Narrator: Coming up on Mayo Clinic Q&A...
Dr. Antonio Forte: If a patient has upper or lower extremity
lymphedema, we want to make sure first that they have a
functioning venous system to make sure that we can then use
the vein as a surrogate of the lymphatic system to remove the
fluid from the arm or leg.
Narrator: When cancer treatments affect the lymph nodes,
swelling, called lymphedema, can develop. Lymphovenous bypass
surgery can help restore the flow of lymphatic fluid and
reduce the pain and swelling.
Dr. Antonio Forte: The beauty about lymphovenous bypass is
that it's minimally invasive. So, it's an outpatient procedure
because we're just working with very superficial and small
incisions. Then the patient can just go home a couple hours
after the procedure.
Jason Howland: Welcome everyone to Mayo Clinic Q&A. I'm Jason
Howland sitting in for Dr. Halena Gazelka. Lymphedema is
tissue swelling caused by the buildup of fluid that's usually
drained through the body's lymphatic system. Because lymph
nodes are an important part of the lymphatic system, lymphedema
can be caused by cancer treatments that remove or damage
the lymph nodes. Treatment for lymphedema focuses on reducing
swelling and preventing complications. One new treatment
option is a microsurgery technique to bypass the damaged
lymph nodes. Joining us today to discuss is Dr. Antonio Forte, a
Mayo Clinic plastic surgeon who specializes in lymphovenous
bypass surgery. Dr. Forte, welcome to the program.
Dr. Antonio Forte: Thank you. Thank you for the opportunity to
be here.
Jason Howland: Well, let's start out with the basics. What is
lymphedema? And is cancer treatment the most common cause?
Dr. Antonio Forte: Well, lymphedema in the United States
is mostly secondary to cancer treatment. If you look in the
whole world, there are other causes, especially infections,
that can be the primary cause of lymphedema. However, since we're
talking about specifically the population in the United States,
then cancer treatment does play a major role in causing
lymphedema. And the way it works is, during cancer treatment,
sometimes lymph nodes need to be removed, and the lymphatic
system that travels around and through these lymph nodes, they
get damaged as well. It's impossible to remove the lymph
nodes without damaging the system. Sometimes the system
doesn't necessarily need to be surgically removed, even just a
radiation treatment could potentially damage the system.
So, you still have a functioning artery and a functioning vein.
But the lymphatic vessel becomes dysfunctional in certain areas.
Now if the area that is dysfunctional is your armpit,
then the arm is going to get very swollen. And if it's on the
groin, then the legs are going to get very swollen, and so
forth.
Jason Howland: So other than the swollen areas of the body, are
there other symptoms of lymphedema?
Dr. Antonio Forte: Well, once lymphedema progresses and more
and more fluid accumulates, then there are tissue changes that
happen and they can happen chronically. So, these tissue
changes can cause the tissue to become much harder and the skin
to have this thicker appearance. Wounds can take longer to heal.
Patients can be more prone to developing cellulitis and so on
and so forth.
Jason Howland: So, what are the typical treatment options?
Dr. Antonio Forte: Well, there are the nonsurgical options and
the surgical options. Nonsurgical options are widely
available. They include wrappings, compression garments.
They're usually guided by, ideally, a certified lymphedema
therapist, which is a physical therapist or occupational
therapist that has additional training on lymphedema. And that
person will then conduct all these treatments that allow for
control of the swelling and make the limb size less
dysfunctional. The surgical options include the resection,
surgical modalities, and the ones that are more microsurgical
in nature. Regarding the resection, you can just make an
incision and remove surgically the tissue and then put the
tissue back, the skin over the area that was resected. You can
also just do liposuction and remove the excess tissue just
using liposuction cannulas. And then microsurgical options would
try to restore the drainage by reconnecting the lymphatics to
the venous system, which then allows the fluid to be drained
out of the extremity, leveraging the venous system as a surrogate
of the lymphatic vessel.
Jason Howland: So, what you're describing there, that's
lymphovenous bypass surgery, correct?
Dr. Antonio Forte: Correct. There are other options that
include the transfer of lymph nodes from one area to the
other, and those lymph nodes would then be connected to the
venous system as well. They would work as pumps and remove
some of the fluid on the adjacent tissue. Or you can
identify the lymphatic and adjacent venous vessel and
connect them both. So, this second option is the
lymphovenous bypass.
Jason Howland: Why is it called microsurgery?
Dr. Antonio Forte: Well, all these connections that we
perform, they are done using a microscope and very small
instruments. The size of the needle is extremely small,
especially just being seen with the naked eye, and the suture is
thinner than hair. Especially when we're doing lymphovenous
bypass, it's not unusual that we use 20 to 25 times magnification
to be able to appropriately visualize the vessels. So, it is
very labor intensive. It is minimally invasive, lymphovenous
bypass; however, it requires very specific skill sets to be
performed given this difficulty of working with structures that
need to be augmented with a microscope 25 times.
