Immediate Lymphatic Reconstruction

Key Points

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The Lymphatic Microsurgical Preventative Healing Approach, or immediate lymphatic reconstruction (ILR), is a surgical procedure for the prevention of lymphedema (LE).
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This procedure is performed by trained microsurgeons in patients at high risk for the development of LE (e.g., patients undergoing lymphadenectomy).
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In ILR, divided lymphatics are identified immediately after the completion of lymph node dissection and lymphovenous anastomoses are created between the extremity lymphatics and the peripheral venous system to restore physiologic lymphatic flow.
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The prevention of LE can have tremendous implications for patient quality of life and can result in decreased healthcare utilization and associated costs.

Introduction

The Lymphatic Microsurgical Preventative Healing Approach (LyMPHA) was first described by Boccardo et al. in 2009 as a surgical technique for the primary prevention of breast cancer–related lymphedema (BCRL). Since then, it has been used for the primary prevention of other malignancies involving lymph node excision. In this chapter, we will refer to this technique as immediate lymphatic reconstruction (ILR) as divided extremity lymphatics are reconstructed at the time of the extirpative procedure. Prior to the advent of ILR, efforts focused primarily on the treatment of chronic lymphedema (LE) ( ).

Conservative treatment for chronic LE can be characterized as largely palliative in nature and involves lifelong participation in complete decongestive therapy (CDT), use of compression garments, and supervised physical activity. Insurance coverage for these therapies is variable and presents a significant barrier for those attempting to access regular care. Furthermore, patients living with BCRL are at continued risk for a high complication profile including recurrent infections, psychosocial distress, and diminished quality of life.

Historically, patients who were refractory to conservative management were considered for surgical intervention. The Charles procedure, initially reported in 1912 for the treatment of scrotal LE, involves a radical excision of the skin, subcutaneous tissue, and deep fascia. While the Charles procedure is still performed today in the most extreme cases, most often for lower extremity LE, less invasive procedures are now available for treatment.

The modern era of lymphatic surgery for chronic LE includes debulking procedures (e.g., power-assisted liposuction), vascularized lymph node transplant, and lymphovenous bypass. We term these procedures “delayed lymphatic reconstruction.” Despite tremendous improvement in the quality of life and objective volumetric reductions in patients treated with delayed lymphatic reconstruction, there remains no cure.

Concepts

This chapter will focus on ILR for the breast cancer patient. Early experience and data also demonstrate efficacy for malignancies affecting the lower extremity and will be briefly discussed at the end of the chapter.

Breast cancer patients diagnosed with invasive disease had a poor prognosis before the advent of the Halsted mastectomy. Halsted introduced a radical operative strategy that involved resection of the tumor, pectoral muscles, lymphatic vessels, and axillary lymph nodes. This led to increased survival but was associated with high rates of postoperative LE. Subsequent studies demonstrating the efficacy of systemic therapy and radiation, combined with smaller resections, have led to the emergence of minimally invasive approaches. Similar trends can be observed in the approach to the axilla. The sentinel lymph node biopsy was instrumental in reducing the need to perform an axillary lymph node dissection (ALND), thereby reducing the rates of LE from 10–40% to 0–7%. Moreover, there is more recent evidence to suggest that ALND may not be needed in the management of node-positive axilla (stages T1 and T2). Further, the advent of axillary reverse mapping allowed for the identification, visualization, and preservation of arm lymphatics. However, this technique carries the risk of residual occult malignancy in the axilla and therefore has not gained universal acceptance.

In breast cancer patients, there are three major risk factors for the development of LE:

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ALND
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Regional lymph node radiation (RLNR)
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Elevated body mass index (BMI, kg/m ²)

Patient Selection

Patients diagnosed with breast cancer undergoing ALND are considered for ILR. In our experience, this patient cohort has node-positive disease and frequently undergoes neoadjuvant chemotherapy. Most patients receive adjuvant treatment, including RLNR, further compounding BCRL risk.

