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46 Prospects for Lymphatic Reconstructive Surgery
Fig. 46.1 Lymphogram with
contrast media showing the
transport of the lymph
through the free flap with the
lymph node (original picture)
389
Fig. 46.2 Greater omentum free flap is vascularized in the axillary area to cover the trunks of the
brachial plexus after microsurgical endoneurolysis (personal observation)
long-lasting function of the LVA there must be a pressure gradient between the
lymphatic vessel and the adjacent vein. When there is successful functioning of the
anastomosis, the pressure gradient is decreased and theoretically we must assume
that when the gradient falls to zero the flux of the lymph from the lymph vessel into
the vein will stop.
There is also another possible outcome, which is the reverse flow of the blood
from the vein into the lymph vessel followed by thrombosis of the anastomosis.
Research must be continued in order to study the remote results of the lymphovenous reconstructive microsurgery.
Microsurgical reconstructive operations on the lymph nodes, a very prospective
direction in the reconstructive lymphatic microsurgery, has its own history. The first
attempts to transfer the lymphatic nodes were made in the hope of helping patients
with primary lymphedema of the lower extremity and the lymph nodes were taken
as part of the free flap of the greater omentum (Fig. 46.2).
5
390 V.S. Krylov
Later, a free transplantation of the lymph node was successfully reported by a few
authors.11 The transplantation of the lymphatic nodes is best accomplished by forming the flap of the tissue with the incorporation of one or several lymphatic nodes.
The greater omentum can be considered the most reliable and safe. The laparotomy
in this case can be minimal with a very low postoperative complication rate.
In conclusion, as conservative treatment of lymphedema offers only temporary
palliation, there is no alternative to the radical approach, namely, reconstructive
microsurgical intervention, which already helps more than 80% of the patients with
secondary lymphedema with good remote results. Preventive microsurgical operations can significantly improve the remote results.
References
1. Bellini C, Witte MH, Campisi C, Bonioli E, Boccardo F. Congenital lymphatic dysplasias:
genetics review and resources for the lymphologist. Lymphology. 2009;42(1):36-41.
2. Foldi M. Foldi’s “Textbook of Lymphology”. 2nd ed. Munchen: Elsevier; 2006.
3. Boccardo FM, Ansaldi F, Bellini C, et al. Prospective evaluation of a prevention protocol for
lymphedema following surgery for breast cancer. Lymphology. 2009;42(1):1-9.
4. Campisi C, Davini D, Bellini C, et al. Is there a role for microsurgery in the prevention of arm
lymphedema secondary to breast cancer treatment? Microsurgery. 2006;26(1):70-72.
5. Abalmasov KG. Microsurgery and plastic surgery (point of view). In: Microsurgery in Russia
ed. Krylov VS. Geotar Moscow, 2005;189-263.
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, Davini D, Bellini C, et al. Lymphatic microsurgery for the treatment of lym-
phedema. Microsurgery. 2006;26(1):65-69.
8. 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.
9. Milanov NO. Postmastectomy Syndrome and Its Surgical Correction [doctoral dissertation].
Moscow; 1984. In: Microsurgery in Russia CD disc. Moscow Geotar, 2005.
10. Becker C, Pham DN, Assouad J, Badia A, Foucault C, Riquet M. Postmastectomy neuropathic
pain: results of microsurgical lymph nodes transplantation. Breast. 2008;17(5):472-476.
11. Becker C, Assouad J, Riquet M, Hidden G. Postmastectomy lymphedema: long-term results
following microsurgical lymph node transplantation. Ann Surg. 2006;243(3):313-315.
Part X
Surgical Treatment: Excisional/
Cytoreductive Surgery
Chapter 47
Historical Background – General Overview
Waldemar L. Olszewski
Introduction
Over the last 200 years, not to mention in more ancient times, the Charles procedure, the buried dermal flap, and the staged subcutaneous excision beneath flaps
were the main surgical options for advanced stages of lymphedema of the lower
1-11
limbs.
and covering with epidermal grafts turned out to be unsatisfactory because of acute
infections of the remaining foot skin, epidermal ulcerations, and plasma leakage
from the uncovered surfaces. So far, the subcutaneous excision beneath skin flaps
has offered the most reliable and consistently beneficial means of surgically
decreasing the size of a limb and controlling recurrences of infective episodes, as
shown in Fig. 47.1.