Jason Howland: And so, who can perform lymphovenous bypass
surgery?
Dr. Antonio Forte: Usually these are microsurgeons that are
trained specifically in this area that we call super
microsurgery. They are plastic surgeons, mostly, and they use a
microscope and these very refined instruments to be able
to execute all these different procedures.
Jason Howland: So, what sort of patient would be a candidate for
this type of surgery?
Dr. Antonio Forte: Well, with the lymphovenous bypass we have
tried to help as many patients as we can. If a patient has an
upper or lower extremity lymphedema, we want to make sure
first that they have functioning venous system to make sure that
we can then use the vein as a surrogate of the lymphatic
system to remove the fluid from the arm or leg. It's always also
good to, before we even talk about surgery, make sure that
they do have a diagnosis of lymphedema, because some
patients can have swelling that is unrelated to dysfunction of
the lymphatics. And once we identify these different
parameters, then we can talk to the patient about whether they
would be a candidate or not. Usually, things that would
preclude patients from having this surgery is an allergy to
the special dye that we use to map the lymphatics or an
extremely advanced lymphedema that would preclude us from even
being able to find lymphatic vessels.
Jason Howland: So, what are the risks of lymphovenous bypass
surgery?
For: Well, the lymphovenous bypass surgery has very little
risk because the lymphatic vessels that we use, they are
right under the dermis. They are located in where we call the
subdermal plexus. And the veins that we use are extremely
superficial. So, the idea is that we use these very
superficial structures and we make various small incisions,
around three centimeters each. We do plan where these incisions
are going to be placed. And the way that we plan them is we use
a special dye called indocyanine green, and a special camera.
That dye is injected on the dermis, and it's drained by the
lymphatics only. So, you can use that camera and map where the
lymphatics are running on a patient's hand, arm or leg. And
once you know where the lymphatics are, then you can
plan where you're going to make these transverse incisions. So,
you can more accurately identify the lymphatic vessel and
adjacent vein, and then connect them both.
Jason Howland: And what is the success rate of this type of
surgery?
Dr. Antonio Forte: There's a very good study that was
published almost a decade ago that looked prospectively at
patients that had lymphovenous bypass, and they average that
42% of the swelling is improved over one year. Now there are
patients that will have much more improvement than that. And
some other patients will have very little improvement. But on
average, all the patients that have lymphovenous bypass
surgery, they have an improvement of 42%, over a year,
of their swelling.
Jason Howland: Well, that's fantastic. So, what if I'm a
patient who comes in for lymphovenous bypass. What can I
expect to experience during surgery, how long is the
procedure, and then also, what sort of recovery is there when
it comes to this surgery?
Dr. Antonio Forte: So, the beauty about lymphovenous bypass
is that it's minimally invasive. So, it's an outpatient
procedure. It's very labor intensive. So, it takes, you
know, the good part of the day, sometimes six hours, sometimes
four hours, because finding those tiny vessels and
performing the connections is difficult. But because we're
just working with very superficial and small incisions,
then the patient can just go home a couple hours after the
procedure. So, it's an outpatient procedure. And the
patients have the extremity wrapped after the surgery, and
they will unwrap it at home, shower, wrap it again, which is
very similar to what the nonsurgical management is of
lymphedema. And then we see them periodically, at two weeks, two
months, six months, and one year. And make sure that every
time we see them, including before surgery, we get
measurements and photos so that we can objectively track how
much they have improved.
Jason Howland: And because it is minimally invasive, I'm assuming
that there's very little scarring as well.
Dr. Antonio Forte: The way people scar is very unique to
them. But the majority of patients that we see, when we
are looking at them a year later, it's even hard to know
where the incision was placed to begin with, because they're very
small.
Jason Howland: Super. Is lymphovenous bypass surgery, is
it available at all cancer centers?
Dr. Antonio Forte: Not necessarily. I would say that
some sort of lymphedema surgery is available at a lot of the
plastic surgery academic centers. And then, I would say a
subset of that would be able to offer lymph node transfers. And
even smaller subset of that would offer lymphovenous bypass,
given that lymphovenous bypass requires additional expertise
and training to be performed.
Jason Howland: And an important question here for patients, and
I'm sure you get asked this, is lymphovenous bypass surgery
covered by insurance?
Dr. Antonio Forte: Yes, most insurances will cover it.
However, it's always hard to determine, you know, each
insurance will have their particular policy and that
varies from year to year. But, in general, we have had good
success with people's ability to get that covered by insurance.
Jason Howland: Fantastic. Unfortunately, we are all out of
time. But I'd like to thank our guest today, Mayo Clinic plastic
surgeon, Dr. Antonio Forte. Thank you for joining us today.
Dr. Antonio Forte: Thank you. Thank you for the opportunity to
be here.
Jason Howland: And thank you for joining us on the Q&A podcast.
Have a great day.
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