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Surgical Management of Lymphedema
Related Terms: Charles Procedure, Thompsons Procedure, Buck's Fascia, Homans-Miller Procedure, Kondoleon Procedure, Sisktrunk Procedure, Thompson Procedure, Lymphedema Microsurgery, Dermal Flap, Miller Sistrunk Procedure, Surgical Therapy
These surgeries, all developed almost a hundred years ago are still widely used in the treatment lymphedema.
The tragic thing is that despite the complications, failure rates and long term outlook, doctors still insist on attempting to convince lymphedema patients that this is the route to go.
Thus far in all the groups I sponsor and associate with, I have met quite a number of us that have had them and to a person, we all regret it.
Everyone of us has had the same experience. Though the leg was initially smaller, the swelling came back. Furthermore, the lymphedema became much worse afterwards. Our cellulitis infections became hard to treat as a result of extreme fibrosis and there has been massive nerve damage (peripheral neuropathy) on everyone of us.
Surgery should only be used for lymphedema in cases of severe lymphatic filariasis or for massive localized lymphedema. Remember, irregardless of the stage of your lymphedema]], it can still be treated or managed by lymphedema physiotherapy, compression bandages, compression garments.
According to the Yale Medical School the approaches to the surgical treatment of lymphedema fall into two categories. Either, one attempts to ablate the offending tissue, leaving behind only those tissues drained by the competent lymphatic system. Alternatively, attempts are made to augment lymph flow or egress from the lymphadematous extremity by 1) attempting to establish communication between the superficial, compromised lymphatics, and the deep, competent system; 2) the provision of an alternative route of lymph drainage (external); 3) the construction of direct lymphatic to venous anastomoses.
Venous anastomoses generally involved the implanting of a shunt in attempting to create a bypass of the obstructed lymphatics. This actually has worked, but the shunts eventually “wear out” and must be replaced.
We cover this subject under Lymphedema Microsurgery.
The surgery I had done was called the Thompson’s Procedure. In the early nineteen seventies, this was somewhat experimental and is a modification of the old Charles and Miller procedures. You can read about my experience with this in My Life with Lymphedema and in my article Complications of Lymphedema Debulking Surgery
June 7, 2008
The Thompson Procedure is actually a combination type using techniques of both the Charles and the Miller surgeries. The limb is first debulked, the a flap of skin was sewn into the muscle of the limb with anticipation that flap would act as a “wick” drawing the fluids into the deeper lymphatics.
I had three of these procedures done from 1971 - 1973. In desperate hopes by my doctors I could be helped. They were performed by Dr. Richard P. Andrews and Dr. Christopher Haugy at the Good Samaritan Hospital in Portland, Oregon.
The effectiveness of the surgeries is doubtful and the procedure has been somewhat discarded. I cover this more in our page Thompson's Procedure.
One of the earliest procedures is the Kondolean procedure (1912). It involves resection of subcutaneous lymphedematous tissue as well as creating a fascial window as a means of establishing communication between the superficial and deep lymphatics. Apparently, the fascial window does not work, and only the tissue resection part of this procedure is still used, and erroneously referred to as the Kondolean procedure.
Kondoleon excised strips of deep fascia while Sistrunk (1917) modified this procedure to excise subcutaneous tissue as well by raising a flap. However, Berthwhistle and Gregg (1928) reported that the deep fascia regrew in 3 months time. The uptake of lymph is due in these patients to the rich vascular bed of the muscle rather than its lymphatic system. This may be the reason via it seems to act even when both the superficial and the deep systems are effected (A.K. Henri, 1921; Peer, 1955). Thompson (1962) described an operation for lymphoedema which involved transposing a flap of dermis with the epidermis shaved off under the deep fascia. He believed that the dermis which is rich in lymph supply would drain directly into the muscle rather than depend on transmission via the subcutaneous tissue. He later (1967, 1971) emphasised on placing the flap on the direction of lymph flow.
The contraindications to his operation were:
1. Extreme obesity 2. Hyperkeratotic warty skin changes 3. Hypoplastic lymph channels 4. Mild cases (i.e. those requiring only cosmetic relief)
Harvey (1969) found improvement of lymph flow (as measured by RIHSA clearance) after Thompsons operation. Sawhney (1974) could not confirm this and said that results were due to excision of subcutaneous tissue only. In 3 patients, he found RIHSA clearance and leg circumference to revert to the same pre- operative level after a gap of 6 months to 2 years. There is a high incidence of sinus and fistula formation due to necrosis of the embedded flap. (Browse, 1986).
