Lymphatic surgery in Quebec. Pathways Vol 7, No 3. Summer 2018.

Surgical Report

Lymphatic surgery in Quebec

The scalpel of hope Snapshots of Canada’s foray into lymphatic surgery Interviews conducted by Anne-Marie Joncas and Anna Towers

Tangible hope is rare in the lymphedema world. But, encouraging news is coming from Quebec where lymphatic surgery is now being performed at two major medical centres in Montreal; the Centre hospitalier universitaire de Montréal (CHUM) and Hôpital Maisonneuve-Rosemont (HMR). L’info AQL (the Quebec publication on lymphedema) met with the microsurgeons to answer the main questions of patients who are considering this strategy.

THE CHUM TEAM. (Left to right) Dr. Michel-Alain Danino, Dr. Ali Izadpanah and Dr. Laurence Paek acquired the special equipment and organized multidisciplinary services that enabled them to put their microsurgical knowledge at the service of lymphedema. Together, they perform venous lymphatic drainage surgery (also called lymphatic venous anastomosis (LVA).

What motivated the CHUM to get involved in lymphatic surgery?

We wanted to create a comprehensive care package, integrating surgery, now a wellaccepted option in the scientific literature.

For ten years, we worked to create a coherent team. Our young residents learned the super microsurgical techniques and use of our Mitaka microscope that magnifies structures up to 80 times, allowing them to work in a submillimetric environment. In 2018, surgeons at the CHUM will operate on 12 candidates, including the two patients who received LVA at the beginning of the year.

How does lymphatic venous drainage (or LVA) surgery work?

LVA works like “plumbing”. For this operation, very small lymphatic vessels measuring barely 0.1 to 0.2 mm are connected to tiny veins. LVA is well suited to early stage 1 and 2 lymphedema. It is not indicated for already fibrosed lymphatic vessels characteristic of more advanced lymphedemas. We use Indocyanin green imaging (ICG) before surgery to assess the condition of affected limbs. LVA has very little morbidity; this is limited to scars and infections. One might even be tempted to say that the only risk of

Anne-Marie Joncas is a patient who chose to put her communication expertise at the service of the Lymphedema Association of Quebec and other related organizations. Editor of L’info AQL, she is leading Strategic plans for the LAQ and provincial expansion of support groups.

Anna Towers MD, FACP, is Associate Professor of Oncology, McGill University and Director of the Lymphedema Program, McGill University Health Centre (MUHC), Montreal.

Summer 2018

B1167_CLF_Pathways_Sum2018.indd 5

“After surgery, the patient must know how to adapt to his new lymphedema.” – Dr. Danino LVA is that it might not produce any results, all without aggravating the lymphedema as it existed before surgery. The earlier it is performed, the better the chances of success.

How does lymph node transfer (LNT) compare to LVA? Nodal transfer is a “transposition” of the nodes. Unlike LVA, which has a 20-year history, LNT is still in its infancy. The possibility exists of great morbidity, since the donor site is deprived of some of its lymph nodes. There is a risk of lymphedema and dystrophic scarring developing at the donor site, as well as a risk of necrosis at the recipient site. Moreover, the mechanisms of Ly m p h e d e m a p a t h w a y s . c a 5

2018-05-15 12:32 PM

LNT are not yet clarified and the sustainability of results is not sufficiently studied. Some believe that the improvement attributed to LNT is due to the release, during the procedure, of scars, tissue or of the axillary vein, rather than the presence of transferred lymph nodes. Few randomized studies are available to compare the results obtained by these different techniques.

What realistic expectations can patients have after surgery?

It is important to realize that lymphedema is caused by damaged lymph vessels that

cannot be repaired. Lymphedema will always remain. For the leg and arm, the patient can expect less pain, heaviness and infection.

Over time, there may be a reduction in time spent in compressive garments, as well as a reduction in compression class. But almost all patients will still need to wear their compression garments for life. Significant results could be observed at three months.

We expect a 40% decrease in excess volume for 80% of patients. The studies confirm for the moment that the results are maintained for 3 to 4 years, but there is a lack of data for longer periods. Lymphatic surgery for primary Tracing the viable lymphatic network detected through imagery, in preparation for LVA surgery. lymphedema potentially has an outcome similar to that of secondary lymphedema.

However, in general and as reported by several centers, primary lymphedema cases have inferior surgical outcomes. This remains a “case by case” situation.

What profile are you looking for in your surgical candidates?

Candidates should be healthy, not obese and not responding well to decongestive lymphatic therapy (DLT). They should already have been very compliant with their treatment for a minimum of six months before surgery. DLT is very important to maintain after the surgery, since the surgery causes acute swelling that needs to be controlled by the team (physiotherapist and patient). The patient needs to remain observant in self-management. The patient has to be engaged in their own care, as we would not want to perform an operation that would lead to failure.

