lymphedema surgery

www.PRSJournal.com 905

Outcomes Article

Peripheral lymphedema represents a com-plex physiologic manifestation of disrupted lymphatic drainage systems. The disease

may be congenital, caused by agenesis or dyspla-sia of any component of the lymphatic network;

or acquired, most commonly secondary to surgi-cal disruption or recurrent infection.1 Regardless of pathophysiologic cause, the clinical presenta-tion is characterized by chronic swelling, accom-panied by localized pain, atrophic skin findings, and recurrent infections, all of which contribute to gradual functional decline.

Treatment for lymphedema begins with com-bined decongestive physiotherapy.2 Although this alone may afford patients enough symp-tomatic relief, conservative therapy relies on a

Disclosure: The authors have no financial interest to declare in relation to the content of this article.Copyright © 2014 by the American Society of Plastic Surgeons

DOI: 10.1097/PRS.0000000000000010

Marten N. Basta, B.A.Lin Lin Gao, M.D.

Liza C. Wu, M.D.

Philadelphia, Pa.

Background: The purpose of this study was to quantify the efficacy and safety of microsurgery for lymphedema through a systematic meta-analysis, which has not been described before.Methods: A literature search was conducted to identify all articles involving microsurgical treatment of lymphedema. Studies meeting criteria for inclusion were rated on methodologic quality based on the American Society of Plastic Surgeons levels of evidence. Demographic information, cause of lymphedema, and surgical technique were recorded. Quantitative change in lymphedema and perioperative complications were noted.Results: Twenty-seven studies were included, with 24 offering level IV evidence and three offering level III evidence. Lymphovenous shunt procedures were performed in 22 studies and lymph node transplantation was performed in five. Excess circumference was reduced by 48.8 ± 6.0 percent, and absolute circumference was reduced by 3.31 ± 0.73 cm. Studies reporting change in volume demonstrated reduction in excess volume by 56.6 ± 9.1 percent, and absolute volume was reduced by 23.6 ± 2.1 percent. The incidence of no improvement in lymphedema postoperatively was 11.8 percent, and 91.2 per-cent of patients reported subjective improvement. Approximately 64.8 percent of patients discontinued compression garments at follow-up. Complications included operative-site infection (4.7 percent), lymphorrhea (7.7 percent), reexploration for flap congestion (2.7 percent), and additional procedures (22.6 percent).Conclusions: Operative interventions for peripheral lymphedema appear to provide consistent quantitative improvements postoperatively, with a relatively wide safety margin. Lymph node transplantation may provide better outcomes compared with lymphovenous shunt, but well-designed head-to-head compari-sons are needed to evaluate this further. (Plast. Reconstr. Surg. 133: 905, 2014.)CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

From the Division of Plastic Surgery, Perelman School of Medicine at the University of Pennsylvania; the Division of Plastic Surgery, Hospital of the University of Pennsylvania; and the Division of Plastic Surgery, University of Pennsyl-vania Health Systems.Received for publication August 29, 2013; accepted Septem-ber 26, 2013.

Operative Treatment of Peripheral Lymphedema: A Systematic Meta-Analysis of the Efficacy and Safety of Lymphovenous Microsurgery and Tissue Transplantation

cpt

RECONSTRUCTIVE

906

Plastic and Reconstructive Surgery • April 2014

substantial amount of patient compliance and ability to tolerate the burdens of lifelong physi-cal therapy appointments and compression gar-ments. As our understanding of the underlying etiopathology and surgical experience evolves, so too has the approach to operative treatment. Spe-cifically, reductive surgery has given way to lym-phovenous shunt and more recently, lymphatic tissue or lymph node transplantation, which have become popularized with advances in microsurgi-cal techniques.

Numerous studies have reported success-ful experiences with operative management of peripheral lymphedema, whereas others have demonstrated rather disappointing outcomes. As current literature reviews on the topic have gen-erally cited heterogeneity in patient selection and outcomes reporting, there have been no system-atic meta-analyses able to quantify what, if any, benefit is evidenced by surgical therapy.3,4 With the inconclusive results of these studies, much controversy surrounds indications for operative intervention, which surgical techniques provide the best outcomes, and which patients are likely to benefit from conservative versus operative man-agement. The purpose of this study, therefore, was to quantify the efficacy and safety of various operative treatments for peripheral lymphedema.

