Microvascular lymph node transfer, a game changer in its management

Lymphedema is a type of swelling that occurs in legs or arms due to accumulation of fluids and protein that develops as result of blockage in the lymph collecting system. Any condition or procedure that damages the lymph nodes or lymph vessels can cause lymphedema. These include filarial parasites like Wucheria bancrofti which enters the lymphatic system and destroys the lymph nodes and the nearby afferent lymphatic vessels leading to a blockage in the lymph collecting system. This is a very common disease, endemic to the southern and eastern parts of India. The advanced stage of this disease is famously called as elephant leg. Here, there is scarring of tissues and makes the treatment more difficult.

This disease is also common in cancer survivors as they undergo surgery, which removes the lymph nodes adjoining the affected areas; in addition radiation treatment for cancer causes scarring and inflammation of lymph nodes or lymph vessels. Another form of lymphedema occurs in patients who have a congenitally deficient lymphatic system without any of the above mentioned causes.

At SIMS Institute of Craniofacial, Aesthetic and Plastic Surgery (ICAPS) lymphedema is treated by a team of specialists, which include plastic surgeons, oncologist, dermatologists, physical therapists, lymphology nurses and counselors. The most widely accepted method of treatment for lymphedema is Complete Decongestive Therapy (CDT). This is a combination treatment that includes manual lymph drainage, compression bandaging, meticulous skin and nail care, and decongestive exercises. All our patients undergo this extensive physical therapy regimen following which they are evaluated whether they are suitable for surgical intervention. Surgery as a treatment modality for lymphedema is very effective in appropriate patients but the techniques involved are highly specialized and expertise is not widely available. These procedures aim to bypass the blocked or diseased lymphatics by creating connections between the lymphatic system and the venous circulation. Nodo-Venous Shunt is one such procedure that creates a surgical shunt between the lymph node and a vein thus bypassing the diseased lymphatics. This procedure has a short patency rate and is usually used as an adjunct before debulking surgery. This procedure is currently the most commonly performed procedure for this problem. Lymph vessel to vein anastomosis is another super microsurgery which has a role.

Ms. A, a 26 year old Sudanese National came to our department with a history of swelling of both lower limbs of 15 years duration. The swelling in the left lower limb was more severe. She also had an ulcer in the back of the left leg with continuous discharge of lymph. She had tried different treatment modalities but none were effective. She was debilitated as she was unable to walk because of the bulkiness of the left leg, inability to wear same size footwear and was socially inhibited because of the foul smell and unsightly deformity. As the required expertise was not available in her country she was referred to us. She was evaluated thoroughly and started on medical management. Skin ulceration and lymphorrhoea healed. She came back after 11 months of medical management. Our team evaluated her and it was decided to offer her the new treatment option of free microvascular lymph node transfer. She underwent Free Vascularised Lymph node transfer. Lymph nodes in the chin region was harvested with the facial artery and facial vein and transferred to the Left ankle. Vascular connections were re-established using a microscope. The transfer was successful and patient was discharged and allowed to go home with significant reduction of swelling. She is able to wear footwear of same size and she has no debilitating symptoms.

This novel and pioneering procedure has not been reported from South India to the best of our knowledge. Long term follow up is required to assess the final outcome; this is being studied extensively all over the world.