Miller (1973, 1975) uses plain excision of subcutaneous tissue undermining from a 1.1/2 inch thick strip of the skin. He used staged procedure for medial and lateral sides. He emphasised on the preservation of the cutaneous nerves. Good results were shown in 6 patients in a follow up of 2-6 years by RIHSA and clinical studies. Both Miller and Thompson (1967) emphasised on the use of strict bed rest to decrease edema before and after surgery. Miller suggested suspending the leg from an overhead bed frame using a Thomas splint to provide dependent drainage.
Yale Medical School
The Charles procedure (1912) is an ablative procedure whereby the affected subcutaneous tissue is resected down to muscle fascia and the area covered with skin grafts taken from the resected specimen. This procedure is no longer performed. The Charles procedure, as an eponym for the surgical treatment of leg edema, is actually a longstanding misnomer, seeing as Sir Richard Henry Havelock Charles is known for describing a treatment for scrotal lymphedema in 1901, having treated a series of 140 patients with this condition. Sir Havelock had never treated a patient with leg edema, but in 1950, Sir Archibald McIndoe, an eminent British plastic surgeon wrote an article in which he mistakenly claimed that Sir Charles had treated a patient with leg edema with excision of subcutaneous tissue and skin grafts back in 1912. Since then, the error has been propagated throughout the years.
*previous link no longer available
The Sistrunk procedure (1918) is an ablative procedure like the Charles procedure, after which the resected areas are covered with skin flaps.
The Homans-Miller procedure (1936) is a modification using thin skin flaps to cover the resected area. Using particularly thin skin flaps, Miller was able to achieve an aesthetically pleasing result. Miller elevates an anterior and posterior flap from both a medial and lateral incision, raising flaps approximately 1 cm thick. The underlying lymphedematous tissue is excised down to muscle fascia. The skin flaps are trimmed and sutured into position. Good aesthetic and functional results are obtained with this procedure, which is now considered the standard ablative approach used in the treatment of forearm and upper extremity lymphedema. However, occasionally second or even third operations are required to obtain the maximum benefit.
*previous link no longer available
There have been several questions on our Lymphedema forum asking about the surgical treatment options for lymphedema so I decided to provide a general discussion of the surgical management of lymphedema. The are several different surgical approaches to the treatment of lymphedema. For the sake of simplicity, most of the techniques involve the formation of an anastamosis between the lymphatic system and the venous system. An anastamosis is essentially a bridge or conduit from the lymphatic system to the venous system. The goal of these microvascular surgeries is to form a channel between the pooled and blocked lymphatic system and the venous system so that the venous system can remove the accumulated lymphatic fluid.
A brief review the physiology of the lymphatic system is in order to help understand these surgical techniques. Arterial, or oxygenated blood is pumped from the heart to the various tissues. The oxygen is removed from the blood by the cells and cellular waste products are dumped into the blood from the cells. The deoxygenated blood is the venous blood and it flows back to the heart where it is pumped to the lungs to pick up more oxygen.
All cells are bathed by a small amount of fluid that circulates around the cells and then drains into the lymphatic system. The lymphatic system arises from these tiny spaces between cells. In many ways, the lymphatic and venous system are similar since they both function to remove excess waste from cells. The lymphatic system differs from the venous system because it is a much more delicate system of channels. In addition, the volume of lymphatic flow is less than 10% of the flow of the venous system. The lymphatic system is so delicate that in many places the walls of the lymphatic channels are only a few cell thick. These channels are often difficult to identify under the microscope and it takes a trained eye to identify them. The lymphatic channels converge into larger channels and finally drain into the venous system before entering the heart.
These lymphatic and venous systems, while separate, run in parallel. Therefore, a bridge can be formed between the two systems allowing for the drainage of excess fluid from an obstructed lymphatic system. As you might imagine, such bridges would have to be very small. In addition, once formed, flow could go from the lymphatic system to the venous system, but flow could also go from the venous system to the lymphatic system. Since the lymphatic system is frequently obstructed in cases of lymphedema, the lymphatic system is more likely to be a higher pressure than the venous system and the flow is likely to go from the lymphatic system to the venous system thereby alleviating the condition of lymphedema.
