Background: Despite the common assertion that little is understood about the pathophysiology of disorders of the lymphatic system and that satisfactory treatments are lacking, there is a rich history in medicine dating back close to 500 years of research on the lymphatic system. In the past 40 years there has been a burgeoning interest in research on, and clinical application for, diseases involving the lymphatic system. Development of microsurgical techniques has significantly advanced the field of Lymphology and the treatment of lymphedema secondary to oncological surgery.
Methods:The author reports on the development of microsurgery for lymphedema and new developments with particular reference to the wealth of experience in treating patients in Genoa, Italy. The “single-site” microsurgical technique is based on the identification, with the use of Patent Blue Dye / Fluorescent Micro-lymphography (PDE Test), of the lymhatics in the axillary or inguinal-crural regions (“single-site”) and the completion of derivative multiple lymphatic–venous anastomoses (MLVA). The lymphatics are anastomosed with telescopic technique to multiple tributary vein, for example, the axillary vein or the saphenous vein, depending on the affected limb.
In cases of advanced lymphedema, patients are treated by a recently developed Fibro-Lipo-Lymph-Aspiration technique to improve this chronic swelling, using a Lymph Vessel Sparing Procedure (FLLA-LVSP). Using microlymphography techniques to highlight the lymphatic pathways, the excess adipose tissue was carefully aspirated with the FLLA-LVSP procedure.
Results: With the “single-site” MLVA, 4000 patients obtained significant reductions in excess limb volume of over 84%, with an average follow-up of 15 years or more. Over 86% of patients with earlier stages of disease (stage IB or IIA) progressively stopped using conservative therapies and 42% of patients with later stages (stages IIB and III) decreased the frequency of physical therapies. DLA attacks considerably reduced by over 91%.
For 250 advanced cases, 0.80L on average for the upper limb and 2.42L for the lower limb was removed with the FLLA-LVSP. For the upper limb, there was an average pre-surgery excess volume of 20.19%, which reduced to 2.68% after the FLLA-LVSP (Z-score =-6.90, p<0.001). Similarly, for the lower limb, there was an average pre-surgery excess limb volume of 21.24% and a reduction to 2.64% post-operatively (Z-score=-3.57, p<0.01). No episodes of post-operative infection occurred. See: Figure 1, pre, post-MLVA, and post-FLLA-LVSP.
Conclusion: MLVA or techniques when performed at a single-site produce excellent outcomes in the treatment of secondary lymphedemas, giving the possibility of a complete restoration of lymphatic flow in early stages of disease when tissue changes are minimal. In cases of advanced lymphedema, the FLLA-LVSP is efficient. It is possible to complete an entire leg within 90 minutes. Recovery time is short and cosmetic results are immediate. More importantly, the removal of excess tissue is completed without further damage to lymphatic vessels, providing evidence of the efficacy of FLLA-LVSP in limb-reshaping, whilst maintaining the optimal lymphatic flow restored by Lymphatic Microsurgery. With this procedure, in some patients, it is possible to achieve almost 100% volume reduction and to eliminate the use of compressive stockings.