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What motivated the CHUM to get involved in lymphatic surgery? We wanted to create a comprehensive care package, integrating surgery, now a well-accepted 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

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

Surgical Report

Lymphatic surgery in QuebecThe scalpel of hopeSnapshots of Canada’s foray into lymphatic surgeryInterviews 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.

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.

“After surgery, the patient must know how to adapt to his new lymphedema.” – Dr. Danino

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).

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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

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.

Tracing the viable lymphatic network detected through imagery, in preparation for LVA surgery.

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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 per-formed 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.

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

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 multi-layer bandages and taking measurements. The patient must be diligent in coming for

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.

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

– Dr. Izadpanah

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.

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

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lymphedema, the final results at 1 or 2 years remain unpredictable. For the obese person, LNT could lead to additional complications and more mixed results.

How long should a person wait after cancer treatment before surgery? A minimum of 6 to 12 months after chemotherapy and one year after radiation therapy is required to allow for an improvement in secondary lymphedema in highly observant patients. Patients who see a deterioration in their condition despite DLT or who reach an uncomfortable therapeutic plateau may benefit from surgery.

What results can one expect?You may have to wait at least 6 months before seeing measurable results. At three months, patients often feel better, but without an impact on measurements. An average decrease in excess volume of 40 to 60% at one year can be achieved for 85% of patients and changes can be observed up to two years after surgery. Only 8% of patients will see no change. Data based on 5-year follow-up showed no recurrence or relapse of lymphedema. Longer term results are not yet available.

How are the results measured? Circumferential, strength, joint mobility and hypoesthesia measurements are recom-mended, as well as SPY lymphangiography and repeated lymphoscintigraphy at one and

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

What can one expect after surgery?Recovery initially involves minimal pain for LVA and moderate pain for LNT. The guidelines for LNT are to avoid compressing the chest on the operated side for 2 to 3 weeks and to maintain a distance between the chest and the arm to protect the armpit, day and night. Compression and manual lymphatic drainage can be resumed soon after LNT, but with LVA there is a relative contraindication to compression for the first

few weeks. For LNT, the operated limb is bandaged with Coban in the operating room and for 2 weeks. This dressing must be changed every 2 days, a service which is not always offered by the community health care system. Afterwards, the patient must self-apply multilayer bandages. The patient should plan for the cost of single-use dressings (Coban), reusable multi-layer bandages (Comprilan and CompriFoam) and all subsequent compression garments for the duration. The return to work (without physical effort) for LVA is about 3 weeks and about 6 weeks for LNT. The patient must continue to follow the precautionary

measures for lymphedema, commit to a healthy lifestyle and maintain a healthy weight for years to come.

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

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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).

“Waiting 6 to 12 months before surgery allows natural improve-

ment of secondary lymphedema in highly observant patients.”

– Dr. Tremblay-Champagne

The target patient for LVA or LNT is an

adult with secondary lymphedema due to

cancer or post-trauma, stage 2 or less with

pitting edema. The target patient should be non-obese, without venous

problems in the case of the legs, should be highly observant of compression,

DLT and experiencing a deterioration in

quality of life despite conservative treatments. Major cardiopulmonary comorbidities or stage 4 cancer under treatment are exclusion criteria.

Children are not candidates for

these surgeries.