While the concept of forming a surgical channel to remove excess lymphatic fluid is very appealing, forming an effective and stable anastamosis between obstructed lymphatic vessels and the venous system is technically very difficult. The trials that report on these techniques are often very small, the follow-up is often short and there is inadequate information about what happens to the patients in cases where the surgery was ineffective. A paper entitled, Microsurgical lymphovenous anastomosis for treatment of lymphedema: a critical review(1) was published from the Mayo Clinic several years ago and the authors followed their patients for an average of three years after the surgery. Their trial was also small, involving only 18 patients. The patients were mixed, some had secondary lymphedema, some had filariasis and some had primary lymphedema. 14 patients were evaluated and of these 14, 5 had improvement, 5 were unchanged and 4 had progression of their lymphedema at the time of last follow-up. The authors concluded that there was no objective evidence supporting the value of microsurgical treatment for lymphedema.
One of the main concerns about using surgical approaches to the management of lymphedema is the probability of making the condition significantly worse. Patients with lymphedema have enough problems without making the condition worse with an invasive surgical procedure. One of the critical questions that must be addressed by these studies is the complication rate and the extent of worsening of edema experienced by these patients. There will be discussion of the surgical approach to the treatment of lymphedema at the upcoming NLN conference and I look forward to learning of any new and effective treatments.
One of the more exciting possibilities is the use of growth factors that selectively stimulate the growth of lymphatic vessels. These growth factors have been identified recently and research is ongoing to understand how they work and whether they will be of benefit in the treatment of lymphedema. While this is only in the earliest stages of research, such technology offers the promise of effective therapy in the future.
One of the problems with these by-pass surgeries is that the by-pass tract becomes blocked soon after the surgery. We learned this while studying cardiac by pass surgeries and surgeries to by pass obstructed veins in the legs. Since obstruction of the lymphatic by pass channels also appeared to occur, anastomoses were performed in dogs to determine the rate of blockage of lymphatic venous by-pass surgeries (2). By 8 months, 75% of the anasotmoses were blocked. The authors concluded that the rate of blockage was high; therefore, chances of success were better when several anastomoses were performed in the early stages of lymphedema, before significant tissue fibrosis and complete loss of lymphatic valvular function occurred.
There have been relatively few papers written about these techniques from centers in the United States in recent years. Many of the publications have come from Russia, China and Japan.
In a Russian study, 152 patients were followed for a period of 2 to 6 years after surgery to form an anastomosis between the lymphatic and venous systems (3). Approximately 2/3 of the patients demonstrated improvement; however, 1 of 3 patients did not improve or got worse. Only the abstract is available in English and the authors did not report the percent of overall percent changes in limb volume. In addition, they did not discuss the whether complications of the surgery were observed.
In China, 110 patients with lymphedema of the were treated with microsurgery forming an anastomosis between lymphatics and veins (4). Ninety-eight patients with lymphedema of the extremities were followed-up for 26 months and about 2/3 of the patients demonstrated improvement. In those patients, the average reduction in circumference of the affected limb was 59%. However, there was no discussion of the long-term effects of the surgery or the results or complications among the patients that did not respond to the surgery.
In Australia, 52 patients were treated by microlymphatic surgery (5). Significant improvement was observed in 22 patients (42 percent), with an average reduction of 44 percent of the excess volume. However, long-term results were not available. In addition, the authors concluded that better results can be expected with earlier operations because the patients usually have less lymphatic disruption.
A recent article from Japan, reports the use of microsurgical lymphaticovenous implantation for the treatment of chronic lymphedema (6). This technique involves placing a lymphatic shunt in the area of obstruction. Only 8 patients were treated with this method and larger studies are need to assess the long-term benefit of this technique.
One of the main concerns about using surgical approaches to the management of lymphedema is the probability of making the condition significantly worse. One of the critical questions that must be addressed by these studies is the complication rate and the extent of worsening of edema experienced by these patients. There will be discussion of the surgical approach to the treatment of lymphedema at the upcoming NLN conference and I look forward to learning of any new and effective treatments.
One of the more exciting possibilities is the use of growth factors that selectively stimulate the growth of lymphatic vessels. While this is only in the earliest stages of research, such technology offers the promise of effective therapy in the future.
Tony Reid MD Ph.D
Peninsula Medical, Dr. Reid's Corner
I have long been an outspoken opponent on the use of debulking surgeries for lymphedema patients. In my article Complications of Debulking Surgery, I shared my own experience with this proceure and the long term effects on my left leg.
