J Reconstr Microsurg 2018; 34(09): 735-741
DOI: 10.1055/s-0038-1648220
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Cumulative Experience in Lymphovenous Anastomosis for Lymphedema Treatment: The Learning Curve Effect on the Overall Outcome

Nicolas Pereira
1   Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
2   Department of Plastic Surgery and Burns, Hospital del Trabajador, Santiago, Chile
3   Department of Plastic Surgery, Clínica Las Condes, Santiago, Chile
,
Yeon Hoon Lee
1   Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
,
Youngchul Suh
1   Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
,
Dong Hoon Choi
1   Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
,
Hyun Suk Suh
1   Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
,
Jae Yong Jeon
4   Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
,
Joon Pio Jp Hong
1   Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
› Author Affiliations
Further Information

Publication History

02 November 2017

22 March 2018

Publication Date:
03 May 2018 (online)

Abstract

Background The lymphovenous anastomosis (LVA) has become one of the treatment options for lymphedema. However, it is regarded as a difficult surgery that many young microsurgeons are reluctant to try. This report investigates the learning curve in regard to symptom improvement.

Methods This is a retrospective analysis performed in 33 consecutive lymphedema patients (38 extremities) who underwent only LVAs from August 2010 to February 2016. Surgical outcomes in regard to surgeon's experience were evaluated. The surgeons experience was divided into three groups: early group with less than 2 years, moderate with 2 to 4 years, and mature group with more than 4 years of experience.

Results A total of 31 limbs (8/8 in upper extremity and 23/30 in lower extremity) showed improvement. When we compare volume change and recurrence of cellulitis with regard to surgeon's experience, there were no statistically significant differences. However, the mean time per LVA was significantly decreased as the experience increased over time (p = 0.017).

Conclusion LVA is an effective treatment option to reduce the volume in the affected limb and to improve symptoms involved. Regardless of the number and experience of the surgeons, cellulitis improves significantly after LVA. The experience of the surgeon does not significantly impact the positive outcome while proficiency increases with experience.