PATIENTS AND METHODS

Literature SearchA literature search was conducted to identify

all articles involving microsurgical interventions to treat lymphedema. Ovid MEDLINE was searched using the following headings and keyword terms: “lymphedema,” “microsurgery,” “lymphovenous,” “lympholymphatic,” “shunt,” and “anastomosis.” Search results were limited to English articles only, yielding 124 results. Titles and abstracts were examined and selected for full article review based on appropriate scope of study and patient popu-lation. In addition, selected study references and review articles were examined for further article sources.

Study Selection and Methodologic QualityAfter identifying relevant studies through title

and abstract information, studies were selected for inclusion based on the following criteria:

1. The study involved lymphatic reconstruc-tion with lymphovenous shunt or lym-phatic tissue transplant and described the

surgical protocol and methodology of patient evaluation.

2. The study was published between 1985 and 2013.

3. The study reported relevant outcomes data.4. The study was not limited to single case

reports.5. The study was in English.

Studies were not included if they did not meet the above criteria and/or if multiple publica-tions were from the same group; only studies that reported data from nonoverlapping time periods were included. Studies were then rated on meth-odologic quality based on the American Society of Plastic Surgeons Evidence Rating Scale for Thera-peutic Studies.5

Data ExtractionBaseline patient characteristics such as age,

cause of lymphedema, and anatomical sites of involvement were recorded. Surgical protocols were categorized as either lymphovenous shunt or vascularized lymph node transplantation, and the configuration(s) of microsurgical anastomo-sis was recorded. Outcomes collected included both objective and subjective preoperative to postoperative change in lymphedema, average patient follow-up, and incidence of complica-tions. Objective methods for measuring change in lymphedema included serial circumferen-tial limb measurements and volumetric water displacement. Measurements were grouped as either change in absolute limb circumference or volume or change in excess limb circumference or volume relative to the contralateral, unaffected limb. When multiple levels of circumferential measurements were reported, measurements were averaged for each patient. For studies miss-ing data such as standard deviations, the study authors were contacted and data were retrieved as available or qualitative analysis was performed alternatively.

Statistical AnalysisData was input to RevMan5.2 (The Cochrane

Collaboration, Copenhagen, Denmark) for anal-ysis.6 Continuous variables, such as age, were compared by means of standard summary statis-tics. Outcomes for improvement of lymphedema were compared in forest plots and summarized with mean differences, and the confidence inter-val was set to 95 percent. Separate comparisons were made for improvement in studies reporting

Volume 133, Number 04 • Surgery for Lymphedema Meta-Analysis

907

circumferential change and volumetric change. Patient populations were subdivided into those with upper limb lymphedema or lower limb lymph-edema, and the effect size was calculated sepa-rately and with both populations combined when possible. Dichotomous data, such as the incidence of complications, were summarized with Fisher’s exact test, with significance set to p < 0.05. Hetero-geneity of comparison data was judged by means of the I2 statistic when applicable, ranging from 0 to 99 percent (judged acceptable for I2, <50 per-cent; borderline heterogeneous, 50 to 75 percent; and unacceptable, >75 percent). Publication bias was inspected routinely by means of funnel plots for each comparison.

RESULTS

Study CharacteristicsA total of 27 studies were included in this sys-

tematic review. Twenty-four studies were retro-spective case series presenting level IV evidence, two studies were cohort studies with level III evi-dence, and one was a case-control study with level III evidence (Table 1).7–33 Twenty studies provided sufficient data to be included in quantitative meta-analysis, and the remaining seven studies were included for qualitative summary.

Both upper and lower extremity populations were included in this meta-analysis. There were 10 studies that examined upper extremity lymph-edema reduction, 11 studies that examined lower extremity reduction, and five studies that exam-ined both upper and lower extremities. One study involved external genitalia lymphedema.

