Surgical success can be defined as the downgrading of the patient’s lymphedema grades with improved symptoms, at least a 10% decrease in circumferential difference, a decrease in episodes of cellulitis, and improved quality of life.
Surgical cure can be defined as a return to a normal limb circumference and the ability to wean off compressive therapy—in other words, not curing the lymphatic pathology, rather restoring a physiologically compensated limb and return to normal quality of life with surgery.
Tracking outcomes post lymphedema surgeries include limb circumferential or volumetric measurement, skin tonometry, bioelectrical impedance, perometry, bioelectrical impedance, duplex ultrasound, computed tomography, magnetic resonance imaging, indocyanine green lymphography, and lymphoscintigraphy.
A new objective Cheng Lymphedema Grading system presented here aims at standardizing grading for the severity of lymphatic obstruction, selection of procedures, and improved communication about the disease.
Tracking the long-term subjective and objective outcomes, including patient’s report outcomes measures, is mandatory to improve the quality of lymphedema surgeries.
Modern lymphedema care is a growing field, currently defining itself, its breadth, its indications, and its promises. As with any emerging field, it also requires a better-defined framework for debate and effective communication. Due to recent rapid evolution, there still is a relative paucity of outcomes data from which to draw strong conclusions. More data and research are required to determine benchmarks for patient treatment outcomes, a key aspect in the progress of care. The goal of this chapter is to help navigate published data, but also to attempt to fill the required gaps to treat lymphedema patients based on expert opinions for best practice. This chapter outlines a step-by-step approach for postoperative care and management. Lastly, experience with quality of life measures is presented for the various types of lymphedema surgeries. By accruing knowledge of patient-related, subjective outcomes, the field of lymphatic surgery can gauge itself with the ultimate measure of patient satisfaction and in turn reflect on and pave the way for refinement and innovation in technique.
Definitions and Assessing Outcomes
Relatively few ailments can be truly cured in medicine. Instead, we would like to propose definitions for surgical success, surgical failure, and surgical cure in lymphatic microsurgery procedures. Several staging systems exist, with the International Society of Lymphology (ISL) staging being the most accepted by the medical community so far. However, it is difficult to use the ISL staging without objective measurements for surgical patients and apply it to track outcomes. Therefore, we propose the Cheng Lymphedema Grading system for preoperative and postoperative assessment based on objective observations including circumferential difference (CD), lymphoscintigraphy, indocyanine green (ICG) lymphography, episodes of cellulitis in the last year, and quality of life ( Table 26.1 ). This grading system provides easy communication between the surgeon and the patient and between healthcare professionals. Surgical success can be defined as the downgrading of the patient’s lymphedema with at least a 10% decrease in CD, with improved symptoms, decreased episodes of cellulitis, and improved quality of life. Surgical failure can be defined as the inability to improve the symptoms and quality of life, including worsening them. Surgical cure can be defined as a return-to-normal limb circumference and ability to wean off compressive therapy—in other words, not curing the lymphatic pathology, rather restoring a physiologically compensated limb and return-to-normal quality of life with surgery. Fig. 26.1 shows representative grading examples, also depicting the clinical improvement that can be seen with downgrading.
|Grade||CD||Episode of Cellulitis in the Last Year||Taiwan Lymphoscintigraphy Staging||ICG Pattern||Options for Management|
|I||10–19%||<2||Partial obstruction||Linear, splash||CDT, LVA, liposuction|
|II||20–29%||2–4||Total obstruction||Linear, splash, stardust||VLN transfer, LVA|
|III||30–39%||4–6||Total obstruction||Splash, stardust, diffuse||VLN transfer with liposuction or partial excision|
|IV||>40%||>6||Total obstruction||Stardust, diffuse||Excision surgery with VLN transfer|
Schedule of Visits
Postoperative clinic visits are conducted weekly for the first month, then monthly for a year, and then every 3 months afterward unless otherwise guided by symptoms. Visits occur at the same time or in parallel to physiotherapy appointments, depending on the facilities and patient preference. The goals of the early visits are to identify and manage early postoperative complications, ensure timely coordination with other specialists, and maintain good rapport and encouragement among this challenging group of patients. As some studies have found, patient compliance is the most important factor in lymphedema treatment. It is also important to be vigilant and to look for early signs of complications, such as hematoma, dehiscence, wound infection, and flap compromise or decrease in function from early compressive therapy. Fig. 26.2 depicts skin changes that can be seen postoperatively. Later visits mostly aim at maintenance of the surgical result, assessment of need for revisionary surgery, and adjunctive liposuction, as needed.
