- Email: [email protected]
Optimizing Surgical Treatment of Lymphedema
Vol. 216, No. 1, January 2013
hospitals. Organ procurement organizations also provide extensive grief support resources to the families with whom they interact; these services can have immense benefits for the families of our patients and they should direct us to consider the representatives of the OPO as collaborative partners in our own mission to provide the best care possible. In the end, optimizing the care of patients with devastating neurologic injuries has the potential to primarily benefit these patients and their families as well as the recipients of their organs for those who go on to donate. If we, as a trauma and critical care community, can appreciate the tangible benefits of preserving all care options for patients with devastating neurologic injuries, both those aimed at survival as well as those directed at end-of-life care options, the perceived conflicts of interest can be minimized and comfort for all involved can be maintained. REFERENCES 1. Malinoski DJ, Patel MS, Lush S, et al. Impact of compliance with the American College of Surgeons trauma center verification requirements on organ donation-related outcomes. J Am Coll Surg 2012;215:186e192. 2. Malinoski D, Patel MS, Daly M, et al. The impact of meeting donor management goals on the number of organs transplanted per donor: results from the UNOS Region 5 Prospective Donor Management Goals Study. Crit Care Med 2012;40: 2773e2780. 3. Donate Life America National Donor Designation Report Card e June 2012. Available at: http://donatelife.net/2012national-donor-designation-report-card-released/. Accessed October 10, 2012. 4. Merchant SJ, Yoshida EM, Lee TK, et al. Exploring the psychological effects of deceased organ donation on the families of the organ donors. Clin Transplant 2008;22:341e347. 5. OneLegacy e a donate life organization. Available at: http:// www.onelegacy.org/site/about/mission.html. Accessed October 10, 2012.
Disclosure Information: Nothing to disclose.
Optimizing Surgical Treatment of Lymphedema Tetsuji Fujita, Tokyo, Japan
MD
In a collective review of surgical treatment of lymphedema, referring to the study by Campisi and coworkers,1 Dr Doscher and colleagues2 state that rebuilding lymphatic channels by lymphatic venous drainage is a recommended approach for patients with early stage
Letters
169
lymphedema. Although Campisi and coworkers treated more than 1,800 patients with chronic peripheral lymphedema using microsurgical reconstructive techniques such as lymphatic venous anastomosis and venous interposition between lymphatic collectors over 30 years, and reported excellent outcomes, they did not show how many patients were followed up for long enough to be suitable for the analysis.1,3 It is interesting that Campisi and coworkers mentioned that unresponsiveness to conservative treatment is a relative contraindication to lymphatic microsurgery,3 meaning that both medical management and microsurgery are acceptable in the treatment of early stage lymphedema. In a recent prospective study that evaluated the efficacy of lymphatic venous anastomosis in patients with stage 3 lymphedema (permanent lymphedema with repeated episodes of lymphangitis) after breast cancer surgery, a short-term marginal benefit of lymphatic venous anastomosis disappeared during a mean follow-up period of 8 years.4 Given the lack of randomized controlled trials and systematic reviews comparing conservative and surgical therapy, conservative decongestive therapies such as pneumatic decompression and elastic bandage appear still to be the first line treatment. Microsurgical lymphatic venous drainage will be offered to patients with early stage lymphedema by well trained plastic surgeons if lymphedema trends toward progression. As mentioned by Doscher and colleagues,2 surgical treatment is advocated for a subset of patients with stage 4 (column limb) and stage 5 (elephantiasis) lymphedema. Doscher and colleagues focused on the Charles procedure, which is understood to be radical circumferential excision of lymphedematous tissue down to fascia and immediate resurfacing of the denuded wound with split-thickness skin graft harvested from the entire circumference of the affected limb. But Charles did not present a single patient treated successfully using this technique. After description of the reason for re-emergence of the Charles procedure for late stage lymphedema, Doscher and colleagues briefly discussed liposuction in the treatment of lymphedema, but did not mention the differences in operative results between surgical excision with skin grafting and liposuction. Adipocyte hyperplasia is associated with lymphedema, and may be attributable to the progression of the disease as an endocrine organ that induces chronic inflammation.5 Although Doscher and colleagues recognized liposuction as a newly developed approach for peripheral lymphedema, liposuction was attempted as a radical treatment of arm lymphedema or as an adjunct to surgical excision for leg lymphedema before 1989.6-8 With refinements in liposuction techniques and perioperative
170
Letters
management such as the use of vibrating suction cannulas and preoperative and postoperative compression therapy using a compression garment, the outcome of liposuction for advanced lymphedema in the specialized center appears excellent.9 Constant use of compression garments and need for changes in garment size after operation may address an argument against aggressive circumferential liposuction. However, liposuction is far less invasive than the Charles procedure. In addition, cosmetic results of liposuction seem to be much better than those of the Charles procedure when looking at the appearance of the affected limbs after liposuction and after the Charles procedure.9,10 The Charles procedure is an extremely challenging operation that poses a risk for severe complications, which may have been rarely published. Such an operation should be attempted in selected patients at a well equipped specialized center. It was estimated that approximately 140 million people worldwide were suffering from lymphedema in 1990s.11 Presently, there is no cure for lymphedema. Patients with advanced lymphedema will be interested in access to a specialized lymphedema clinic, where surgical therapies will be optimized on the basis of a patient’s condition, surgical experience, and much better understanding of the pathophysiology of lymphedema. REFERENCES 1. Campisi C, Bellini C, Campisi C, et al. Microsurgery for lymphedema: clinical research and long-term results. Microsurgery 2010;30:256e260.