Patient CharacteristicsOverall, the study population consisted of

1619 patients, with a female-to-male ratio of approximately 3:2. Patient age ranged from 7 to 92 years of age; however, the majority of patients were aged between 45 and 60 years. Although cause of lymphedema included both congenital and acquired, the vast majority of patients suf-fered from postsurgical lymphedema associated with oncologic conditions, including breast can-cer and various gynecologic cancers. The staging system of lymphedema was inconsistent across studies. Of those studies reporting stage, either the Campisi lymphedema classification or the International Society of Lymphology classifica-tion system was used.2,34 Of studies reporting International Society of Lymphology classifica-tion, approximately 50 percent of patients were stage II, 25 percent were stage III, and the remaining 25 percent were stage I or IV. Average

Table 1. Summary of Included Studies

Reference DesignLymphedema

SiteOperative Technique No. F/U (yr) LOE

Felmerer et al., 20127 R-CS U + L E-E 12 2.6 IVHuang et al., 19858 R-CS L E-E, sleeve 91 2.0 IVMatsubara et al., 20069 R-CS L E-S 9 5.7 IVYamamoto et al., 200310 P-CS U E-E, sleeve 18 2.0 IVKoshima et al., 200311 R-COH L E-E 13 4.6 IIIKoshima et al., 200012 R-COH U E-E 12 2.2 IIICheng et al., 201213 R-CS L LN-T 7 0.7 IVFurukawa et al., 201114 P-CS U E-E, sleeve 9 1.2 IVLin et al., 200915 R-CS U LN-T 13 4.7 IVYamamoto et al., 201116 R-CS L E-E, S-E, E-S, lambda 20 NA IVNarushima et al., 201017 R-CS L E-E, E-S, DE-E, S-E 14 0.7 IVAuba et al., 201218 R-CS U + L E-E 9 1.5 IVIpsen et al., 198819 R-CS L S-E 7 1.0 IVDemirtas et al., 201020 R-CS L E-E 78 1.1 IVO’Brien et al., 199021 R-CS U + L E-E 52 4.2 IVChang et al., 201022 P-CS U E-E 20 1.5 IVBaumiester and Siuda, 199023 R-CS U + L E-E 48 1.3 IVWeiss et al., 200224 R-CS U E-E, E-S 12 7.7 IVBecker et al., 200625 R-CS U LN-T 24 8.3 IVOlszewski, 201326 R-CS L E-E, E-S 960 5.0 IVMaegawa et al., 201227 R-CS L S-E 57 1.2 IVMaegawa et al., 201028 R-CS L S-E 111 NA IVMukenge et al., 201129 R-CS O E-E, S-E 5 0.6 IVYamamoto and Sugihara, 199830 R-CS U + L E-E 7 1.5 IVCheng et al., 201331 P-CC U LN-T 20 3.3 IIIGharb et al., 201132 R-CS U LN-T 21 3.6 IVDamstra et al., 200933 P-CS U E-S 10 8 IVLN-T, vascularized lymph node transfer; LOE, level of evidence; DE-E, double end-to-end; U, upper limb; L, lower limb; O, other (external genitalia lymphedema); R, retrospective; P, prospective; CS, case series; COH, cohort; CC, case-control; F/U, follow-up; NA, not applicable.

908


follow-up among all studies was 3.3 years, with individual cohort follow-up ranging from 8 months to 10 years.

Patient Selection CriteriaAlthough the majority of studies described

factors taken into consideration for operative treatment of lymphedema, parameters for patient selection were inconsistently specified. All studies indicated that patients who underwent operative management had previously failed conservative therapy. In general, this criterion was fulfilled with less than 50 percent reduction of lymph-edema with a minimum of 6 months of conser-vative therapy. Other indications were recurrent or severe cellulitis inadequately treated with antibiotics and functional impairment second-ary to lymphedema. Important exclusion criteria reported included chronic venous insufficiency and severe fibrosclerotic lymphedema diagnosed on preoperative lymphoscintigraphy, and most studies were composed of patients with secondary lymphedema only.

Operative TechniqueLymphovenous ShuntThe majority of studies used lymphovenous

shunt as the operative approach to treatment. A variety of configurations were described for recon-structing the lymphedematous limb. The most popular was the lymphaticovenous end-to-end anastomosis. In this technique, patent blue dye can be injected intraoperatively to identify pat-ent lymphatics. Subdermal venules are selected as the proximal recipient of lymphatic vessels. Spe-cific advantages of these vessels cited by numer-ous authors included less size discrepancy, which facilitates more precise anastomosis, and a rela-tively lower intraluminal pressure compared with cutaneous veins, which prevents backflow from the venous system. Operative microscopes were uniformly used, and anastomosis was completed with 11-0 or 12-0 suture.

