title: Lymphaticovenular bypass for lymphedema management in breast cancer patients: a prospective study.
abstract: BACKGROUND
  Lymphedema is a common and debilitating condition. Management options for lymphedema are limited and controversial. The purpose of this prospective study was to provide a preliminary analysis of lymphaticovenular bypass for the treatment of upper limb lymphedema in breast cancer patients.
  
  
  METHODS
  Twenty patients with upper extremity lymphedema secondary to treatment of breast cancer underwent lymphaticovenular bypass using a "supermicrosurgical" approach. The mean age of the patients was 54 years, 16 patients had received preoperative radiation therapy, and all patients had received axillary lymph node dissection. The mean duration of lymphedema was 4.8 years, and the mean volume differential of the lymphedematous arm compared with the unaffected arm was 34 percent. Evaluation included qualitative assessment and quantitative volumetric analysis before surgery and at 1 month, 3 months, 6 months, and 1 year after the procedure.
  
  
  RESULTS
  The mean number of bypasses performed per patient was 3.5 (range, two to five), and the size of bypasses ranged from 0.3 to 0.8 mm. The mean operative time was 3.3 hours (range, 2 to 5 hours). Hospital stay was less than 24 hours for all patients. The mean follow-up time was 18 months. Nineteen patients (95 percent) reported symptom improvement following surgery, and 13 patients had quantitative improvement. The mean volume differential reduction was 29 percent at 1 month, 36 percent at 3 months, 39 percent at 6 months, and 35 percent at 1 year. No patients experienced postoperative complications or lymphedema exacerbation.
  
