The Combination of Lymph Node Transfer and Excisional Procedures in Bilateral Lower Extremity Lymphedema: Clinical Outcomes and Quality of Life Assessment with Long-Term Follow-Up

Abstract

Background: Bilateral lower extremity lymphedema is a rare and invalidating condition that poses a great challenge to the scientific community, and deeply affects the quality of life (QoL) of affected patients. A combined protocol consisting of lymph node transfer and a reductive method have never been reported for the treatment of this condition, except for small case series with brief follow-up periods.

Methods: This retrospective study analyzed data of 29 patients, mean age 51 ± 17.1 years, who had been diagnosed with bilateral lower extremity lymphedema. Gastroepiploic vascularized lymph node transfer was performed in all the patients, and an excisional procedure was associated according to the clinical stage. Clinical history, circumferential limb measurements, complications, episodes of cellulitis, and responses to the Lymphedema Quality of Life Questionnaire were analyzed.

Results: The mean follow-up was 38.4 ± 11.8 months. A significant reduction in the episodes of cellulitis per year was observed (p < 0.001). In our series, BMI and duration of symptoms were significantly related to the development of cellulitis during the postoperative period, p = 0.006 and p = 0.020, respectively. The LYMQoL questionnaire showed a significant quality of life improvement from 3.4 ± 0.9 to 6.2 ± 0.8 (p < 0.05).

Conclusions: An integrated approach is essential for the treatment of bilateral lower extremity lymphedema: reductive and reconstructive methods are complementary to achieve a successful outcome. Timely treatment and BMI reduction are relevant in order to decrease the number of episodes of cellulitis. An attentive follow-up is necessary to identify recurrence and treat affected patients in time.

Keywords: LYMQoL questionnaire; bilateral lymphedema; liposuction; lymph node flap; lymphedema; lymphedema of the lower limbs; modified Charles procedure; primary lymphedema; quality of life; vascularized lymph node transfer.

Figure 1

(a) Preoperative picture. The curved incision line is depicted in black. The course of posterior tibial artery (PTA) is highlighted, and the future position of gastroepiploic lymph node flap is simulated. (b) Gastroepiploic lymph node flap. The flap is positioned on a separate table for vessel preparation under the operative microscope. The vessel loops trace the path of the gastroepiploic vessels. (c) After the whole flap is anastomosed to one ankle, the vessels highlighted by the median loop are divided and the distal half of the flap is transferred to the contralateral ankle.

Figure 2

Authors’ two-stage protocol for bilateral lymphedema treatment—moderate clinical grade. * Two microscopes should be available. GE-VLNT—gastroepiploic-vascularized lymph node transfer; LPS—laparoscopic team; PRS: plastic reconstructive surgery team.

Figure 3

Authors single-stage protocol for bilateral lymphedema treatment—advanced clinical grade. GE-VLNT—gastroepiploic-vascularized lymph node transfer; LPS—laparoscopic team; PRS-RED—reduction team; PRS-PHY—physiologic procedure team; RL—right lower limb; LL—left lower limb. * RRPP could be performed instead of Charles’ procedure. ** Tourniquet is released before vessel preparation.

Figure 4

(a) Preoperative picture of a 59-year-old female patient. The patient was affected with stage II bilateral secondary lymphedema; the left lower limb was more severely affected. Bilateral GE-VLNF was transferred, and suction lipectomy was performed during the second surgical stage. A unilateral lymphedema progression was observed during follow-up, and we had to plan a step forward in the surgical protocol: a Charles’ procedure was performed to treat the left lower limb. (b) Twenty-four-month post operative picture shows a satisfactory result. Charles’ procedure was carried out on the left limb. Right limb did not require any further treatment.