Could Lymphaticovenous Bypass Offer New Hope for Lymphedema Patients?

New research that suggests a combination of certain anti-inflammatory compounds already in use can stop and even reverse the progression of lymphedema when the condition is caught early enough. Now, a new surgical procedure called lymphaticovenous bypass (LVB) may be able to reverse lymphedema even after it is established.

Present research into this groundbreaking surgery is focused on lymphedema of the upper and lower extremities (arms and legs). It should be noted, however, that research is presently limited to patients with early-stage lymphedema, which includes stage 1 and stage 2.

LVB Seeks to Undo Once-Irreversible Damage

Technically known as lymphaticovenous anastomosis, this is a relatively new surgical procedure. Enabled by recent advances in microsurgical instrumentation and procedures, this delicate procedure seeks to reverse the blockages in lymph vessels that are responsible for chronic lymphedema. The minuscule vessels that must be repaired and surgically reconnected to existing vessels are so small, this branch of surgery has been called supermicrosurgery.

Rather than attempt to create new connections among existing lymphatic vessels, the surgery typically involves splicing an existing lymph drainage vessel to a viable small vein, or venule. Ordinarily, the lymphatic system of vessels and nodes does not directly interface with the parallel vessels of the blood circulatory system.

The latter consists of arteries, veins, and smaller vessels called arterioles and venules, and even smaller-still vessels called capillaries. At the heart of this vast network of vessels, of course, is the human heart. The lymphatic system is somewhat similar, but it lacks a central pump.

A Direct Route to the Blood Circulatory System

Veins, of course, are part of the blood circulatory system. They carry “used” blood away from the tissues and back towards the heart for recirculation to the lungs, where the blood takes on fresh oxygen and release wastes such as carbon dioxide. From there, refreshed blood travels to the heart, for pumping back through the arteries and arterioles to the far-flung tissues and organs of the body. And so it goes, continually, with every beat of the heart.

Lymph travels more slowly than blood, because lymph fluid relies on a more passive system, including simple muscle contractions in the legs and arms during ordinary movement, rather than relying on a powerful central pump. Doctors have learned in recent years to be far more selective about when to remove armpit lymph nodes when performing breast cancer surgeries.

They tend to remove far fewer these days, and this is having an effect on the number of new post-surgical lymphedema patients. In the past, up to one-third of breast cancer survivors were at risk for developing lymphedema. Fortunately, those numbers are dropping, but there’s clearly still a need for better approaches to treating this condition. LVB may one day become routine if initial successes are any indication. Among other indicators, investigators looked at changes in the skin in affected areas.

The health of the skin is a good indicator of the severity of lymphedema because chronic lymphedema tends to cause undesirable, irreversible changes in the skin. Among other positive changes, researchers documented decreased inflammation and decreased skin stiffening (fibrosis) among patients who had undergone LVB. “These findings suggest that some of the pathologic changes of lymphedema are reversible and may be related to lymphatic fluid stasis,” investigators concluded. [Torrisi JS ’15]    

Yet Another Surgical Option

Another surgical procedure, known as vascularized lymph node transfer, or simply microsurgical lymph node (LN) transplantation, involves attempts to replace damaged or surgically removed lymph nodes with healthy nodes harvested from other places within the body. One small study removed healthy lymph nodes from patients’ groins and transplanted them to the underarm area.

Of two dozen patients, only two did not experience improvements in their existing arm lymphedema after this procedure. Ten experienced a return to normal arm volumes and were considered cured, while 12 experienced improvements in their condition.

Investigators concluded that LN is, “a safe procedure permitting good long-term results, disappearance, or a noteworthy improvement, in post-mastectomy lymphedema…” In this pilot study, 42% of patients were deemed cured by the procedure. [Becker C ’06] Subsequent reviews of this relatively new procedure indicate it holds great promise, especially when replacement nodes are transferred from the inguinal (groin) area.

A Word of Caution

It should be noted that, while these interventions are promising, they remain experimental treatments. They are not — yet, at least — well-established, routine procedures. Advances in medicine require rigorous research, conducted with many patients before a given therapy can be adopted widely and with great confidence.

Despite mounting evidence of promising results, indicating that these surgical approaches can prevent the development of — or even reverse — lymphedema (especially in the arms, following breast cancer treatments), these procedures are far from the standard at this time. Feel free to ask your doctor about the possibility of exploring these options, but be aware that it is unlikely, right now, they will be offered to you as a matter of course.

References

Baltzer HL, Winocour S, Harless C, Saint-Cyr M. Lymphaticovenous Bypass: Adaptations and Lessons Learned. Plast Reconstr Surg Glob Open. 2017 Jun 7;5(6):e1328. doi: 10.1097/GOX.0000000000001328. eCollection 2017 Jun.

Becker C, Assouad J, Riquet M, Hidden G. Postmastectomy lymphedema: long-term results following microsurgical lymph node transplantation. Ann Surg. 2006 Mar;243(3):313-5.

Campisi C, Bellini C, et al. Microsurgery for lymphedema: clinical research and long-term results. Microsurgery. 2010 May;30(4):256-60. doi: 10.1002/micr.20737.

Campisi C, Davini D, et al. Lymphatic microsurgery for the treatment of lymphedema. Microsurgery. 2006;26(1):65-9.

Scaglioni MF, Arvanitakis M, et al. Comprehensive review of vascularized lymph node transfers for lymphedema: Outcomes and complications. Microsurgery. 2018 Feb;38(2):222-229. doi: 10.1002/micr.30079. Epub 2016 Jun 7.

Tourani SS, Taylor GI, Ashton MW. Long-Term Patency of Lymphovenous Anastomoses: A Systematic Review. Plast Reconstr Surg. 2016 Aug;138(2):492-8. doi: 10.1097/PRS.0000000000002395.

Torrisi JS, Joseph WJ, et al. Lymphaticovenous bypass decreases pathologic skin changes in upper extremity breast cancer-related lymphedema. Lymphat Res Biol. 2015 Mar;13(1):46-53. doi: 10.1089/lrb.2014.0022. Epub 2014 Dec 18.