Surgical Treatment of Lymphedema at LE&RN Comprehensive Centers of Excellence

James E. Fanning; Rosie Friedman; Kathleen Shillue; Aaron Fleishman; William Repicci; Kevin Donohoe; Dhruv Singhal

doi:10.1055/a-2540-0648

Journal of Reconstructive Microsurgery, Table of Contents

J Reconstr Microsurg 2026; 42(01): 001-006
DOI: 10.1055/a-2540-0648

Original Article

Surgical Treatment of Lymphedema at LE&RN Comprehensive Centers of Excellence

Authors

James E. Fanning

¹Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
Rosie Friedman

¹Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
Kathleen Shillue

²Department of Rehabilitation Services, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
Aaron Fleishman

¹Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
William Repicci

³Lymphatic Education and Research Network, New York, New York
Kevin Donohoe

⁴Division of Nuclear Medicine, Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
Dhruv Singhal

¹Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts

Abstract

Background

Despite major advancements in lymphatic care, there remains a lack of consensus across institutions regarding the evaluation and surgical management of lymphedema. The aim of this study is to describe the practices for diagnosis and surgical treatment of lymphedema across accredited Lymphatic Education & Research Network (LE&RN) comprehensive Centers of Excellence (COEs).

Methods

A survey was distributed to directors of the 16 LE&RN comprehensive COEs in January 2023. Directors were queried on lymphatic surgeon training, evaluation of potential surgical patients, description of surgical operations offered at their center, surgical algorithms, and operative techniques for various procedures.

Results

Nine COEs completed the survey (56% response rate). Eight of nine centers reported having an interdisciplinary surgical evaluation program, including lymphatic surgery (100%, 8/8), certified lymphedema therapy (100%, 8/8), and lymphatic medicine (75%, 6/8). COEs use a variety of lymphatic imaging modalities, with indocyanine green lymphography (89%, 8/9) and lymphoscintigraphy (78%, 7/9) being the most common. While all COEs offered debulking procedures, 67% (6/9) offered physiologic procedures (lymphovenous bypass and vascularized lymph node transplant), and 56% (5/9) offered immediate lymphatic reconstruction. There was no consensus on surgical algorithms or operative approaches.

Conclusion

LE&RN comprehensive COEs consistently use multidisciplinary care teams for medical and surgical evaluations, but there is significant variability in lymphatic imaging modalities used and lymphatic surgery types and techniques. These findings underscore the need for continued research and standardization of lymphatic surgery outcomes to develop consensus.

Keywords

lymphedema - lymphatic surgery - breast cancer–related lymphedema - lymphatic - lymphatic imaging