In our Children with Lymphedema Group, we recently had a discussion on this and one of our members sent the following post. It is one of those rare instances when I am left speechless. I feel such anger and sadness in what has been done to a prescious little two year old girl.
“I have not read what others have posted yet because I read emails in order of first received, but I am guessing that you are getting a lot of responses “against” debulking surgeries. Not having any experience with these procedures myself, I communicate with a mother whose 9-year old daughter is now unable to walk (probably for life) because of repeated surgeries (including debulking) that she has undergone at the insistence of doctors who promised things they could not deliver. I actually don’t know what to say to this poor woman when she tells me that her daughter’s leg is permanently oozing lymphatic fluid and that she changes the dressings on her legs every few hours because they are soaking wet. She tells me that she cries every day and blames herself for inflicting soooo much pain and agony on her daughter. She said that before the first surgery (age 2) her daughter was able to walk. Up to that point, her daughter’s LE had not been treated properly (MLD, bandaging, compression, etc…) so her right leg was pretty big and she was desperate to try anything that was a cure or fix, but 6 years later and many, many surgeries to correct each previous one, her daughter is permanently using a wheelchair and has to be home schooled because her leg is worse than she can even explain to me. After so many surgeries (who only knows what combination of different surgeries she has had), her right leg/foot is now shorter (doesn’t reach the floor) and her foot is turned completely in (not facing straight out) so she can not plant her foot on the ground. Oh and her foot is also completely limp (apparently they must have damaged muscle and tendons and bones too). So what I’m trying to say is to be very careful about what a doctor claims to be able to do because you may end up making an already difficult situation completely tragic. If debulking surgeries worked, all LE patients would be in line to have them done and there would be no need for the tedious (but effective) treatments such as MLD and daily bandaging and compression garments. I would love to be able to offer Sophie a quick fix, even if it entailed a surgery and recovery, but any reputable therapist will not even humor you by speaking of these procedures. Please use your “Mommy judgment” and don’t rush into anything. If you speak Spanish, I’m sure this mother would be willing to speak to you and offer some advice as well. Unfortunately for her, hind sight was 20/20 and now she regrets her decisions every day of her life.”
From a mom in our Children with Lymphedema Group
Lymphedema Surgical Therapy
Author: Don R Revis, Jr, MD, Consulting Staff, Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Florida College of Medicine
Excerpt - E Med
Surgical therapy: Surgical treatment is palliative, not curative, and it does not obviate the need for continued medical therapy. Moreover, it is rarely indicated as the primary treatment modality. Rather, reserve surgical treatment for those who do not improve with conservative measures or in cases where the extremity is so large that it impairs daily activities and prevents successful conservative management. The goals of surgical therapy are volume reduction to improve function, facilitation of conservative therapy, and prevention of complications. A myriad of surgical procedures have been advocated, reflecting a lack of clear superiority of one procedure over the others. In general, surgical procedures are classified as physiologic or excisional.
Physiologic procedures attempt to improve lymphatic drainage. Multiple techniques have been described, including omental transposition, buried dermal flaps, enteromesenteric bridging, lymphangioplasty, and microvascular lympholymphatic or lymphovenous anastomoses. None of these techniques has clearly documented favorable long-term results. Further evaluation is necessary. Moreover, many of theses physiologic techniques also include an excisional component, making it difficult to distinguish the two approaches.
Excisional techniques remove the affected tissues, thus reducing the lymphedema load. Some authors advocate suction-assisted removal of subcutaneous tissues, but this technique is difficult because of the extensive subcutaneous fibrosis that is present. Additionally, this approach does not reduce the skin envelope, and the lymphedema often rapidly recurs. Suction-assisted removal of subcutaneous tissue followed by excision of the excess skin envelope has no clear advantage over direct excisional techniques alone.
The Charles procedure is another quite radical excisional technique. This procedure involves the total excision of all skin and subcutaneous tissue from the affected extremity. The underlying fascia is then grafted, using the skin that has been excised. This technique is extreme and is reserved for only the most severe cases. Complications include ulceration, hyperkeratosis, keloid formation, hyperpigmentation, weeping dermatitis, and severe cosmetic deformity.
Staged excision has become the option of choice for many authors and is described in greater detail. This procedure involves removing only a portion of skin and subcutaneous tissue, followed by primary closure. After approximately 3 months, the procedure is repeated on a different area of the extremity. This procedure is safe, reliable, and demonstrates the most consistent improvement with the lowest incidence of complications.