Variations on the end-to-end configura-tion were frequently used in different studies. These included lymphaticovenous end-to-side, side-to-end, and double end-to-side shunts. Furthermore, Yamamoto et al. described the “lambda-shaped” configuration, which joined the proximal end of the lymphatic vessel to the side of the vein and the distal end of the lymphatic vessel to the end of the same vein.16

Finally, the end-to-end or sleeve anastomosis has been used in creating the lymphaticovenous shunt by multiple authors.8,10,14 The indication

for this configuration was the inability to iden-tify a suitable lymphatic vessel of appropriate size for microsurgical anastomosis. As such, mul-tiple lymphatics and their surrounding soft-tissue adventitia are implanted into the end of a larger, cutaneous vein and anastomosed with 10-0 or 11-0 sutures in an interrupted fashion.

Vascularized Lymph Node TransplantationVascularized lymph node transplantation

was the method of reconstruction in five of the included articles. Both Lin et al.15 and Becker et al.25 used the groin as a donor site in the treat-ment of upper limb lymphedema. The recipient sites were the distal wrist and the axilla, respec-tively. Cheng et al.13 recently proposed the sub-mental vascularized lymph node flap as the donor for lower limb lymphedema, and the ankle served as the recipient site. In 2013, this same group described a groin flap designed off of perforators, with the wrist or elbow serving as the recipient site.31 Similarly, Gharb et al. used the same design in a 2011 study.32 Intraoperative lymphatic dye staining with methylene blue or indocarmine was reported in 19 studies, and lymphatic patency was assessed by means of lymphoscintigraphy or lym-phography in 19 studies as well.

Postoperative CarePostoperative management was assessed for

each study. Six studies specified routine postoper-ative antibiotic prophylaxis for 1 week in patients without a history of recurrent cellulitis and 6 months or more in patients with a history of recur-rent or severe cellulitis. Six studies detailed peri-operative anticoagulation, with two studies using low-molecular-weight heparin, two using dextran, and two using low-dose aspirin. The duration of anticoagulation was approximately 1 month for heparin or dextran and 3 months for aspirin. The protocol for use of compression stockings was reported variably, with 14 studies initiating com-pression garments either in the immediate post-operative period or within 1 month of surgery, continued on an as-needed basis, and seven stud-ies in which use of compression garments postop-eratively was not recommended.

Primary OutcomesObjective improvement of lymphedema post-

operatively was reported heterogeneously, with studies presenting either change in limb circum-ference or volume as either absolute difference or difference of excess size relative to the contralat-eral limb in patients with unilateral lymphedema.


909

Table 2 summarizes the four major parameters reported, and measures of heterogeneity indicate that circumferential measurements were homog-enous and reliable, although all parameters dem-onstrated statistically significant improvement in lymphedema postoperatively. Specifically, excess circumference and volume were reduced by 49 percent and 57 percent of preoperative values, respectively; absolute volume was reduced by 23.6 percent; and absolute circumference was reduced by 3.31 cm (8.5 percent) of preoperative values. Figure 1 depicts the forest plots of the four major parameters (Fig. 1).

Secondary OutcomesResults were comparable between patients

with upper and lower limb lymphedema, and in studies of lymphovenous shunt procedures versus lymph node transplantation (Fig. 2). Overall, the incidence of no change or worsen-ing of lymphedema postoperatively was approxi-mately 11.8 percent; only studies detailing each patient’s outcomes were included in this statis-tic. Subjective improvement of lymphedema was documented in 13 studies, and overall, 92.7 percent of patients related symptomatic improvement after operative intervention. How-ever, only two studies used a validated patient-reported outcomes scale in assessing subjective improvement. Finally, the proportion of patients able to discontinue compression therapy was 78 percent in lymph node transplantation studies, compared with 56.3 percent in lymphovenous shunt studies (p = 0.04).