There is no global consensus on how to best measure and define the limb volume changes in lymphedema or how to assess progress or regression with treatment. Limb measurement is important to track surgical results and outcomes, and to ease communication between the surgeon and the patient and between healthcare professionals, as mentioned. The CD obtained from these measurements is a key objective parameter in the grading system introduced in this chapter. Modern lymphedema care requires such limb measurement standardization for diagnosis and grading. Several modalities exist and are discussed and compared in the literature, including circumferential tape measurement, water displacement, skin tonometry, perometry, bioelectrical impedance, and computed tomography (CT). Further investigation to find an easier and universal measurement may help global communication among lymphedema specialists.
Limb volume can be determined by using Archimedes’ principle of water displacement. The limb is placed in a container housing a volume of water that can be displaced outside the container and measured. Water displacement is considered by some to be the gold standard in the laboratory, but not necessarily in the clinical setting, as this method of volume measurement is not amenable to patients with open wounds, is cumbersome, and reveals no information about the localization of the edema in the limb. Furthermore, it may be difficult to perform in severe, higher-grade lower limb lymphedema.
Circumferential Tape Measurement
Tape measurements are easily performed at every postoperative visit. In our institution, measurements for limb lymphedema are taken at 10 cm above and below the elbow joint for the upper limb and at 15 cm above and below the knee and 10 cm above the ankle for the lower limb. If limb volumes are desired, they can be approximated by calculation of the volume of a frustum, CT, or magnetic resonance imaging (MRI). Serial measurements are used to track improvement in limb size and also to determine when patients reach a plateau in circumferential reduction.
As shown in Fig. 26.3A–D , CD is defined as the circumference of the lesion limb minus the healthy limb, divided by that of the healthy limb. Circumferential reduction rate (RR) is defined as the preoperative difference between the circumferences of the lesion and healthy limbs minus the postoperative difference, divided by the preoperative difference. As an example, in a study of vascularized lymph node transfer (VLNT) for upper limb lymphedema, at a mean follow-up of 39 months, the mean improvement of CD was 7% and the RR was 40% in postmastectomy upper limb lymphedema.
There are several advantages to this measurement modality:
Circumferential tape measurement can be performed readily in many settings.
It is a test that does not have to be performed or administered by a doctor.
It is low cost, accessible, and easily reproducible.
It does not require special equipment.
It does not expose the patient to radiation.
With this modality, it is easy to compare the improvement of lymphatic microsurgery ( Fig. 26.4 ). A comparative study between different modalities for limb volume measurement concluded that, compared to water displacement volumetry, circumferential measurement has better reliability and that this technique should be considered as the method for lymphedema measurement in clinical practice.
A tonometer measures tissue tension, which is representative of tissue resistance to compression. As lymphedema worsens with fibrotic change, the tissue becomes firmer. Postoperatively, tonometry can be used to assess the improvement in tissue tension as lymphedema improves, especially in cases where frank fibrotic change has not set in. Skin tonometry assesses only the skin tension of the superficial compartment, which may not accurately represent any deep-compartment pathology.
Perometry is an optoelectronic volumetry device that uses infrared light to measure cross-sectional areas of a limb. The limb is placed in the perometer’s frame, which scans the limb longitudinally, and a computer then integrates this information to obtain a volume. Standard deviations of 8.9 mL, or about 0.5% of arm volume, have been reported. Perometers, although not readily available, are validated measuring tools.
Bioelectrical impedance determines the amount of extracellular fluid in a limb via resistance to an electrical current. The current is passed through the limb via standardized electrodes, and resistance is determined at various points. With increasing fluid content, resistance lowers. The measurement is rapid and can be readily used in community settings, and it is reliable. However, a study by Fu showed that bioelectrical impedance has low sensitivity and can miss about 20% of lymphedema cases. The advantages of its postoperative use are ease of measurement in the clinic and ability to place electrodes away from wounds. However, values can take time to normalize as postoperative changes such as edema resolve and the results of surgery become evident.
Duplex ultrasound is used not only preoperatively for the assessment of venous competence but also postoperatively if there is any sign of venous incompetence or varicose veins becoming engorged with lymphedema improved. In our institution, duplex ultrasound examination is also performed at 6 months postoperatively to count the number of lymph nodes transferred and document pedicle patency and vessel diameters.
CT scans have an important role preoperatively and postoperatively for several reasons. This imaging modality, exemplified in Fig. 26.5 , can show the current state of lymphedema and its improvement and areas of poor lymphatic drainage and allow exact volume measurement. In our institution, CT scans are performed preoperatively and at 6 months postoperatively. They also represent valuable comparative data with preoperative scans.