Classic operations such as total denuding of the limb down to the fascia
The Morphological Changes in Advanced Lymphedema
Morphological changes include (a) hyperkeratosis and fibrosis of the skin,
(b) fibrosis of the subcutaneous tissue, (c) lack of lymphatic channels with formation of numerous tissue fluid lakes (Fig. 47.2), (d) fibrosis of inguinal lymph nodes,
(e) growth of fat tissue, (f) tissue fluid subepidermal blisters with leakage,
(g) superficial skin ulcers, and (h) doubling or tripling limb weight with subsequent
destruction of the hip and knee joints.
W.L. Olszewski
Department of Surgical Research and Transplantology,
Medical Research Centre, Warsaw, Poland
B.-B. Lee et al. (eds.), Lymphedema,
DOI 10.1007/978-0-85729-567-5_47, © Springer-Verlag London Limited 2011
393
394 W.L. Olszewski
Fig. 47.1 The stage IV
obstructive lymphedema
of the lower limb with
overgrowth of fat and fibrous
tissue. It developed over a
2-year period after foot skin
abrasion. Although a
infrequent case in the western
hemisphere, it is quite
common in other parts of the
world and creates a challenge
for surgeons
Fig. 47.2 Specimen of skin
and subcutaneous tissue of
10 cm in thickness containing
fibrous and fat tissue and
thousands of fluid-filled
blisters, some large (arrows).
Patent Blue injected
subdermally spreads around
in the tissue and does not
visualize lymphatics. This is
proof that the lymphatics are
obliterated and that the
tissue-containing stagnant
fluid and microbes should
be removed
Indications for Debulking
The changes qualifying for debulking procedures, as they have evolved over the
years, are (a) overall changes, as described in the section “The Morphological
Changes in Advanced Lymphedema”; (b) recurrent local skin infections in the toe
web, foot, and lower calf; (c) recurrent septic attacks of dermatolymphangioadenitis
(DLA) of increasing frequency (>3 per year).
Bacteriology of Skin and Deep Tissues
Advanced stages of lymphedema are characterized by colonization of toe web and
skin crevices by fungi and environmental bacteria. Deep tissues and tissue fluid
contain a number of bacterial species. They include S. epidermidis, S. aureus,
47 Historical Background – General Overview
Removed skin,
Subcutis
and Fascia
Muscles
2
3
1
Fascia
Subcutaneous
tissue
395
Bacilli, Pseudomonas, Enterobacter, Enterococcus, and Acinetobacter.12
Colonization of tissue requires proper antibacterial preparation before planned surgery. Frequent attacks of DLA are the consequence of colonization and limited
capillary filtration of immune proteins and the cessation of immune cell extravasation. Infection of the lymphedematous tissues is an inherent factor of the disease
and requires proper preoperative preparations.
Surgical Technique
Preparatory procedures: (a) Antibiotics: patients usually remain on long-term penicillin administration at a dosage of 1,200,000 IU every 3 weeks. Additionally, they should
be given oral amoxicillin + clavulanic acid at a dosage of 1 g for 30 days before surgery
or alternatively 1 g of ciprofloxacin as well as 0.5 g daily of oral metronidazole. This
low dosage of antibiotics controls deep bacterial flora and lowers the postoperative
wound infection rate. (b) Two-week limb manual massage and elevation in bed.
According to our years-long experience, surgery is divided into three stages
(Fig. 47.3). (a) Lymph node–vein shunt (if lymph is oozing from the cut node) or
Fig. 47.3 Excisional operation in the advanced stages of lymphedema is divided into three stages.
Stage 1: lymphovenous shunt or, if there is no lymph flow from the cut node, removal of fibrotic
nodes and afferent lymphatics. Stage 2: excision of the obliterated lymphatics on the anterior
aspect of the thigh. Stage 3: subdermal excision of the subcutaneous tissue and fascia of the calf.