ComplicationsComplications are listed in Table 3. Post-

operative wound-site infection occurred in 4.7

percent of patients, all of which resolved with antibiotic administration. In four studies report-ing wound infection, the protocol did not include prophylactic antibiotics, whereas in two others, no wound infections occurred after the authors began administering prophylactic antibiotics rou-tinely. The incidence of lymphorrhea was 7.7 per-cent overall; however, duration of symptoms and management were not reported. Furthermore, all lymph node transplantation studies reported this outcome, whereas only nine of 21 lymphovenous shunt studies did so. Operative reexploration for vascularized lymph node flap venous conges-tion was required in two of 75 patients. Finally, 35 patients underwent additional elective pro-cedures to improve lymphedema subsequent to the initial procedure, including donor-site split-thickness skin grafting, liposuction, and excess skin excision.

DISCUSSIONThis systematic meta-analysis attempts to

quantify the efficacy and safety of operative treatment of peripheral lymphedema. Of the 27 studies included, only three were level III evi-dence and the remainder were level IV. As such, interpretation of the findings of this review mandates evaluation of the evidence in light of the methodologic flaws inherent in the studies included. However, a number of observations can be ascertained from our results and deserve consideration.

Of the four outcome measures presented here, change in excess circumference as a percent-age of preoperative excess was most frequently reported. It follows that this measure was also the most homogenous and therefore most reli-able of the pooled outcomes. We demonstrated

Table 2. Primary Outcomes*

Parameter No. of Studies No. Mean (95% CI) I2 (%)

Excess circumference reduction, % All 11 131 48.8 (42.8–54.8) 0 ULL 7 90 46.0 (39.0–53.0) 0 LLL 4 34 57.4 (44.5–70.3) 0 LV shunt 7 80 48.9 (40.7–57.2) 0 LN-T 4 51 48.5 (35.3–61.6) 49Absolute circumference reduction, cm All 11 138 3.31 (2.58–4.04) 0 ULL 6 79 2.73 (1.63–3.83) 16 LLL 5 52 3.52 (2.28–4.75) 0Excess volume reduction, % All 4 165 56.6 (47.5–65.6) 78Absolute volume reduction, % All 2 60 23.6 (21.5–25.7) 42ULL, upper limb lymphedema; LLL, lower limb lymphedema; LV, lymphovenous, LN-T, lymph node transplantation.*p < 0.00001 for all endpoints (or p < 0.05).

910


an average reduction in excess circumference of approximately 48.8 percent across 11 studies with 131 patients. Although there is no existing litera-ture with which to compare this result, it appears as though surgical treatment does consistently lead to a substantial improvement in this param-eter. Furthermore, circumference reduction (in centimeters) consistently supports this finding, with an average 3.31-cm reduction across 11 stud-ies. Admittedly, few studies reported on volume reduction, and an immediate consequence of this is an unacceptably high heterogeneity statistic.

Although this brings into question the validity of the result, the magnitude of change in volume is very similar to that found for circumferential measurements.

Notably, secondary outcomes were promising. Specifically, the incidence of no postoperative quantifiable improvement in lymphedema was only 11.8 percent, suggesting that a great major-ity of patients derived benefit from surgery. In an attempt to translate this benefit into a clinically relevant parameter, the ability to discontinue conservative therapy was investigated and found

Fig. 1. Primary outcomes. (Above) Excess circumference reduction (values are percentages). (Second row) Circumference reduction (in centimeters). (Third row) Excess volume reduction (values are percentages). (Below) Absolute volume reduction (values are percentages).


911

to be 65 percent across all studies reporting this outcome. Moreover, lymph node transplantation was superior to lymphovenous shunt, affording a 20 percent greater chance of discontinuing conservative treatment. Complication rates were relatively low throughout, and major complica-tions such as operative reexploration had an incidence of less than 3 percent and a concomi-tant flap salvage rate of 100 percent. It appears, in general, that these procedures are safe for most patients.

A comparison of lymph node transplantation to lymphovenous shunt operative techniques dem-onstrates similar preoperative to postoperative improvements in lymphedema. There are, how-ever, notable differences in secondary outcomes and complication rates. Patients undergoing lymph node transplantation procedures tended to have greater subjective improvement and were more likely to discontinue compression garments.

