steady pro­gression of the disease for preferably 2 years.

Therefore, reconstructive surgery is now limited to a supplemental role in the management of lymphedema in the non- to poor-responding group of CDT patients. It is now an adjunctive treatment in the management of lymphedema along with CDT-based treatment. Both treatment modalities have mutually complementary effects. Reconstructive surgical therapy requires maintenance CDT. Therefore, the success of reconstructive surgical therapy is dependent on patient compliance with postoperative CDT.

The various modes of surgical therapy have recently been found to be more effective when combined with CDT, which is in line with the new concept of a mul­tidisciplinary approach to the treatment of lymphedema.

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All 32 patients were selected due to failure of CDT alone to relieve intractable symptoms with various indications. Various non-invasive tests including lymphos­cintigraphy were performed to determine clinical and laboratory staging in all surgi­cal candidates.

The inclusion criteria and indications for reconstructive surgery were:

II to III) in the setting of CDT-based treatment

All patients selected met all the inclusion criteria for this additional treatment, particularly among the “secondary” lymphedema patients. Nineteen patients (mean age 49 years; female = 18, male = 1; primary = 4, secondary = 15) underwent a mini­mum of 3–4 anastomoses between healthy, well-functioning collecting lymph ves­sels and competent branches of the saphenous vein.

For free lymph node transplant surgery (FLTS), candidates were selected based on the same indications as for LVAS, but preferably for “primary” lymphedema with progress from clinical stage II to III. Thirteen patients (mean age 34 years, female = 10, male = 3; primary = 6, secondary = 7) at clinical stage II or III underwent FLTS using a microsurgical free grafting technique when LVAS could not be performed.

Long-term maintenance of satisfactory clinical improvement following the sur­gical therapy to this less ideal group in particular is totally dependent on the patient’s “compliance” in maintaining postoperative CDT/compression therapy.

We also have to keep in mind that contemporary conservative treatment, when properly indicated and carried out, such as well-organized and systematized manual lymphatic drainage,2 must be tried first, before the patient is offered any reconstruc­tive surgery. Today, only 20–25% of patients with secondary lymphedema can ben­efit from modern reconstructive microsurgery of the lymphatic system. The remaining 75–80% of the patients are candidates for conservative palliation, which, if carried out thoroughly enough and with the cooperation of the patient, can offer a quite tolerable quality of life.

Sometimes the situation during surgery does not allow the creation of the direct anastomosis between the lymphatic vessel and the systemic vein. In these case such maneuvers like interposition of the auto-vein graft is a very important innovation, which will to improve results considerably. The auto-vein interposition technique provides a connection between the afferent lymphatic vessels, bringing the lymph from the extremity with the outflow tract − either the adjacent vein or the efferent lymphatic vessels, or the lymph node.7 Using this technique today can improve remote results by offering subjective improvement in 87% of the patients and objective improvement in 83%. Reduction of 67% of the excess volume in the extremity was achieved with this technique. In 87% of the patients there were no new episodes of erysipelas. This perspective of technical innovation, interposition of the vein between two lymphatic vessels, or connection of the lymph vessel with the vein, makes it pos­sible to overcome technical difficulties in many cases. Both microsurgical techniques are prospective and progress is only limited by organizational difficulties.

Microsurgery is one of the highly specialized parts of today’s surgery and we cannot expect the required facilities to be available everywhere. Because microsur­gical technique requires the surgeon to maintain an appropriate level of training − so-called technical optimum − it is not currently used as widely as it deserves. Future development and refinement of this technique can be accomplished in the centers where these operations are performed often. This can significantly improve the results, even at the present level of the diagnostic and surgical technique.

One important question remains unsolved in the literature − how stable are the remote results of the lymphatico-venous reconstruction? To get the stable and