There has been a paradigm shift in the management of lymphedema recently, with a better understanding of the physiology of lymphatic system and with the recent advances in super-microsurgical techniques.
Lymphedema management starts with conservative management, followed by surgery and maintaining the surgical results during the entire lifetime of the patients. For lymphedema treatment to be effective, it has to be initiated early in the disease and demands a continued compliance from the patient.
Recent advances in management of lymphedema are mostly focused on a thorough understanding of the microscopic anatomy of lymphatics (please refer to the section of the symposium on pathogenesis) and provision of alternate physiologic pathways to redirect lymph flow to prevent secondary changes in the tissues such as cellulitis, fibrosis, adipose tissue deposition, and functional loss.
Lymphedema is divided into stages 0-5 using indo cyanine green (ICG) lymphography, based on the patency of lymphatic vessels, dermal backflow, and lymphatic vessel contractility. The International Society of Lymphology (ISL) staging charts the progress and reversibility of lymphedematous changes from subclinical disease in stage 0 to irreversible lymphostatic elephantiasis in stage 3 With the progression of the disease.
the microvascular networks that nourish the collecting lymphatic vessels are lost; the lymphatic vessel lumen is dilated with an increase in endolymphatic pressure in the ectasis type, whereas in contraction and the sclerosis types, an increase in smooth muscles and collagen fibers make the lymphatics more thickened and prominent.
RECENT ADVANCES IN SURGICAL MANAGEMENT OF LYMPHEDEMA
Success of surgical management of lymphedema is dependent on the severity of the disease. In tropical countries, where endemic filariasis is the predominant etiology, patients tend to seek treatment only in late fibrotic stages with severe functional impairment of the affected limbs, where only radical excision and resurfacing surgeries will be the only possible option. Ramachandran et al.
have proposed an algorithm for lymphedema management based on the ISL stages. In the last decade, with an increasing interest in the early management of post-mastectomy lymphedema, focus is shifting towards more physiologic surgical procedures to promote lymphatic drainage. This parallels the advent of “super-microsurgery” as well as new imaging techniques such as ICG fluorescence and magnetic resonance lymphangiography to visualize the lymphatics and veins.
Super-microsurgery is the technique by which vascular channels such as lymphatics of less than 1 mm diameter can be anastomosed. Lymphatics are very small, transparent, thin walled and easily collapsible.
Their identification, dissection and suturing demand considerable technical expertise and a thorough understanding of lymphatic anatomy and physiology of our body. Patients in early stages of disease will benefit from procedures like LVA whereby lymphatic vessels are connected to the veins or by VLNT where lymph nodes from one donor lymph node basin are transferred to the affected area to reestablish the lymphatic drainage.
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