J Am Coll Surg
2. Doscher ME, Herman S, Garfein ES. Surgical management of inoperable lymphedema: the re-emergence of abandoned techniques. J Am Coll Surg 2012;215:278e283. 3. Campisi C, Eretta C, Pertile D, et al. Microsurgery for treatment of peripheral lymphedema: long-term outcome and future perspectives. Microsurgery 2007;27:333e338. 4. Damstra RJ, Voesten HGJ, van Schelven, et al. Lymphatic venous anastomosis (LVA) for treatment of secondary arm lymphedema. A prospective study of 11 LVA procedures in 10 patients with breast cancer related lymphedema and a critical review of the literature. Breast Cancer Res Treat 2009;113: 199e206. 5. Brorson H. Adipose tissue in lymphedema: the ignorance of adipose tissue in lymphedema. Lymphology 2004;37: 175e177. 6. Sando WC, Nahai F. Suction lipectomy in the management of limb lymphedema. Clin Plast Surg 1989;16:360e373. 7. O’Brien BM, Khazanchi RK, Kumar PA, et al. Liposuction in the treatment of lymphedema: a preliminary report. Br J Plast Surg 1989;42:530e533. 8. Louton RB, Terranova WA. The use of suction curettage as adjunct to the management of lymphedema. Ann Plast Surg 1989;22:354e357. 9. Brorson H, Ohlin K, Olsson G, et al. Controlled compression and liposuction treatment for lower extremity lymphedema. Lymphology 2008;41:52e63. 10. Karri V, Yang MC, Lee J, et al. Optimizing outcome of Charles procedure for chronic lower extremity lymphedema. Ann Plast Surg 2011;66:393e402. 11. Miller TA, Wyatt LE. Lymphedema. In: Aston SJ, Beasley RW, Thorne CH, eds. Grabb and Smith’s Plastic Surgery. 5th ed. Philadelphia: Lippincott-Raven; 1997:1077e1082.
Disclosure Information: Nothing to disclose.
hospitals. Organ procurement organizations also provide extensive grief support resources to the families with whom they interact; these services can have immense benefits for the families of our patients and they should direct us to consider the representatives of the OPO as collaborative partners in our own mission to provide the best care possible. In the end, optimizing the care of patients with devastating neurologic injuries has the potential to primarily benefit these patients and their families as well as the recipients of their organs for those who go on to donate. If we, as a trauma and critical care community, can appreciate the tangible benefits of preserving all care options for patients with devastating neurologic injuries, both those aimed at survival as well as those directed at end-of-life care options, the perceived conflicts of interest can be minimized and comfort for all involved can be maintained. REFERENCES 1. Malinoski DJ, Patel MS, Lush S, et al. Impact of compliance with the American College of Surgeons trauma center verification requirements on organ donation-related outcomes. J Am Coll Surg 2012;215:186e192. 2. Malinoski D, Patel MS, Daly M, et al. The impact of meeting donor management goals on the number of organs transplanted per donor: results from the UNOS Region 5 Prospective Donor Management Goals Study. Crit Care Med 2012;40: 2773e2780. 3. Donate Life America National Donor Designation Report Card e June 2012. Available at: http://donatelife.net/2012national-donor-designation-report-card-released/. Accessed October 10, 2012. 4. Merchant SJ, Yoshida EM, Lee TK, et al. Exploring the psychological effects of deceased organ donation on the families of the organ donors. Clin Transplant 2008;22:341e347. 5. OneLegacy e a donate life organization. Available at: http:// www.onelegacy.org/site/about/mission.html. Accessed October 10, 2012.
Disclosure Information: Nothing to disclose.
