Supermicrosurgery: offering new hope for patients with lymphoedema

In a normal person, fluid is lost from the circulation as it passes through the capillaries of a limb. This fluid helps carry nutrients and oxygen to cells that are not in direct contact with capillaries. This fluid is then recycled back to veins in the neck by a system called the lymphatics, which lymphatics return around three litres per day of this tissue fluid back to the circulation. The lymphatic system, and the lymph nodes in particular, play a vital role in the body’s defence against infection and cancer.
In patients with lymphoedema, an excess of this tissue fluid builds up in the limbs. This causes excessive swelling, restricted movement, pain, recurrent episodes of severe infection, and subsequently a greatly decreased quality of life.

Lymphoedema can be caused by a congenital or developmental problem with the lymphatics. This is called primary lymphoedema. It can also be caused by a “blockage” to the outflow of the lymphatic fluid from an affected area secondary to another disease process, such as surgical removal of lymph nodes, radiotherapy, or infection. This is called secondary lymphoedema.

Worldwide, infection with the parasitic roundworm W. Bancrofti, causing filiariasis and subsequent elephantiasis, is the commonest cause of lymphoedema. In the UK, secondary lymphoedema caused by surgery or radiotherapy for treatment of cancer is common. It is estimated that over 125,000 people in the UK are affected by lymphoedema. Up to 60% of patients treated for breast cancer and 60% of patients treated for gynaecological cancer suffer with lymphoedema, as well as patients affected by other forms of cancer.

Conventional treatment for lymphoedema consists of life-long meticulous skin care to prevent infections, massage, and compression bandaging. At best, this can control the disease, but it fails to address the usual cause – a blockage to the outflow of lymph fluid.

Supermicrosurgery for lymphoedema is a relatively new technique, pioneered in Japan, which offers new hope for the treatment of patients with this debilitating condition. We connect superficial lymphatic channels beyond the obstruction to superficial venules just under the skin, thereby allowing the lymphatic fluid to drain directly back into the veins and bypass the obstruction, reducing the swelling and the complications. This operation is called lymphaticovenular anastomoses (LVA).

We locate the lymphatics using a fluorescent dye injection and an infra-red detection camera, to guide incision placement. We make around four 2cm incisions on the affected limb at the site of some of the detected lymphatic channels. We then locate the lymphatic channels and sub-dermal venules just underneath the skin. The diameter of the lymphatics and the venules are both between 0.2 and 0.8 mm, and we perform the entire operation under the operating microscope, using stitches thinner than a human hair. The operation is very minimally invasive, and most patients can have their surgery under local anaesthetic, speeding their recovery.

Longitudinal case series in patients with established lymphoedema show that LVA is an effective treatment, even for relatively advanced disease, working in over 80% of patients. In severely affected patients, it is unlikely to make the limb completely normal, but reduces both symptoms and complications. The size of the affected limb typically continues decreasing for 3-4 years after surgery. We have found that LVA is especially effective in patients who have really distressing problems like leaking of lymph fluid through the skin, or recurrent severe infections.

Other surgical treatments, such as specialist lymphoedema liposuction, can also be effective in reducing the size of the limb in established lymphoedema. Furthermore, transfer of lymph glands at the same time as abdominal tissue for breast reconstruction can be effective in treating lymphoedema that is caused by mastectomy and lymph gland removal or radiotherapy for breast cancer.

There is also data from a randomised controlled trial showing that LVA is effective in preventing lymphoedema in patients undergoing axillary dissection for the treatment of breast cancer. This is an exciting area of active research, as it offers the opportunity to prevent secondary lymphoedema from occurring in the first place. As survival rates from cancer treatments improve, it is important to improve the quality of life of cancer survivors, and this technique is one example of how plastic surgery is helping to achieve this aim.

Dominic Furniss