Although complication rates were higher for lymph node transplantation procedures, a report-ing bias likely contributed to this finding, as all lymph node transplantation studies reported com-plications whereas several lymphovenous shunt studies did not. Furthermore, the additional pro-cedures were elective and minimally invasive—cir-cumferential liposuction and split-thickness skin grafting. It appears that lymph node transplan-tation procedures may offer the most benefit to patients. A recently published review on outcomes of microsurgery for secondary upper limb lymph-edema concluded that there was consistent benefit to surgery and further indicates that lymphatic tis-sue transplantation was the more successful opera-tive modality.4 Although more investigation into this claim is certainly warranted, our findings sug-gest that this may in fact be true.

Perhaps the most apparent observation and pressing limitation of our study is the

Fig. 2. Secondary outcomes compared by operative technique (*p = 0.04, lymph node transplan-tation versus lymphovenous shunt). LV, lymphovenous; LN-T, lymph node transplantation.

Table 3. Complications

Complication

LV Shunt LN-T Overall

p*Studies Incidence (%) Studies Incidence (%) Studies Incidence (%)

Infection 11 8/207 (3.9) 4 4/51 (7.8) 15 12/258 (4.7) 0.26Lymphorrhea 9 6/145 (4.1) 5 11/75 (14.7) 14 17/220 (7.7) 0.008Reexploration 0 NA 5 2/75 (2.7) 5 2/75 (2.7) NAAdditional procedure 7 8/80 (10.0) 5 27/75 (36.0) 12 35/155 (22.6) 0.0001LV, lymphovenous; LN-T, lymph node transplantation; NA, not applicable.*Fisher’s exact test p value.

912


heterogeneity of the patient population, assess-ment modalities, and inconsistent reporting of complications of included studies. Although the validity of our findings is subject to careful inter-pretation, there is a clear message to be gleaned. Future studies must attempt to standardize every aspect of management, from consistent clinical staging of lymphedema at initial consultation to uniform evaluation of postoperative evolution of disease. The International Society of Lymphology Consensus provides specific recommendations for grading lymphedema in a three- or four-point standardized grading system. Furthermore, a discussion of the various assessment modalities for documenting efficacy of surgery is provided. Ideally, preoperative measurements would be taken both before initiating and after finishing conservative therapy, and immediately preopera-tively. Postoperatively, measurements should be taken at routine follow-up, with attention paid to both short-term and long-term outcomes.2 These measures may serve to better delineate whether surgical intervention is indicated, and if so, which patients are most likely to benefit from surgery. As study populations were diverse, it was not possible to compare outcomes for patients with primary lymphedema to those with acquired lymphedema. Furthermore, acquired lymph-edema is frequently encountered in association with two different clinical contexts: postsurgical and in the setting of chronic elephantiasis.2 As the pathophysiologic basis and natural history is different for all three of these conditions, it may be that surgical intervention is more appropri-ate for some patients and more likely to fail in others. Although this study did not differentiate between primary and secondary lymphedema, the great majority of patients had postsurgical lymphedema, and as such, the results are most reflective of operative treatment for this patient population.

CONCLUSIONSMicrosurgical interventions for peripheral

lymphedema appear to provide consistent quan-titative improvements postoperatively and have a relatively wide safety margin. These quantitative improvements have clinical relevance, as a sub-stantial number of patients are able to discontinue conservative therapy. Lymphatic tissue transplan-tation may provide better outcomes compared with lymphovenous shunt; however, well-designed head-to-head comparisons are still needed to eval-uate this more definitively.

Liza C. Wu, M.D.University of Pennsylvania Health Systems

3400 Spruce Street10 Penn Tower

Philadelphia, Pa. [email protected]

ACKNOWLEDGMENTThis study was funded by the Department of Surgery

of the Perelman School of Medicine at the University of Pennsylvania.

CODING PERSPECTIVEThis information provided by Dr. Ray-mond Janevicius is intended to pro-vide coding guidance.

Lymphovenous Shunt, Upper Extremity35206 Repair blood vessel, upper extremity69990 Use of operating microscope

Lymphovenous Shunt, Lower Extremity35226 Repair blood vessel, lower extremity69990 Use of operating microscope

Lymphatic Tissue Transplant15758 Free flap

• Lymphovenous shunts are microvascular procedures. The following blood vessel re-pair codes are used: 35206 for the upper ex-tremity; 35226 for the lower extremity.