Optimizing Surgical Treatment of Lymphedema Tetsuji Fujita, Tokyo, Japan
MD
In a collective review of surgical treatment of lymphedema, referring to the study by Campisi and coworkers,1 Dr Doscher and colleagues2 state that rebuilding lymphatic channels by lymphatic venous drainage is a recommended approach for patients with early stage
Letters
169
lymphedema. Although Campisi and coworkers treated more than 1,800 patients with chronic peripheral lymphedema using microsurgical reconstructive techniques such as lymphatic venous anastomosis and venous interposition between lymphatic collectors over 30 years, and reported excellent outcomes, they did not show how many patients were followed up for long enough to be suitable for the analysis.1,3 It is interesting that Campisi and coworkers mentioned that unresponsiveness to conservative treatment is a relative contraindication to lymphatic microsurgery,3 meaning that both medical management and microsurgery are acceptable in the treatment of early stage lymphedema. In a recent prospective study that evaluated the efficacy of lymphatic venous anastomosis in patients with stage 3 lymphedema (permanent lymphedema with repeated episodes of lymphangitis) after breast cancer surgery, a short-term marginal benefit of lymphatic venous anastomosis disappeared during a mean follow-up period of 8 years.4 Given the lack of randomized controlled trials and systematic reviews comparing conservative and surgical therapy, conservative decongestive therapies such as pneumatic decompression and elastic bandage appear still to be the first line treatment. Microsurgical lymphatic venous drainage will be offered to patients with early stage lymphedema by well trained plastic surgeons if lymphedema trends toward progression. As mentioned by Doscher and colleagues,2 surgical treatment is advocated for a subset of patients with stage 4 (column limb) and stage 5 (elephantiasis) lymphedema. Doscher and colleagues focused on the Charles procedure, which is understood to be radical circumferential excision of lymphedematous tissue down to fascia and immediate resurfacing of the denuded wound with split-thickness skin graft harvested from the entire circumference of the affected limb. But Charles did not present a single patient treated successfully using this technique. After description of the reason for re-emergence of the Charles procedure for late stage lymphedema, Doscher and colleagues briefly discussed liposuction in the treatment of lymphedema, but did not mention the differences in operative results between surgical excision with skin grafting and liposuction. Adipocyte hyperplasia is associated with lymphedema, and may be attributable to the progression of the disease as an endocrine organ that induces chronic inflammation.5 Although Doscher and colleagues recognized liposuction as a newly developed approach for peripheral lymphedema, liposuction was attempted as a radical treatment of arm lymphedema or as an adjunct to surgical excision for leg lymphedema before 1989.6-8 With refinements in liposuction techniques and perioperative
170
Letters
management such as the use of vibrating suction cannulas and preoperative and postoperative compression therapy using a compression garment, the outcome of liposuction for advanced lymphedema in the specialized center appears excellent.9 Constant use of compression garments and need for changes in garment size after operation may address an argument against aggressive circumferential liposuction. However, liposuction is far less invasive than the Charles procedure. In addition, cosmetic results of liposuction seem to be much better than those of the Charles procedure when looking at the appearance of the affected limbs after liposuction and after the Charles procedure.9,10 The Charles procedure is an extremely challenging operation that poses a risk for severe complications, which may have been rarely published. Such an operation should be attempted in selected patients at a well equipped specialized center. It was estimated that approximately 140 million people worldwide were suffering from lymphedema in 1990s.11 Presently, there is no cure for lymphedema. Patients with advanced lymphedema will be interested in access to a specialized lymphedema clinic, where surgical therapies will be optimized on the basis of a patient’s condition, surgical experience, and much better understanding of the pathophysiology of lymphedema. REFERENCES 1. Campisi C, Bellini C, Campisi C, et al. Microsurgery for lymphedema: clinical research and long-term results. Microsurgery 2010;30:256e260.
J Am Coll Surg
2. Doscher ME, Herman S, Garfein ES. Surgical management of inoperable lymphedema: the re-emergence of abandoned techniques. J Am Coll Surg 2012;215:278e283. 3. Campisi C, Eretta C, Pertile D, et al. Microsurgery for treatment of peripheral lymphedema: long-term outcome and future perspectives. Microsurgery 2007;27:333e338. 4. Damstra RJ, Voesten HGJ, van Schelven, et al. Lymphatic venous anastomosis (LVA) for treatment of secondary arm lymphedema. A prospective study of 11 LVA procedures in 10 patients with breast cancer related lymphedema and a critical review of the literature. Breast Cancer Res Treat 2009;113: 199e206. 5. Brorson H. Adipose tissue in lymphedema: the ignorance of adipose tissue in lymphedema. Lymphology 2004;37: 175e177. 6. Sando WC, Nahai F. Suction lipectomy in the management of limb lymphedema. Clin Plast Surg 1989;16:360e373. 7. O’Brien BM, Khazanchi RK, Kumar PA, et al. Liposuction in the treatment of lymphedema: a preliminary report. Br J Plast Surg 1989;42:530e533. 8. Louton RB, Terranova WA. The use of suction curettage as adjunct to the management of lymphedema. Ann Plast Surg 1989;22:354e357. 9. Brorson H, Ohlin K, Olsson G, et al. Controlled compression and liposuction treatment for lower extremity lymphedema. Lymphology 2008;41:52e63. 10. Karri V, Yang MC, Lee J, et al. Optimizing outcome of Charles procedure for chronic lower extremity lymphedema. Ann Plast Surg 2011;66:393e402. 11. Miller TA, Wyatt LE. Lymphedema. In: Aston SJ, Beasley RW, Thorne CH, eds. Grabb and Smith’s Plastic Surgery. 5th ed. Philadelphia: Lippincott-Raven; 1997:1077e1082.
Disclosure Information: Nothing to disclose.