Lymphedema surgery and the science of lymphology rapidly advanced in the past decades.
Today, procedures such as supermicrosurigcal lymphaticovenular anastomosis (LVA),
vascularized lymph vessel transfer (VLVT), and vascularized lymph node transfer (VLNT)
are performed worldwide and are no longer considered esoteric. Despite the increased
popularity of these procedures, the debate on these procedures' efficacies continues.
More specifically, is lymphedema surgically curable? Here, we offer our experience
and viewpoint.
In our experience, with cure defined as a patient being free of all lymphedema-related
symptoms without the need for further treatments including the use of compression
garments, lymphedema cure is most definitely a clinical reality. Although achievable
only in a small fraction of our patients, we have seen all three procedures (LVA,
VLVT, and VLNT) capable of effecting cure since 2011.[1]
[2]
[3]
[4] The feasibility of cure seems to correlate with the fluid-predominant state of lymphedema
or stages of the pathology in which edema was fully reversible. No cure was ever observed
in patients with solid-predominant disease or when the affected limbs were prominently
affected by lymphedema-induced lipodystrophy. These physiologic procedures seemed
not capable of reversing the pathologic lipodystrophy once developed. Interestingly,
complete disease reversal was possible even in patients with advanced lymphatic injury,
or those showing “diffuse” pattern on indocyanine green lymphography, provided that
their conditions remained fluid predominant.
Regardless of the physiologic procedure performed, all of those who achieved cure
followed a consistent time course of prompt, notable symptomatic improvement within
2 weeks from surgery. All then experienced progressive amelioration of pain, paresthesia,
heaviness, clumsiness, rigidity, severity and frequency of spontaneous infection,
exercise intolerance, and other related symptoms in the following 6 postoperative
months. All cases of cure were documented between 6 to 18 months following surgery.
None achieved cure if they were still dependent on a compression garment on the 18th
month. Frequently, those who achieved cure had such insight – they knew they were
ready to stop wearing compression garments and would stop doing so themselves before
being given permission by us at subsequent clinic follow-up. Although remarkable improvements
were consistently seen in those who underwent hybrid reconstruction (debulking procedure
in combination with a physiologic procedure), fewer cure cases were observed in this
patient group relative to those with fluid-predominant disease who underwent physiologic
procedure only.
In our opinion, we should not be complacent with only ameliorating lymphedema. We
need to aim to cure. We should review our collective experience and investigate patient/technical
characteristics that are associated with cure. With these known, we hope to be able
to achieve cure with increased confidence and frequency. For now, with this commentary,
we hope to convey to the lymphedema surgery community that cure is a clinical reality,
and it is time that we set our therapeutic bar higher.
