Lymphatic Reconstructive Surgery for Lymphedema: No Cure Yet

Chronic lymphedema is a type of swelling that typically manifests in an arm or leg, due to the accumulation of lymph fluid.  This accumulation is a result of damage to a patient’s lymphatic system, typically through lymph node removal or irradiation during cancer therapy, or as a congenital dysfunction.

Chronic lymphedema is routinely managed with manual lymphatic drainage as part of a treatment approach known as combined decongestive therapy (CDT).  While CDT is effective in reducing swelling, it does not represent a cure, and so patient commitment to life-long management is required.

Reconstructive surgery offers an exciting possibility to cure this condition. Unfortunately, since its debut in the 60’s, surgical efforts have met with mixed reviews.  Best results have been observed for surgeries performed in the early stage post cancer treatment.

A variety of direct and indirect surgical approaches are currently in use in a handful of specialized centers worldwide.  Indirect surgical reconstruction typically involves lymph-node transplantation.  Direct surgical reconstruction approaches include a variety of methods to bypass the afflicted area.  This includes tying still-functional portions of lymph vessels together, or avoiding the damaged lymphatic area entirely by tying lymph vessels into the venous system.  This latter approach known as “lymphatic-venous anastomotic” surgery is one of the most popular methods of direct reconstruction.

One interesting recent article reviews the experiences of the George Washington University School of Medicine with lymphatic reconstructive surgery (Int J Angiol. 2011 June; 20(2): 73–80.).  In this article they describe why they believe lymphatic surgery has failed to gain popularity:

“Because of the complexity of reconstructive lymphatic surgery, it has never been fully understood by most surgeons. These procedures subsequently gained a bad reputation with poorly reproducible outcomes in the majority of cases.”

Worse still, the odds of surgical success are further reduced by typical health policy surrounding surgical procedures.  Since manual lymphatic drainage-based CDT can provide adequate management of lymphedema in most cases, reconstructive surgery is NOT recommended for patients until a failure of CDT is clearly documented. As the authors point out, this policy reduces the likelihood of subsequent surgical success since the majority of patients offered surgery would, as a result, have considerable additional damage to their remaining lymphatic vasculature from long-term lymphatic hypertension during this waiting period.

The authors conclude that:

“Reconstructive lymphatic surgery at best remains an adjunctive treatment that is effective in some patients”, but that “improved long-term results is dependent on patient compliance with maintenance CDT and the prevention and treatment of infection”.

While still holding promise as a potential future cure, additional research is needed.