Granzow, J.W., Soderberg, J.M., Kaji, A.H., & Dauphine, C. (2014). An effective system of surgical treatment of lymphedema. Annals of Surgical Oncology, 21, 1189–1194. 

DOI Link

Study Purpose

To review the effectiveness and safety outcomes of patients selected to receive surgical procedure for lymphedema (LE) after a program of complete decongestive therapy (CDT)

Intervention Characteristics/Basic Study Process

LE therapy consisted of manual lymph drainage, compression bandaging and garments, and vascularized lymph node transfer (VLNT), which was used for upper extremity LE by removing lymph nodes from the groin and transferring them to the affected axilla or along with a deep inferior epigastric perforator (DIEP) flap. Lymphaticovenous anastomosis (LVA) was preferred for lower extremity LE, which was completed by connecting lymphatics to nearby microscopic veins. Both VLNT and LVA are for LE with primarily fluid component. Suction-assisted protein lipectomy (SAPL) is used to treat the solid type of LE and requires continued compression after procedure.

Sample Characteristics

  • N = 26
  • MEAN AGE = 53 years
  • FEMALES: 100%
  • KEY DISEASE CHARACTERISTICS: Women with upper extremity LE secondary to breast cancer, congenital lower extremity LE, or lower extremity LE secondary to gynecologic cancer treatment

Setting

  • SITE: Single-site    
  • SETTING TYPE: Inpatient    
  • LOCATION: University of California, Los Angeles, United States

Phase of Care and Clinical Applications

  • PHASE OF CARE: Transition phase after active treatment
  • APPLICATIONS: Elder care, palliative care

Study Design

Retrospective chart review

Measurement Instruments/Methods

  • Circumferential limb volume
  • Excel database
  • Paired T-tests for pre-/postoperative comparisons
  • Volume reduction for SAPL at 4 and 12 months after surgery
  • Change in compression garment use and lymphedema therapy necessary for VLNT and LVA
  • Change in the incidence of cellulitis in all cases

Results

Good outcomes of volume reduction, decreased need for compression garments, and reduction of episodes of cellulitis were achieved for a small, selective group of patients who received one of three treatment procedures (VLNT, LVA, or SAPL coupled with CDT by a certified lymphedema therapist). The incidence of severe cellulitis decreased from 58% to 15% (p < 0.0001). Patients who underwent  VLNT reported wearing their compression garments significantly less (p = 0.009) and needing less lymphedema therapy (p = 0.009). LVA was associated with a significant reduction in lymphedema therapy (p = 0.008) and trended toward significance in garment reduction (0.07). 88% of patients who underwent either VLNT or LVA showed a postoperative improvement in lymphedema symptoms. For patients who underwent SAPL, those who had arm lymphedema showed an average of a 111% reduction of excess fluid volume and those who had leg lymphedema showed an average reduction of 86% 12 months post operatively.

Conclusions

The retrospective chart review of 26 selected patients from one surgeon identifying phases of LE, earlier with fluid component swelling, using VLNT, LVA, or SAPL showed positive results in regard to volume reduction, decreased infection episodes, and decreased garment/CDT requirements.

Limitations

  • Small sample (< 30)
  • Baseline sample/group differences of import
  • Risk of bias (no control group)
  • Selective outcomes reporting
  • Key sample group differences that could influence results
  • Intervention expensive, impractical, or training needs

Nursing Implications

CDT performed by a certified therapist is still needed for patients with lymphedema. This study identifies the surgical outcomes for selective patients, but it does not identify the specific inclusion or exclusion criteria for the surgical interventions. The average body-mass index for patients receiving one of the three interventions was 27.5. The relatively short interval of follow-up did not identify if the surgical interventions will continue to have the desired effects long-term. Financial reimbursement and payment issues were not addressed. The results may not be reproducible across all healthcare settings.