Is the CHUM lymphatic surgery program open to all patients?

The CHUM team will welcome all patients from Quebec who are candidates for surgical treatment of lymphedema. This includes women with breast cancer related lymphedema. In this case, breast reconstruction by abdominal flap (DIEP) with simultaneous lymph node transfer would be possible. If necessary, lymphatic venous anastomosis surgery could be added later.

6 Ly m p h e d e m a p a t h w a y s . c a

B1167_CLF_Pathways_Sum2018.indd 6

Summer 2018

2018-05-15 12:32 PM

What does the surgical process involve for LVA? The patient is evaluated by both the surgeon and the physiotherapy department.

Before surgery, a patient with primary lymphedema will have a CT scan to check the lymph nodes. Both those with primary and secondary lymphedema will undergo lymphoscintigraphy and ICG to assess the state of the lymphatic system. After discussing the case as a group, we work as a team of two surgeons in the operating room. One sutures, while the other facilitates the work of his colleague. LVA surgery lasts 3-5 hours under general anesthesia. This is a day surgery. The patient is discharged

with an elastic tensor bandage to keep on for one week. All compression and decongestive lymphatic therapy (DLT) treatments are suspended for three weeks and the operated limb is maintained in elevation. Once the anastomoses have healed, DLT is reintroduced. Return to work takes place after 2-3 weeks.

What is the role of the CHUM physiotherapy team?

Mélanie Robitaille, PT and her team follow up with patients after the operation, performing manual lymphatic drainage, applying multilayer bandages and taking measurements.

The patient must be diligent in coming for

“ The patient must be competent in monitoring his body and skillful in self-management strategies.”

– Dr. Izadpanah

physiotherapy follow-up care at the CHUM. We will collect volumetric and circumferential measurements over several years, as well as quality of life questionnaires to help us determine the ideal LVA sites and the number of LVA needed to achieve optimal results.

This is the focus of our research.

OPTIONS AT HÔPITAL MAISONNEUVE-ROSEMONT (HMR) With 55 lymph super microsurgical procedures performed during her Fellowship in lymphatic surgery, Dr. Marie-Pascale Tremblay-Champagne of HMR offers lymphaticovenous anastomosis and lymph node transfer, depending on the severity of the damage to the lymphatic system.

Does lymphatic surgery require special training?

When we operate on the lymphatic vessels— which are very fragile and smaller than veins— we speak of super microsurgery, the grade of difficulty being higher than traditional microsurgery. Lymphatic surgery requires lymphedema specific training and practice since the techniques and instruments are different. At the HMR, LVA and LNT are performed under general anaesthesia and last 8 to 12 hours. The HMR team estimates that it can perform 30 lymphatic surgeries per year.

What are the risks associated with lymphatic surgery?

For LVA, there is risk of infection (6 - 8%) prevented by the administration of pro-

phylactic antibiotics for one week. The need to follow a protocol without compression to protect the anastomoses for 2 to 3 weeks after surgery also creates a risk of lymphedema decompensation for 1 to 2 months. A risk of induced lymphedema at the donor site is inherent in LNT (2% in the groin reported in the literature). Reverse mapping technology can reduce risk by identifying less essential lymph nodes. Also lymph nodes tend to be harvested from places where they are abundant. Usually, 3 to 8 nodes are transferred. LNT can be performed simultaneously with breast reconstruction

by DIEP (Deep inferior epigastric perforator).

During the operation, the scarred and fibrosed tissues are removed and the axillary vein decompressed.

Right arm of a patient of Dr Tremblay-Champagne showing pre-operative swelling, sutures in place and post-operative bandaging.

Summer 2018

B1167_CLF_Pathways_Sum2018.indd 7

How does LNT surgery work?

LNT is thought to act as a sponge to absorb interstitial liquid and to recreate some lymphatic network. European studies have focused on patients who had an axillary node dissection and radiotherapy, and who showed a lack of lymphatic network on imaging. One year after LNT, 80-83% of these patients had some lymphatic network in the armpit and descending into the arm. No cases of deterioration in the affected limb after LVA and LNT have been reported in the literature.

What determines the technique to be used?

For LVA, the lymphatic vessels must still function. A person with primary lymphedema (legs, genital) for 20 years is statistically less likely to have functional vessels. However, lymphangiography (Spy ICG) or targeted MRI can be used to check the status of the network of an individual. LVA is not indicated in a person with no functional lymphatic vessels, venous insufficiency (leg lymphedema) or obesity (BMI of 30 or more).