Patients with established disease undergoing ALND are considered eligible for ILR. Boccardo et al. proposed that important indications for the LyMPHA technique in these patients include a BMI ≥30 kg/m ² (at highest risk) and a transit index on lymphoscintigraphy of ≥10. They contend that patients who do not meet these criteria should not be considered as surgical candidates. At our institution, all patients undergoing ALND are offered ILR. Elevated patient BMI is not a parameter used as an indication for ILR at our institution as statistical support for the use of this criteria in patients is lacking. Further, it could have the inimical effect of preventing a subset of women from undergoing this procedure. Similarly, we do not routinely perform preoperative lymphoscintigraphy in this patient cohort.

Preoperative Considerations

At our institution, all patients have their baseline LE measurements taken preoperatively by certified LE therapists. These include bioimpedance spectroscopy, perometry, and circumferential measurements of both extremities. Circumferential measurements are converted to volume using the truncated cone formula. We also administer the Short Form 36 Health Survey to all patients every 6 months. This survey provides data on physical functioning (physical component scale) and mental health, emotional, and social functioning (mental component scale). In addition, although not clinically validated for use in patients without LE, we utilize the Lymphedema Quality of Life (LYMQOL) to track quality of life measures every 6 months. Pertinent patient data, including demographics, medical history, cancer characteristics, and treatment, and baseline LE measurements are entered into a REDCap Lymphedema Quality Improvement clinical database in order to facilitate surveillance.

Surgical Technique

ICG Lymphography

Following the induction of general anesthesia, preoperative ICG lymphography is universally performed to visualize the superficial lymphatic drainage pattern of the affected extremity, in which 0.1 mL of stock (0.625 mg/mL) ICG solution with albumin is prepared and injected intradermally into the first and fourth volar web spaces, the distal third of the volar forearm, and over the cephalic vein 4 cm proximal to the antecubital crease of the operative extremity. The PDE-Neo (Hammamatsu, Japan) is used to visualize and capture images of the lymphatic channels, and a report is generated documenting the patient’s baseline lymphatic anatomy. These images are stored and can be used as reference by the LE therapists to guide therapy if concern for LE arises during surveillance.

ILR: Dye Injection

Immediately prior to the start of the ALND (typically involving level I and II nodes), we inject a 2% fluorescein isothiocyanate (FITC) and albumin solution into the upper medial arm. Specifically, we inject 0.25 mL into the dermis at two sites 4 cm apart from one another. An additional 0.25 mL of this solution is injected at the level of the muscle fascia, with care to avoid inadvertent puncture of the brachial artery, at these two sites. We have previously described the benefits of FITC for ILR and find it especially useful if the breast surgeon plans on injecting blue dye into the breast. However, if no blue dye will be utilized by the breast team, isosulfan blue dye can be used for ILR and was the dye used in the original description of the procedure.

ILR: Surgical Approach

Immediately after completion of the ALND, we utilize a Bookwalter retractor set with Kelley blades (1″ by 2.5″) (Codman Inc., Raynham, MA, USA) to expose the axillary bed ( Fig. 22.1 ). The bed is then carefully evaluated, and a tributary of the axillary vein with appropriate length (~5 cm) is identified. Early in our experience, performing the ALND with the breast team helped increase the chances of an appropriate vein being preserved. The most common vein utilized is the accessory vein, which arises from the axillary vein and, most commonly, travels 2 cm anterior and parallel to the thoracodorsal vessels through the axillary bed ( Fig. 22.2 ). When not present or compromised, other veins coursing along the chest wall or, less commonly, more laterally located veins can be dissected. Significant variation in venous anatomy has been noted. Of note, the presence or absence of valves can often be visualized during dissection of the vein. Competent valves are critical to minimize back-bleeding from the vein. During dissection, care is taken to avoid injury to the intercostobrachial nerve and long thoracic nerve. The vein is then doubly clipped distally and rotated to the proximal arm. Adventitial stripping is performed in a standard manner. Ideally, there is no back-bleeding from the vein. Although not optimal, minimal venous back-bleeding is acceptable as the patient is under positive pressure ventilation and, presumably, the direction of flow will reverse after extubation. The decision of whether or not to bypass to a back-bleeding vein is ultimately at the discretion of the surgeon.