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International Angiology 1999 March;18(1):42-6


lingua: Inglese

Principles of surgical treatment of chronic lymphoedema

Gloviczki P.

From the Division of Vascular Surgery, Mayo Clinic, Rochester, MN, USA


Lymphoedema, refrac­to­ry to non-oper­a­tive man­age­ment, may ­require sur­gi­cal treat­ment. Potential indi­ca­tions ­include ­impaired limb func­tion, recur­rent epi­sodes of cel­lu­litis and lym­phan­gitis, intract­able pain, lym­phan­gio­sar­co­ma and cos­me­sis (­patient unwill­ing to under­go more con­ser­va­tive treat­ment and will­ing to pro­ceed even with experi­men­tal oper­a­tions). The prin­ci­ple of exci­sion­al oper­a­tions is to ­remove ­excess tis­sue to ­decrease vol­ume of the extrem­ity. Good reduc­tion can be ­achieved with ­staged resec­tion of the sub­cu­ta­ne­ous tis­sue, with resec­tion of the ­excess skin and using the remain­der for cover­age. However, pro­longed hos­pi­tal­iza­tion, poor wound heal­ing, long sur­gi­cal scars, sen­so­ry nerve loss, resid­u­al oedema of the foot and ankle and poor cos­met­ic ­results can be sig­nif­i­cant prob­lems and pre­vent offer­ing such pro­ce­dures short of a large and truly dis­abling lym­phoed­e­ma, not respond­ing to med­i­cal meas­ures. Physiologic oper­a­tions have been aimed at restor­ing lym­phat­ic trans­port capac­ity, most fre­quent­ly with lym­phov­e­nous anas­to­mos­es or lym­phat­ic graft­ing. Chylous ­reflux due to val­vu­lar incom­pe­tence has been treat­ed effec­tive­ly by liga­tion and exci­sion of ret­ro­per­i­to­neal lym­phat­ics, with or with­out lym­phov­e­nous anas­to­mos­es. Lymphovenous anas­to­mos­es oper­a­tions for obstruc­tive lym­phoed­e­ma have been per­formed for sev­er­al ­decades, but their use con­tin­ues to be con­tro­ver­sial. Such recon­struc­tions can be indi­cat­ed in a sub­set of ­patients who have prox­i­mal obstruc­tion with pre­served or dilat­ed lym­phat­ics dis­tal­ly. While few ­groups have report­ed good late clin­i­cal ­results, ­direct con­fir­ma­tion of long-term paten­cy of lym­phov­e­nous anas­to­mos­es in ­patients is unavail­able. Lymphatic graft­ing is a prom­is­ing oper­a­tion, but it ­requires true micro­sur­gi­cal exper­tise and com­mit­ment to treat this fre­quent­ly frus­trat­ing and dif­fi­cult dis­ease. Long-term paten­cy rates asso­ciat­ed with doc­u­ment­ed clin­i­cal improve­ment have to be report­ed in larg­er num­ber of ­patients, oper­at­ed on in more than one cen­tre ­before this oper­a­tion can be rec­om­mend­ed for treat­ment as an alter­na­tive to con­ser­va­tive meas­ures. The large num­ber of indi­vid­u­al sur­gi­cal tech­niques of phys­io­log­ical and exci­sion­al oper­a­tions that are prac­ticed today world­wide to treat lym­phoed­e­ma con­tin­ues to be tes­ti­mo­ny to our frus­tra­tion in dealing with this dif­fi­cult prob­lem.

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