Full Text

References

References
1 Lymphatic Education & Research Network. . Centers of Excellence. June 1, 2024 . Accessed at: https://lymphaticnetwork.org/centers-of-excellence
2 Bhattacharya P, Mada F, Salowich-Palm L. et al. Are racial disparities in stroke care still prevalent in certified stroke centers?. J Stroke Cerebrovasc Dis 2013; 22 (04) 383-388
3 Miller ME, Bleicher RJ, Kaufman CS. et al. Impact of breast center accreditation on compliance with breast quality performance measures at commission on cancer-accredited centers. Ann Surg Oncol 2019; 26 (05) 1202-1211
4 Gupta V, Parikh R, Nguyen L. et al. Is office-based surgery safe? Comparing outcomes of 183,914 aesthetic surgical procedures across different types of accredited facilities. Aesthet Surg J 2017; 37 (02) 226-235
5 Spinzi G, Milano A, Capelli M. Accreditation of digestive endoscopy services: a method of quality assuring?. Expert Rev Gastroenterol Hepatol 2021; 15 (01) 1-4
6 Peacock JC, Zizzi SJ. An assessment of patient behavioral requirements pre- and post-surgery at accredited weight loss surgical centers. Obes Surg 2011; 21 (12) 1950-1957
7 Johnson AR, Fleishman A, Tran BNN. et al. Developing a lymphatic surgery program: a first-year review. Plast Reconstr Surg 2019; 144 (06) 975e-985e
8 Singhal D, Tran BN, Angelo JP, Lee BT, Lin SJ. Technological advances in lymphatic surgery: bringing to light the invisible. Plast Reconstr Surg 2019; 143 (01) 283-293
9 ARPHA-H LIGHT. . Lymphatic Imaging, Genomics, and Phenotyping Technologies. June 1, 2024 . Accessed at: https://arpa-h.gov/research-and-funding/programs/light
10 ARPHA-H GLIDE. . Groundbreaking Lymphatic Interventions and Drug Exploration. June 1, 2024 . Accessed at: https://arpa-h.gov/research-and-funding/programs/glide
11 Quartuccio N, Agugliaro F, Alongi P, Sturiale L, Arnone G, Corrao S. A systematic review comparing lymphoscintigraphy and magnetic resonance imaging techniques in the assessment of peripheral lymphedema. Curr Med Imaging 2022; 19 (05) 469-475
12 Case TC, Witte CL, Witte MH, Unger EC, Williams WH. Magnetic resonance imaging in human lymphedema: comparison with lymphangioscintigraphy. Magn Reson Imaging 1992; 10 (04) 549-558
13 Bae JS, Yoo RE, Choi SH. et al. Evaluation of lymphedema in upper extremities by MR lymphangiography: comparison with lymphoscintigraphy. Magn Reson Imaging 2018; 49: 63-70
14 Liu NF, Lu Q, Liu PA, Wu XF, Wang BS. Comparison of radionuclide lymphoscintigraphy and dynamic magnetic resonance lymphangiography for investigating extremity lymphoedema. Br J Surg 2010; 97 (03) 359-365
15 Akita S, Mitsukawa N, Kazama T. et al. Comparison of lymphoscintigraphy and indocyanine green lymphography for the diagnosis of extremity lymphoedema. J Plast Reconstr Aesthet Surg 2013; 66 (06) 792-798
16 Gentili F, Mazzei FG, Monteleone I. et al. Comparison of indocyanine green fluorescence lymphangiography and magnetic resonance lymphangiography to investigate lymphedema of the extremities. Ann Ital Chir 2021; 92: 452-459
17 AlJindan FK, Lin CY, Cheng MH. Comparison of outcomes between side-to-end and end-to-end lymphovenous anastomoses for early-grade extremity lymphedema. Plast Reconstr Surg 2019; 144 (02) 486-496
18 Kwon JG, Jeong S, Pak CJ, Suh HP, Hong JP. Comparative analysis between side-to-end and end-to-end lymphaticovenous anastomosis for secondary lower limb lymphedema. Plast Reconstr Surg 2022; 150 (05) 1138-1148
19 Mukarramah DA, Kageyama T, Sakai H. et al. Comparison of outcomes between side-to-end and end-to-end lymphovenous anastomoses for early-grade extremity lymphedema. Plast Reconstr Surg 2020; 145 (06) 1112e-1113e
20 Suzuki Y, Sakuma H, Yamazaki S. Evaluation of patency rates of different lymphaticovenous anastomosis techniques and risk factors for obstruction in secondary upper extremity lymphedema. J Vasc Surg Venous Lymphat Disord 2019; 7 (01) 113-117 10.1016/j.jvsv.2018.05.030 Erratum in: J Vasc Surg Venous Lymphat Disord. 2019 May;7(3):468. doi: 10.1016/j.jvsv.2018.12.010
21 Cho J, Yoon J, Suh HP, Pak CJ, Hong JP. Further insight in selecting the ideal vein for lymphaticovenous anastomosis: utilizing the venturi effect. Plast Reconstr Surg 2024; 154 (03) 673-682
22 Desai A, Dahl V, De Castro Silva I. et al. Larger recipient vein caliber during lymphatic microsurgical preventive healing approach (LYMPHA) is associated with lower lymphedema rates. Surgery 2024; 176 (05) 1485-1491
23 Onoda S, Satake T, Kinoshita M. Relationship between lymphaticovenular anastomosis outcomes and the number and types of anastomoses. J Surg Res 2022; 269: 103-109
24 Akita S, Mitsukawa N, Kuriyama M. et al. Comparison of vascularized supraclavicular lymph node transfer and lymphaticovenular anastomosis for advanced stage lower extremity lymphedema. Ann Plast Surg 2015; 74 (05) 573-579
25 Basta MN, Gao LL, Wu LC. Operative treatment of peripheral lymphedema: a systematic meta-analysis of the efficacy and safety of lymphovenous microsurgery and tissue transplantation. Plast Reconstr Surg 2014; 133 (04) 905-913
26 Braizat O, Jarrar S, El-Debs M. et al. Comparing different donor sites after vascularized lymph node transfer to the lymphedematous upper limb: a systematic review and meta-analysis of clinical outcomes. Ann Plast Surg 2024; 93 (01) 130-138
27 Ciudad P, Agko M, Perez Coca JJ. et al. Comparison of long-term clinical outcomes among different vascularized lymph node transfers: 6-year experience of a single center's approach to the treatment of lymphedema. J Surg Oncol 2017; 116 (06) 671-682
28 Kenworthy EO, Nelson JA, Verma R, Mbabuike J, Mehrara BJ, Dayan JH. Double vascularized omentum lymphatic transplant (VOLT) for the treatment of lymphedema. J Surg Oncol 2018; 117 (07) 1413-1419
29 Grünherz L, Barbon C, von Reibnitz D. et al. Analysis of different outcome parameters and quality of life after different techniques of free vascularized lymph node transfer. J Vasc Surg Venous Lymphat Disord 2024; 12 (06) 101934
30 Manrique OJ, Bustos SS, Kapoor T. et al. Gastroepiploic vascularized lymph node transfer for the treatment of extremity lymphedema: comparison between middle and distal inset. Gland Surg 2020; 9 (02) 528-538
31 Felmerer G, Behringer D, Emmerich N, Grade M, Stepniewski A. Donor defects after lymph vessel transplantation and free vascularized lymph node transfer: a comparison and evaluation of complications. World J Transplant 2021; 11 (04) 129-137
32 Ho OA, Lin CY, Pappalardo M, Cheng MH. Comparisons of submental and groin vascularized lymph node flaps transfer for breast cancer-related lymphedema. Plast Reconstr Surg Glob Open 2018; 6 (12) e1923
33 Chang DW, Dayan J, Greene AK. et al. Surgical treatment of lymphedema: a systematic review and meta-analysis of controlled trials. Results of a consensus conference. Plast Reconstr Surg 2021; 147 (04) 975-993

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