Preoperative details: Prior to surgery, appropriate documentation is necessary to evaluate the outcome of treatment. This includes photographic documentation as well as extremity measurements. Ideally, these measurements are of limb volume by water displacement, although some rely on circumferential measurements alone. Obtain measurements and photographs at the same time of day each time, document both affected and contralateral extremities, and preferably conduct documentation in the morning after extremity elevation in bed overnight.
Institute strict elevation and pneumatic compression, if available, 24-72 hours prior to surgery. This allows maximum excision to be performed. The extremity must also be free of infection at the time of surgery, and a single dose of preoperative intravenous antibiotic is administered.
After the establishment of appropriate anesthesia, the operative field is sterilized and draped according to surgeon preference.
A pneumatic tourniquet is placed at the root of the extremity and insufflated after the extremity has been exsanguinated.
A longitudinal incision is made along the entire extremity, and skin flaps 1.0-1.5 cm thick are elevated.
Subcutaneous tissue is then excised, taking care not to injure peripheral sensory nerves.
Some authors also excise a strip of deep fascia, but this should not be performed around joints because it may cause instability.
Once the subcutaneous excision is complete, redundant skin is resected. Often, a strip that is 5-10 cm wide may be removed.
The wound is closed over suction drains.
Postoperatively, the extremity is immobilized in a splint and elevated while the patient is placed on strict bedrest.
Antibiotics may be continued until drain removal, according to surgeon preference.
Drains are typically removed at 5-7 days postoperatively, as dictated by a decrease in drain output.
Sutures are removed at 10-14 days and replaced by Steri-Strips.
Measure the patient for a new compression garment when the new dimensions of the extremity have stabilized.
After approximately 10 days, the patient may gradually begin dependency on the extremity with compression bandages or an elastic garment in place.
Once discharged from the hospital, the patient should be seen regularly in the outpatient clinic.
Patients must wear compression garments for 4-6 weeks continuously, and dependency on the involved extremity may be gradually increased at the discretion of the treating physician.
Once healed to physician satisfaction, the patient may return to a normal routine of elevation at night and compression garment therapy during the day.
Follow-up visits should include documentation of circumferential measurement or water displacement of the affected and contralateral extremities as well as photographic documentation.
When staging procedures, allow approximately 3 months between procedures to allow complete healing of the initial operative site.
Anuar I Mitre*, Miguel Modolin, Sami Arap, Marcus Ferreira, Sao Paulo, Brazil
Introduction and Objective: Several factors may cause progressive penis and scrotum swelling associated with an intense local inflammatory process, thickened dermis and lymphatic vessel ectasia. Besides the unaesthetic aspect, the disease evolution may determine voiding problems, sexual dysfunction, lack of local hygiene, infection and even difficult walking in extreme cases. We report our experience with the surgical treatment of genital lymphedema using the modified Charles procedure.
Methods: Between January 1998 and February 2000 fourteen patients with average age of 42.7 years (15-72) with severe lymphedema of the penis and scrotum of different etiologies (table) were treated by the modified Charles surgery. All patients were unable to engage in sexual intercourse due to the lymphedema. Two patients had difficult walking and most complained of voiding problems caused by the excessive penile soft tissues. The procedure consisted in removing all the inflammatory soft tissues of the penis and scrotum, preserving only the basis of the scrotum, which is usually normal. The testicles and spermatic cords are isolated and closure of the scrotum is accomplished with the healthy local skin flap from the preserved scrotal basis. A split thicken skin graft is used to cover the penile shaft. A tubular scrotal drain was left in place for 48 hours.
Results: Median operative time was 2.5 hours (range 2 to 3.5 hours). No significant operative complication was observed. The minimum follow-up was two years. All patients were satisfied with the surgical treatment and benefited in both the cosmetic and functional aspects. All were able to regain sexual function and the voiding dysfunction was alleviated. Only one patient needed an additional scrotum reduction.
Conclusions: Severe genital lymphedema is an unusual condition that can be successfully treated with reconstructive surgery. The modified Charles procedure is a safe and effective operation for these patients.
Translated from Portguese
Surgical Treatments for Lymphedema *editors note - for information only - does not mean I endorse the procedures* Stanford Hospital and Clinics
Inclusion of these pages does not consitute an acceptance of the treatment modality.
The pages are for patient information and education. In situations where I feel the treatments are either ineffective, dangerous or just plain bogus I have added my personal commentary.