People without functional vessels, but who still have pitting edema (predominance of fluid), may still be candidates for LNT. In the case of venous insufficiency with Ly m p h e d e m a p a t h w a y s . c a 7

2018-05-15 12:32 PM

“Waiting 6 to 12 months before surgery allows natural improvement of secondary lymphedema in highly observant patients.”

two years. MRI lymphoimaging will soon be implemented at the HMR to ensure followup in accordance with the techniques found in the current literature. Patients will be followed every 3 months for the first year, then annually for the long term.

– Dr. Tremblay-Champagne

What can one expect after surgery?

Recovery initially involves minimal pain lymphedema, the final results at 1 or 2 years for LVA and moderate pain for LNT. The remain unpredictable. For the obese person, guidelines for LNT are to avoid compressing LNT could lead to additional complications the chest on the operated side for 2 to 3 and more mixed results. weeks and to maintain a distance between the chest and the arm to protect the armpit, How long should a person wait day and night. Compression and manual after cancer treatment before surgery? lymphatic drainage can be resumed soon A minimum of 6 to 12 months after after LNT, but with LVA there is a relative chemotherapy and one year after radiation contraindication to compression for the first therapy is required to allow for few weeks. For LNT, the an improvement in secondary operated limb is bandaged The target patient for lymphedema in highly with Coban in the operating LVA or LNT is an observant patients. Patients room and for 2 weeks. adult with secondary who see a deterioration in This dressing must be lymphedema due to their condition despite DLT or changed every 2 days, cancer or post-trauma, who reach an uncomfortable a service which is not stage 2 or less with therapeutic plateau may always offered by the pitting edema. The target benefit from surgery. community health care patient should be nonsystem. Afterwards, the obese, without venous What results can patient must self-apply problems in the case of one expect? multilayer bandages. The the legs, should be highly You may have to wait at observant of compression, patient should plan for the least 6 months before seeing cost of single-use dressings DLT and experiencing measurable results. At three (Coban), reusable multia deterioration in months, patients often feel layer bandages (Comprilan quality of life despite better, but without an impact and CompriFoam) and all conservative treatments. on measurements. An average subsequent compression Major cardiopulmonary decrease in excess volume of garments for the duration. comorbidities or stage 4 40 to 60% at one year can be The return to work (without cancer under treatment achieved for 85% of patients physical effort) for LVA is are exclusion criteria. and changes can be observed about 3 weeks and about Children are not up to two years after surgery.

6 weeks for LNT. The candidates for Only 8% of patients will see no patient must continue to these surgeries. change. Data based on 5-year follow the precautionary follow-up showed no recurrence or relapse measures for lymphedema, commit to a of lymphedema. Longer term results are not healthy lifestyle and maintain a healthy yet available. weight for years to come.

How are the results measured?

Circumferential, strength, joint mobility and hypoesthesia measurements are recommended, as well as SPY lymphangiography and repeated lymphoscintigraphy at one and 8 Ly m p h e d e m a p a t h w a y s . c a

B1167_CLF_Pathways_Sum2018.indd 8

How does weaning from compression work?

After 3 to 6 months of compression wear, the patient can gradually decrease garment wear by two hours every two weeks, depending

on the reaction of the affected limb. This tapering off extends over one to two years.

Once the limb is stable, the patient will have to change the compression garment every 6 months according to his condition.

How will you orient your research?

Current research is trying to determine the ideal time to operate and the choice of the optimal surgical technique for each individual.

At the HMR we are particularly interested in studying the choice of technique according to type of patient. LP ______________________________________________________________ Surgeons interviewed Dr. Michel-Alain Danino, Chief of Plastic Surgery at the CHUM. Graduated in Plastic surgery from Faculty of Medicine in Paris, with training in microsurgery from the University of Chiba and the University of Tokyo.

Dr. Ali Izadpanah, Microsurgeon at the CHUM. A graduate of McGill University, he trained in microsurgery at the Mayo Clinic.

He is director of the Provincial Burn Center (CEVARMU).

Dr. Laurence Paek is part of the microsurgery team at the CHUM. A graduate of McGill University, with training in microsurgery at Stanford University and burn surgery at the University of Toronto.

Dr. Marie-Pascale Tremblay-Champagne is a microsurgeon at the HMR, specialized in lymphatic surgery. A graduate of McGill University, with training in microvascular reconstruction and lymphedema surgery at the University of Washington in Seattle.

Editor’s Note: Reports from some patients who underwent surgery are planned for publication in a future issue of Pathways, once longer-term postoperative results and views are available. We encourage readers to note two other surgical references in this magazine: Page 9 (Letter to the Editor) and page 21 (Did You Know).

Summer 2018

2018-05-15 12:32 PM