  
  CONCLUSIONS
  Lymphaticovenular bypass may effectively reduce the severity of lymphedema in breast cancer patients. Long-term analysis is needed.
authors.affiliation: Houston, Texas From the Department of Plastic Surgery, University of Texas M. D. Anderson Cancer Center.
authors.forename: David W
authors.initials: DW
authors.lastname: Chang
mesh_terms: D000714:Anastomosis, Surgical; D001943:Breast Neoplasms / Q000601:surgery*; D005260:Female; D006801:Humans; D042601:Lymphatic Vessels / Q000601:surgery*; D008209:Lymphedema / Q000209:etiology* / Q000601:surgery*; D008408:Mastectomy / Q000009:adverse effects*; D008875:Middle Aged; D011446:Prospective Studies
references.citation: Kissin MW, Querci della Rovere G, Easton D, Westbury G. Risk of lymphoedema following the treatment of breast cancer. Br J Surg. 1986;73:580–584.
references.citation: Mazeron JJ, Otmezguine Y, Huart J, Pierquin B. Conservative treatment of breast cancer: Results of management of axillary lymph node area in 3353 patients. Lancet 1985;1:1387.
references.citation: Erickson VS, Pearson ML, Ganz PA, Adams J, Kahn KL. Arm edema in breast cancer patients. J Natl Cancer Inst. 2001;93:96–111.
references.citation: Fleissig A, Fallowfield LJ, Langridge CI, et al. Post-operative arm morbidity and quality of life: Results of the ALMANAC randomised trial comparing sentinel node biopsy with standard axillary treatment in the management of patients with early breast cancer. Breast Cancer Res Treat. 2006;95:279–293.
references.citation: Langer I, Guller U, Berclaz G, et al. Morbidity of sentinel lymph node biopsy (SLN) alone versus SLN and completion axillary lymph node dissection after breast cancer surgery: A prospective Swiss multicenter study on 659 patients. Ann Surg. 2007;245:452–461.
references.citation: Lucci A, McCall LM, Beitsch PD, et al. Surgical complications associated with sentinel lymph node dissection (SLND) plus axillary lymph node dissection compared with SLND alone in the American College of Surgeons Oncology Group Trial Z0011. J Clin Oncol. 2007;25:3657–3663.
references.citation: Fisher B, Redmond C, Fisher ER, et al. Ten-year results of a randomized clinical trial comparing radical mastectomy and total mastectomy with or without radiation. N Engl J Med. 1985;312:674–681.
references.citation: Veronesi U, Paganelli G, Viale G, et al. A randomized comparison of sentinel-node biopsy with routine axillary dissection in breast cancer. N Engl J Med. 2003;349:546–553.
references.citation: Wilke LG, McCall LM, Posther KE, et al. Surgical complications associated with sentinel lymph node biopsy: Results from a prospective international cooperative group trial. Ann Surg Oncol. 2006;13:491–500.
references.citation: Sakorafas GH, Peros G, Cataliotti L, Vlastos G. Lymphedema following axillary lymph node dissection for breast cancer. Surg Oncol. 2006;15:153–165.
references.citation: Koshima I, Inagawa K, Urushibara K, Moriguchi T. Supermicrosurgical lymphaticovenular anastomosis for the treatment of lymphedema in the upper extremities. J Reconstr Microsurg. 2000;16:437–442.
references.citation: Charles RH. Elephantiasis scroti. In: Latham A, English TC, eds. A System of Treatment, Vol. III. London: Churchill Livingstone; 1912:504–513.
references.citation: Sistrunk WE. Contribution to plastic surgery: Removal of scars by stages; an open operation for extensive laceration of the anal sphincter; the Kondoleon operation for elephantiasis. Ann Surg. 1927;85:185–193.
references.citation: Thompson N. The surgical treatment of chronic lymphoedema of the extremities. Surg Clin North Am. 1967;47:445–503.
references.citation: Thompson N. Buried dermal flap operation for chronic lymphedema of the extremities: Ten-year survey of results in 79 cases. Plast Reconstr Surg. 1970;45:541–548.
references.citation: O'Brien BM, Khazanchi RK, Kumar PA, Dvir E, Pederson WC. Liposuction in the treatment of lymphoedema; a preliminary report. Br J Plast Surg. 1989;42:530–533.
references.citation: Brorson H, Svensson H. Liposuction combined with controlled compression therapy reduces arm lymphedema more effectively than controlled compression therapy alone. Plast Reconstr Surg. 1998;102:1058–1067.
references.citation: Ho LC, Lai MF, Kennedy PJ. Micro-lymphatic bypass in the treatment of obstructive lymphoedema of the arm: Case report of a new technique. Br J Plast Surg. 1983;36:350–357.
references.citation: Kleinhans E, Baumeister RG, Hahn D, Siuda S, Bull U, Moser E. Evaluation of transport kinetics in lymphoscintigraphy: Follow-up study in patients with transplanted lymphatic vessels. Eur J Nucl Med. 1985;10:349–352.
references.citation: Campisi C. Use of autologous interposition vein graft in management of lymphedema: Preliminary experimental and clinical observations. Lymphology 1991;24:71–76.
references.citation: Campisi C, Boccardo F. Lymphedema and microsurgery. Microsurgery 2002;22:74–80.
references.citation: Becker C, Assouad J, Riquet M, Hidden G. Postmastectomy lymphedema: Long-term results following microsurgical lymph node transplantation. Ann Surg. 2006;243:313–315.
references.citation: Lin CH, Ali R, Chen SC, et al. Vascularized groin lymph node transfer using the wrist as a recipient site for management of postmastectomy upper extremity lymphedema. Plast Reconstr Surg. 2009;123:1265–1275.
references.citation: Laine JB, Howard JM. Experimental lymphatic-venous anastomosis. Surg Forum 1963;14:111–112.
references.citation: Yamada Y. Studies on lymphatic venous anastomosis in lymphedema. Nagoya J Med Sci. 1969;32:1–21.
references.citation: O'Brien BM, Sykes P, Threlfall GN, Browning FS. Microlymphaticovenous anastomoses for obstructive lymphedema. Plast Reconstr Surg. 1977;60:197–211.
references.citation: O'Brien BM, Shafiroff BB. Microlymphaticovenous and resectional surgery in obstructive lymphedema. World J Surg. 1979;3:3–15.
references.citation: O'Brien BM, Mellow CG, Khazanchi RK, Dvir E, Kumar V, Pederson WC. Long-term results after microlymphaticovenous anastomoses for the treatment of obstructive lymphedema. Plast Reconstr Surg. 1990;85:562–572.
references.citation: Degni M. New technique of lymphatic-venous anastomosis (buried type) for the treatment of lymphedema. Vasa 1974;3:479–483.
references.citation: Degni M. New technique of lymphatic-venous anastomosis for the treatment of lymphedema. J Cardiovasc Surg (Torino) 1978;19:577–580.
references.citation: Fox U, Montorsi M, Romagnoli G. Microsurgical treatment of lymphedema of the limbs. Int Surg. 1981;66:53–58.
references.citation: Gloviczki P, Fisher J, Hollier LH, Pairolero PC, Schirger A, Wahner HW. Microsurgical lymphovenous anastomosis for treatment of lymphedema: A critical review. J Vasc Surg. 1988;7:647–652.
references.citation: Unno N, Inuzuka K, Suzuki M, et al. Preliminary experience with a novel fluorescence lymphography using indocyanine green in patients with secondary lymphedema. J Vasc Surg. 2007;45:1016–1021.
references.citation: Ogata F, Narushima M, Mihara M, Azuma R, Morimoto Y, Joshima I. Intraoperative lymphography using indocyanine green dye for near-infrared fluorescence labeling in lymphedema. Ann Plast Surg. 2007;59:180–184.
references.citation: Toole BP. Hyaluronan and its binding proteins, the hyaladherins. Curr Opin Cell Biol. 1990;2:839–844.
references.citation: Banerji S, Ni J, Wang SX, et al. LYVE-1, a new homologue of the CD44 glycoprotein, is a lymph-specific receptor for hyaluronan. J Cell Biol. 1999;144:789–801.
references.citation: Matsui K, Breitender-Geleff S, Soleiman A, Kowalski H, Kerjaschki D. Podoplanin, a novel 43-kDa membrane protein, controls the shape of podocytes. Nephrol Dial Transplant. 1999;14(Suppl 1):9–11.
references.citation: Wigle JT, Harvey N, Detmar M, et al. An essential role for Prox1 in the induction of the lymphatic endothelial cell phenotype. EMBO J. 2002;21:1505–1513.
references.citation: Suami H, Taylor GI, Pan WR. A new radiographic cadaver injection technique for investigating the lymphatic system. Plast Reconstr Surg. 2005;115:2007–2013.
references.citation: Suami H, O'Neill JK, Pan WR, Taylor GI. Perforating lymph vessels in the canine torso: Direct lymph pathway from skin to the deep lymphatics. Plast Reconstr Surg. 2008;121:31–36.
references.citation: Suami H, Taylor GI, O'Neill J, Pan WR. Refinements of the radiographic cadaver injection technique for investigating minute lymphatic vessels. Plast Reconstr Surg. 2007;120:61–67.
references.citation: Shin WS, Szuba A, Rockson SG. Animal models for the study of lymphatic insufficiency. Lymphat Res Biol. 2003;1:159–169.
references.citation: Hadamitzky C, Pabst R. Acquired lymphedema: An urgent need for adequate animal models. Cancer Res. 2008;68:343–345.