Lymphaticovenular anastomosis is unique in the surgical treatment of lymphoedema, in that it has been subjected to a randomized controlled trial (Boccardo et al, 2011). This high level evidence demonstrated that LVA is highly effective in preventing lymphoedema from developing. In those patients undergoing axillary dissection for breast cancer treatment, 30% of those not having LVA developed lymphoedema at 18 months, compared to just 4% of those patients who had LVA.
This shows that LVA is very highly effective in the prevention of lymphoedema. However, it also means that around 70% of patients will not go on to get lymphoedema, and therefore would have had unnecessary surgery. We therefore feel it is more appropriate to detect lymphoedema as early as possible, and treat only those patients who will go on to develop lymphoedema.
Akita et al (2014) have demonstrated the ability of Indocyanine green lymphography to detect subclinical lymphoedema, before the onset of clinical symptoms. Some specific splashback patterns of dermal backflow were transient and reversible, and related to simple post-operative swelling. This perhaps corresponds to the transient oedema seen in the early postoperative period in both groups in Boccardo et al (2011).
However, other patterns of dermal backflow, such as starburst pattern, were irreversible, and consistently went on to become clinically apparent lymphoedema. In their paper, Akita et al allowed these patients to choose either LVA or conservative management. Those choosing LVA didn’t develop lymphoedema, and the dermal backflow patterns were reversed. Those who chose conservative management progressed to clinical lymphoedema, and the dermal backflow patterns did not reverse.
Therefore it is possible to detect those patients who will go on to develop lymphoedema before clinical symptoms, and reverse the lymphatic dysfunction and prevent lymphoedema using LVA.
We offer an initial consultation and ICG scan three months after completion of cancer treatment. If this scan displays irreversible signs of lymphoedema, an appropriate treatment plan is discussed. If there are no signs of lymphatic dysfunction, we organise repeat scanning at six-monthly intervals for the next three years – the time period when lymphoedema is most likely to develop. This allows the detection of sub-clinical lymphoedema at the earliest possible opportunity, preventing the development of lymphoedema.