• These codes are used whether the anasto-mosis is end to end, end to side, side to side, sleeve, or lambda.

• Codes 35206 and 35226 are macrovascular codes. To report the techniques of micro-surgery, code 69990 is used.

• Code 69990 is an add-on code, so the multi-ple procedure modifier, 51, is not appended.

• These codes are used for each anastomosis performed. Thus, in the case of the lambda procedure (if performed in the upper ex-tremity), the procedure is reported as follows:35206 Repair blood vessel, upper ex-

tremity 35206-59 Repair blood vessel, upper ex-

tremity69990 Use of operating microscope

• Code 69990 is used only once per operative session.

• The lymph node transfer is a free flap, so code 15758 is used. Free flap codes include use of the operating microscope, so code 69990 is not reported.

cpt

mailto:[email protected]


913

REFERENCES 1. Garfein ES, Borud LJ, Warren AG, Slavin SA. Learning from

a lymphedema clinic: An algorithm for the management of localized swelling. Plast Reconstr Surg. 2008;121:521–528.

2. International Society of Lymphology. The diagnosis and treatment of peripheral lymphedema. Consensus docu-ment of the International Society of Lymphology. Lymphology 2009;42:51–60.

3. Abbas S, Seitz M. Systematic review and meta-analysis of the used surgical techniques to reduce leg lymphedema following radical inguinal nodes dissection. Surg Oncol. 2011;20:88–96.

4. Penha TR, Ijsbrandy C, Hendrix NA, et al. Microsurgical tech-niques for the treatment of breast cancer-related lymphedema: A systematic review. J Reconstr Microsurg. 2013;29:99–106.

5. Sullivan D, Chung KC, Eaves FF III, Rohrich RJ. The level of evidence pyramid: Indicating levels of evidence in Plastic and Reconstructive Surgery articles. Plast Reconstr Surg. 2011;128:311–314.

6. Review Manager (RevMan) (Computer program). Version 5.2. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration; 2013.

7. Felmerer G, Sattler T, Lohrmann C, Tobbia D. Treatment of various secondary lymphedemas by microsurgical lymph ves-sel transplantation. Microsurgery 2012;32:171–177.

8. Huang GK, Hu RQ, Liu ZZ, Shen YL, Lan TD, Pan GP. Microlymphaticovenous anastomosis in the treatment of lower limb obstructive lymphedema: Analysis of 91 cases. Plast Reconstr Surg. 1985;76:671–685.

9. Matsubara S, Sakuda H, Nakaema M, Kuniyoshi Y. Long-term results of microscopic lymphatic vessel-isolated vein anasto-mosis for secondary lymphedema of the lower extremities. Surg Today 2006;36:859–864.

10. Yamamoto Y, Horiuchi K, Sasaki S, et al. Follow-up study of upper limb lymphedema patients treated by microsurgi-cal lymphaticovenous implantation (MLVI) combined with compression therapy. Microsurgery 2003;23:21–26.

11. Koshima I, Nanba Y, Tsutsui T, Takahashi Y, Itoh S. Long-term follow-up after lymphaticovenular anastomosis for lymph-edema in the leg. J Reconstr Microsurg. 2003;19:209–215.

12. 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.

13. Cheng MH, Huang JJ, Nguyen DH, et al. A novel approach to the treatment of lower extremity lymphedema by transfer-ring a vascularized submental lymph node flap to the ankle. Gynecol Oncol. 2012;126:93–98.

14. Furukawa H, Osawa M, Saito A, et al. Microsurgical lymphati-covenous implantation targeting dermal lymphatic backflow using indocyanine green fluorescence lymphography in the treatment of postmastectomy lymphedema. Plast Reconstr Surg. 2011;127:1804–1811.

15. 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.

16. Yamamoto T, Narushima M, Kikuchi K, et al. Lambda-shaped anastomosis with intravascular stenting method for safe and effective lymphaticovenular anastomosis. Plast Reconstr Surg. 2011;127:1987–1992.

