Lymphedema after cancer treatment: Relief through minimally invasive surgery
By Jessica Saenz
Cancer treatment and surgery are some of the most common causes of lymphedema, a sometimes painful and serious condition that causes swelling from accumulated lymphatic fluid.
"During cancer treatment, sometimes lymph nodes need to be removed, and the lymphatic system that travels around and through these lymph nodes gets damaged," says Antonio Forte, M.D., Ph.D., a Mayo Clinic plastic surgeon. "Even radiation treatment could potentially damage the system."
Much like arteries and veins, lymphatic vessels are always moving and carrying fluid to the lymph nodes and around your body, but if a blockage occurs due to damage to the lymphatic system, lymphedema can develop.
Though lymphedema can't be cured, Dr. Forte says a minimally invasive microsurgery, called lymphovenous bypass, is helping some patients see dramatic improvement.
How lymphovenous bypass works
Swelling from lymphedema typically occurs in the nearest extremity to the damaged or removed lymphatic vessels or lymph nodes. This might occur in your arms or legs, but it also can occur in the chest wall, abdomen, neck and genitals. Lymphovenous bypass restores drainage of lymphatic fluid by connecting lymphatic vessels to nearby veins that can drain fluid away from the area.
"If a patient has an upper or lower extremity lymphedema, we first want to make sure that they have a functioning venous system so we can use the vein as a surrogate to the lymphatic system," says Dr. Forte.
To identify the location of the lymphatic vessels, Dr. Forte says a dye called indocyanine green is injected into the dermis (the inner layer of the two main layers of the skin) and a special camera is used to track the path of drainage. "The camera can map where the lymphatics are running on a patient's hand, arm or leg. Once we know where the lymphatics are, we can plan where to make the incisions."
The incisions — which are no larger than a paper cut — provide access to the hair-thin lymphatic vessels in the area, and powerful microscopes are used to create the tiny detour.
Aside from being minimally invasive, which means faster and easier recovery, lymphovenous bypass also is considered a regenerative solution because, if it's successful, your body usually can reverse the damage caused by fluid buildup.
Risks associated with lymphovenous bypass
Lymphovenous bypass is a low-risk outpatient surgery, and while it can take up to six hours, you can go home the same day and only require periodic follow-up. "Lymphovenous bypass surgery has very little risk because the lymphatic vessels we use are right under the dermis. And the veins we use are extremely superficial," says Dr. Forte. Because of this, he says most of the time scarring is hardly visible after a year.
If it's successful, Dr. Forte says, patients have a significant reduction of swelling in the months and year following surgery. "There's a very good study published almost a decade ago that looked prospectively at patients that had lymphovenous bypass. And, on average, 42% of the swelling is improved after one year," he says. "Some patients have much more improvement than that, and some patients might have very little improvement. But, on average, patients who have lymphovenous bypass surgery have improvement of their swelling."
Though it's a low-risk surgery, Dr. Forte says lymphovenous bypass still requires very specific training and a skillset from a plastic surgeon who specializes in what is called super microsurgery. And he recommends exploring options at academic medical centers with expertise in lymphovenous bypass.
Determining who is a candidate for lymphovenous bypass
Dr. Forte says lymphovenous bypass is a good option for many people, but confirming a diagnosis of lymphedema and ruling out other conditions is key. "Before we even talk about surgery, it's always good to make sure that they have a diagnosis of lymphedema because some patients can have swelling that is unrelated to dysfunction of the lymphatics."
A good candidate for lymphovenous bypass also should have healthy veins that can support additional flow. "If a patient has an 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," says Dr. Forte.
If you think lymphovenous bypass might be a good option for you, discuss this with your health care professional.
Dr. Forte also recommends reaching out to your health insurance provider to learn about coverage. "Most insurances will cover it. However, each insurance has their particular policy, and that varies from year to year. But, in general, we have had good success with people's ability to get this procedure covered by insurance."
When traditional treatment to ease the burden of lymphedema from cancer treatment doesn’t provide significant relief, surgical approaches, like lymphovenous bypass, can be a good option. Undergoing another surgery, especially if you've already had cancer surgery, can seem frightening. But Dr. Forte says, for many people, the benefits far outweigh the downsides.
"I love lymphovenous bypass because the morbidity is so low that there's little downside to the procedure. If lymphovenous surgery doesn't relieve fluid buildup, then all you have to heal from is small incisions similar to paper cuts," he says. "If it does work, it's life-changing."
Watch Dr. Forte discuss lymphovenous bypass and how it can help people with lymphedema after cancer treatment on this "Mayo Clinic Q&A" podcast video: