The normal lymphatic system is a series of interconnected tubes that carry interstitial fluid, which has come from the bloodstream in the capillary beds, back from the tissues to the bloodstream. This is an active process, with flow being dependent on peristalsis within the lymphatics. In order for the fluid to flow back into the bloodstream at the thoracic duct or right lymphatic duct, the pressure in the lymphatics must be higher than that in the venous circulation.
The normal lymphatic wall has an intima composed of endothelial cells, a media with collagen fibres and smooth muscle cells, and an outer adventitia. Proximal destruction or damage to the lymphatic system creates a blockage, leading to increased intraluminal pressure, and subsequent lymphatic ectasia. Over the long-term, this chronic lymphatic hypertension causes the intimal smooth muscle cells to begin secreting collagen. This leads to dysfunction of the peristaltic mechanism, and lymphatic sclerosis, worsening fluid clearance.
Lymphaticovenular anastomosis breaks this vicious cycle of lymphatic hypertension and lymphatic vessel sclerosis. By anastomosing functioning lymphatics to veins with competent valves, the lymphatic fluid can drain into the lower pressure venous system, and out of the affected limb. This returns the fluid to the circulation, effectively bypassing the area of blockage.
Here is a selection of papers reporting the efficacy of LVA in both preventing lymphoedema and in treating established lymphoedema, as well as papers co-authored by Oxford Lymphoedema Practice surgeons on the subject of lymphoedema.
This paper demonstrated that after treatment for gynaecological cancer, lower limb lymphoedema can be detected by Indocyanine green lymphography before the onset of clinical symptoms. Furthermore, LVA was able to reverse these changes and normalise limb volume. Importantly, conservative measures such as compression therapy were not able to halt the progression of lymphodema.
This randomized controlled trial randomized women to receive either LVA or no additional procedure at the time of axillary dissection for breast cancer. At 18 months’ follow-up, 4% of those treated with LVA had developed lymphoedema, compared with 30% of those receiving no additional treatment. This equates to an absolute risk reduction of 26%, and a number needed to treat (NNT) of 4 to prevent one case of lymphoedema.
Here, Professor Campisi reports his results of treating lymphoedema with LVA in over 1,800 patients with an average follow-up of over 10 years. 83% of patients showed an improvement in their lymphoedema, and 85% of patients were able to stop wearing compression garments. There was also an 87% reduction in the incidence of cellulitis after LVA surgery.
Professor Koshima was the first to demonstrate the efficacy of LVA under local anaesthesia. He showed improvements in 82.5% of patients with lower limb lymphoedema, despite a small number of anastomoses (average 2.1 per limb) and advanced disease (stage 3 and 4).
We have performed a systematic review of the evidence for modern surgical treatments of arm lymphoedema after breast cancer treatment. LVA is recommended for ISL stages 0-2a lymphoedema, but reductive techniques such as liposuction are more appropriate for more advanced disease with profound fibrosis and lymphostatic warts, or frank elephantiasis (stages 2b or 3).
This paper defines the progressive pathological changes within the lymphatics as lymphoedema progresses. The initially thin walled, translucent lymphatics gradually become thicker, fibrotic and less contractile as they undergo collagen deposition caused by raised intraluminal pressure. This is akin to high blood pressure causing pathological changes in the arterial wall.
A paper where we showed that using the location of healthy lymphatics from an unaffected limb can predict accurately the location of lymphatics in an affected limb. This again highlights the importance of pre-operative Indocyanine green lymphography.
Here, we showed that the rate of cellulitis in the year after LVA was 90% less than in the year preceding LVA. This demonstrates that LVA can be effective in reducing this complication of lymphoedema.
A classic review article detailing all aspects of LVA, from pathology of lymphoedema, to a detailed description of LVA and the technical advances that have made the technique possible.
Here, we demonstrated that pelvic lymphocele, a complication of pelvic lymph node dissection, can be effectively treated by LVA.