17. Narushima M, Mihara M, Yamamoto Y, Iida T, Koshima I, Mundinger GS. The intravascular stenting method for treatment of extremity lymphedema with multiconfigura-tion lymphaticovenous anastomoses. Plast Reconstr Surg. 2010;125:935–943.

18. Auba C, Marre D, Rodríguez-Losada G, Hontanilla B. Lymphaticovenular anastomoses for lymphedema treatment: 18 months postoperative outcomes. Microsurgery 2012;32: 261–268.

19. Ipsen T, Pless J, Frederiksen PB. Experience with microlym-phaticovenous anastomoses for congenital and acquired lymphoedema. Scand J Plast Reconstr Surg Hand Surg. 1988;22:233–236.

20. Demirtas Y, Ozturk N, Yapici O, Topalan M. Comparison of primary and secondary lower-extremity lymphedema treated with supermicrosurgical lymphaticovenous anastomosis and lymphaticovenous implantation. J Reconstr Microsurg. 2010;26:137–143.

21. O’Brien BM, Mellow CG, Khazanchi RK, Dvir E, Kumar V, Pederson WC. Long-term results after microlymphaticove-nous anastomoses for the treatment of obstructive lymph-edema. Plast Reconstr Surg. 1990;85:562–572.

22. Chang DW. Lymphaticovenular bypass for lymphedema management in breast cancer patients: A prospective study. Plast Reconstr Surg. 2010;126:752–758.

23. Baumeister RG, Siuda S. Treatment of lymphedemas by microsurgical lymphatic grafting: What is proved? Plast Reconstr Surg. 1990;85:64–74; discussion 75.

24. Weiss M, Baumeister RG, Hahn K. Post-therapeutic lymph-edema: Scintigraphy before and after autologous lymph ves-sel transplantation: 8 years of long-term follow-up. Clin Nucl Med. 2002;27:788–792.

25. Becker C, Assouad J, Riquet M, Hidden G. Postmastectomy lymphedema: Long-term results following microsurgical lymph node transplantation. Ann Surg. 2006;243:313–315.

26. Olszewski WL. Lymphovenous microsurgical shunts in treatment of lymphedema of lower limbs: A 45-year experi-ence of one surgeon/one center. Eur J Vasc Endovasc Surg. 2013;45:282–290.

27. Maegawa J, Yabuki Y, Tomoeda H, Hosono M, Yasumura K. Outcomes of lymphaticovenous side-to-end anas-tomosis in peripheral lymphedema. J Vasc Surg. 2012; 55:753–760.

28. Maegawa J, Mikami T, Yamamoto Y, Satake T, Kobayashi S. Types of lymphoscintigraphy and indications for lymphatico-venous anastomosis. Microsurgery 2010;30:437–442.

29. Mukenge SM, Catena M, Negrini D, et al. Assessment and follow-up of patency after lymphovenous microsurgery for treatment of secondary lymphedema in external male geni-tal organs. Eur Urol. 2011;60:1114–1119.

30. Yamamoto Y, Sugihara T. Microsurgical lymphaticovenous implantation for the treatment of chronic lymphedema. Plast Reconstr Surg. 1998;101:157–161.

31. Cheng MH, Chen SC, Henry SL, Tan BK, Lin MC, Huang JJ. Vascularized groin lymph node flap transfer for post-mastectomy upper limb lymphedema: Flap anatomy, recipient sites, and outcomes. Plast Reconstr Surg. 2013;131: 1286–1298.

32. Gharb BB, Rampazzo A, di Spilimbergo SS, Xu ES, Chung KP, Chen HC. Vascularized lymph node transfer based on the hilar perforators improves the outcome in upper limb lymphedema. Ann Plast Surg. 2011;67:589–593.

33. Damstra RJ, Voesten HG, van Schelven WD, van der Lei B. Lymphatic venous anastomosis (LVA) for treatment of sec-ondary arm lymphedema: A prospective study of 11 LVA procedures in 10 patients with breast cancer related lymph-edema and a critical review of the literature. Breast Cancer Res Treat. 2009;113:199–206.

34. Campisi C, Boccardo F. Microsurgical techniques for lymph-edema treatment: Derivative lymphatic-venous microsur-gery. World J Surg. 2004;28:609–613.

lymphedema surgery

Documents