 
  • References

  • 1 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
  • 2 Ruocco V, Schwartz RA, Ruocco E. Lymphedema: an immunologically vulnerable site for development of neoplasms. J Am Acad Dermatol 2002; 47 (01) 124-127
  • 3 Garfein ES, Borud LJ, Warren AG, Slavin SA. Learning from a lymphedema clinic: an algorithm for the management of localized swelling. Plast Reconstr Surg 2008; 121 (02) 521-528
  • 4 Cormier JN, Askew RL, Mungovan KS, Xing Y, Ross MI, Armer JM. Lymphedema beyond breast cancer: a systematic review and meta-analysis of cancer-related secondary lymphedema. Cancer 2010; 116 (22) 5138-5149
  • 5 Ki EY, Park JS, Lee KH, Hur SY. Incidence and risk factors of lower extremity lymphedema after gynecologic surgery in ovarian cancer. Int J Gynecol Cancer 2016; 26 (07) 1327-1332
  • 6 Kim JH, Choi JH, Ki EY. , et al. Incidence and risk factors of lower-extremity lymphedema after radical surgery with or without adjuvant radiotherapy in patients with FIGO stage I to stage IIA cervical cancer. Int J Gynecol Cancer 2012; 22 (04) 686-691
  • 7 International Society of Lymphology. The diagnosis and treatment of peripheral lymphedema. 2009 Concensus Document of the International Society of Lymphology. Lymphology 2009; 42 (02) 51-60
  • 8 Lerner R. Complete decongestive physiotherapy and the Lerner Lymphedema Services Academy of Lymphatic Studies (the Lerner School). Cancer 1998; 83 (12, Suppl American): 2861-2863
  • 9 DiSipio T, Rye S, Newman B, Hayes S. Incidence of unilateral arm lymphoedema after breast cancer: a systematic review and meta-analysis. Lancet Oncol 2013; 14 (06) 500-515
  • 10 Warren AG, Brorson H, Borud LJ, Slavin SA. Lymphedema: a comprehensive review. Ann Plast Surg 2007; 59 (04) 464-472
  • 11 Chen WF, Zhao H, Yamamoto T, Hara H, Ding J. Indocyanine green lymphographic evidence of surgical efficacy following microsurgical and supermicrosurgical lymphedema reconstructions. J Reconstr Microsurg 2016; 32 (09) 688-698
  • 12 Narushima M, Yamamoto T, Ogata F, Yoshimatsu H, Mihara M, Koshima I. Indocyanine green lymphography findings in limb lymphedema. J Reconstr Microsurg 2016; 32 (01) 72-79
  • 13 Campisi C, Davini D, Bellini C. , et al. Lymphatic microsurgery for the treatment of lymphedema. Microsurgery 2006; 26 (01) 65-69
  • 14 Chang DW. Lymphaticovenular bypass for lymphedema management in breast cancer patients: a prospective study. Plast Reconstr Surg 2010; 126 (03) 752-758
  • 15 Cheng MH, Huang JJ, Wu CW. , et al. The mechanism of vascularized lymph node transfer for lymphedema: natural lymphaticovenous drainage. Plast Reconstr Surg 2014; 133 (02) 192e-198e
  • 16 Patel KM, Lin CY, Cheng MH. From theory to evidence: long-term evaluation of the mechanism of action and flap integration of distal vascularized lymph node transfers. J Reconstr Microsurg 2015; 31 (01) 26-30
  • 17 Carl HM, Walia G, Bello R. , et al. Systematic review of the surgical treatment of extremity lymphedema. J Reconstr Microsurg 2017; 33 (06) 412-425
  • 18 Sosin M, Yin C, Poysophon P, Patel KM. Understanding the concepts and physiologic principles of lymphatic microsurgery. J Reconstr Microsurg 2016; 32 (08) 571-579
  • 19 Damstra RJ, Voesten HG, Klinkert P, Brorson H. Circumferential suction-assisted lipectomy for lymphoedema after surgery for breast cancer. Br J Surg 2009; 96 (08) 859-864
  • 20 Charles R. The surgical technique and operative treatment of elephatiasis of the generative organs based on a series of 140 consecutive successful cases. Ind Med Gaz 1901; 36: 84
  • 21 Thompson N. The surgical treatment of chronic lymphoedema of the extremities. Surg Clin North Am 1967; 47 (02) 445-503
  • 22 Servelle M. La lymphangiectomie superficielle totale. Traitement chirurgical de l'éléphantiasis. Rev Chir 1947; 85 (9-10): 294
  • 23 Brorson H, Höijer P. Standardised measurements used to order compression garments can be used to calculate arm volumes to evaluate lymphoedema treatment. J Plast Surg Hand Surg 2012; 46 (06) 410-415
  • 24 Penha TR, Botter B, Heuts EM, Voogd AC, von Meyenfeldt MF, van der Hulst RR. Quality of life in patients with breast cancer-related lymphedema and reconstructive breast surgery. J Reconstr Microsurg 2016; 32 (06) 484-490
  • 25 Simon MS, Cody RL. Cellulitis after axillary lymph node dissection for carcinoma of the breast. Am J Med 1992; 93 (05) 543-548
  • 26 Olszewski WL, Jamal S, Manokaran G, Lukomska B, Kubicka U. Skin changes in filarial and non-filarial lymphoedema of the lower extremities. Trop Med Parasitol 1993; 44 (01) 40-44
  • 27 Vignes S, Dupuy A. Recurrence of lymphoedema-associated cellulitis (erysipelas) under prophylactic antibiotherapy: a retrospective cohort study. J Eur Acad Dermatol Venereol 2006; 20 (07) 818-822
  • 28 Mihara M, Hara H, Furniss D. , et al. Lymphaticovenular anastomosis to prevent cellulitis associated with lymphoedema. Br J Surg 2014; 101 (11) 1391-1396
  • 29 Koshima I, Inagawa K, Urushibara K, Moriguchi T. Supermicrosurgical lymphaticovenular anastomosis for the treatment of lymphedema in the upper extremities. J Reconstr Microsurg 2000; 16 (06) 437-442
  • 30 Chang DW, Suami H, Skoracki R. A prospective analysis of 100 consecutive lymphovenous bypass cases for treatment of extremity lymphedema. Plast Reconstr Surg 2013; 132 (05) 1305-1314
  • 31 Akita S, Mitsukawa N, Kuriyama M. , et al. Suitable therapy options for sub-clinical and early-stage lymphoedema patients. J Plast Reconstr Aesthet Surg 2014; 67 (04) 520-525
  • 32 Mihara M, Hara H, Tange S. , et al. Multisite lymphaticovenular bypass using supermicrosurgery technique for lymphedema management in lower lymphedema cases. Plast Reconstr Surg 2016; 138 (01) 262-272
  • 33 Seki Y, Yamamoto T, Yoshimatsu H. , et al. The superior-edge-of-the-knee incision method in lymphaticovenular anastomosis for lower extremity lymphedema. Plast Reconstr Surg 2015; 136 (05) 665e-675e