This procedure is routinely consecutively done on the medial, lateral, and posterior aspects of the
calf. Operation stages can be combined depending on the individual situation
396 W.L. Olszewski
removal of the fibrotic inguinal lymph nodes and optionally vessels down to the
knee level. (b) 3–4 weeks later, depending on the advancement of the lymphedema,
surgical excision of fibrotic lymphatics down to the knee level together with a large
mass of the neighboring fibrous infected tissues beneath the skin. (c) 3 months
later the excision under the skin of the subcutaneous tissue with the fascia on the
lateral side of the calf. (d) 3 months later the excision under the skin on the posterior side of the calf. Continuous intradermal non-absorbable suture retained for
30–40 days prevents dehiscence or later expansion of the scar. Overall, the entire
procedure relies on three longitudinal excisions under the skin at the anteromedial,
posterior, and lateral aspects of the calf. Note that the muscular fascia in advanced
lymphedema could be 1–2 cm thick and should be removed. Skin flaps cover the
denuded muscle and the wound heals up quickly. Large mass on the dorsum of
the foot can also be removed subdermally. (e) Subcutaneous suction drainage, as
long as there is free subdermal tissue fluid. (f) Bed-confined limb elevation. (g)
Continuation of 1 g of amoxicillin + clavulanic acid or 1 g of ciprofloxacin for
another month, followed later by long-lasting penicillin. (h) Elastic support (pressure grade III) after wound healing.
New elements in debulking surgery introduced by us: (a) long-term systemic
antibiotic preparation (1–3 months, depending on the frequency rate of DLA episodes), (b) inguinal lymphovenous shunt or removal of fibrotic nodes and obliterated afferent lymphatics, (c) resection of redundant skin and subcutaneous tissue
(with fibrotic lymphatics) beneath the skin leaving pedunculated flaps, (d) excision
of fibrotic calf muscular fascia, (e) postoperative long-term low-dose antibiotics.
Postoperative complications: They include: (a) partial wound dehiscence usually
at the lower end of the wound (rare), (b) wound inflammation (rare after antibiotic
preparation), (c) occasionally tissue fluid leakage.
References
1. Charles RH. Elephantiasis scroti. In: Latham A, English TC, eds. A System of Treatment,
vol. 3. London: Churchill; 1912.
2. Dellon AL, Hoopes JE. The Charles procedure for primary lymphedema. Plast Reconstr Surg.
1977;60:589.
3. Mavili ME, Naldoken S, Safak T. Modified Charles operation for primary fibrosclerotic
lymphedema. Lymphology. 1994;14:20.
4. Kim DI, Huh S, Lee SJ, Lee BB. Excision of subcutaneous tissue and deep muscle fascia for
advanced lymphedema. Lymphology. 1998;31:190-194.
5. Kondoleon E. Ultimate results of Kondoleon operation for elephantiasis. Arch Fr Belg Chir.
1924;27:104.
6. Sistrunk WE. Experiences with the Kondoleon operation for elephantiasis. JAMA. 1918;71:800.
7. Savage RC. The surgical management of lymphedema. Surg Gynecol Obstet. 1985;160:
283-290.
8. Kobayashi MR, Miller TA. Lymphedema. Clin Plast Surg. 1987;14:303-313.
9. Miller TA, Wyatt LE, Rudkin GH. Staged skin and subcutaneous excision for lymphedema: a
favorable report of long-term results. Plast Reconstr Surg. 1998;102:1486-1498.
47 Historical Background – General Overview
10. van der Walt JC, Perks TJ, Zeeman BJ, Bruce-Chwatt AJ, Graewe FR. Modified Charles pro-
cedure using negative pressure dressings for primary lymphedema: a functional assessment.
Ann Plast Surg. 2009;62:669-675.
11. Campbell W, Harkin DW. Surgical debulking in a case of chronic lymphoedema. Ir J Med Sci.
2009;178:227-229.
12. Olszewski WL, Jamal S, Manokaran G, et al. Bacteriologic studies of skin, tissue fluid, lymph,
and lymph nodes in patients with filarial lymphedema. Am J Trop Med Hyg. 1997;57:7-15.
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