Lymphatic microsurgery for the treatment of lymphedema.

One of the main problems of microsurgery for lymphedema consists of the discrepancy between the excellent technical possibilities and the subsequently insufficient reduction of the lymphoedematous tissue fibrosis and sclerosis. Appropriate treatment based on pathologic study and surgical outcome have not been adequately documented. Over the past 25 years, more than 1000 patients with peripheral lymphedema have been treated with microsurgical techniques. Derivative lymphatic micro-vascular procedures has today its most exemplary application in multiple lymphatic-venous anastomoses (LVA). For those cases where a venous disease is associated to more or less latent or manifest lymphostatic pathology of such severity to contraindicate a lymphatic-venous shunt, reconstructive lymphatic microsurgery techniques have been developed (autologous venous grafts or lymphatic-venous-Iymphatic-plasty - LVLA). Objective assessment was undertaken by water volumetry and lymphoscintigraphy. Subjective improvement was noted in 87% of patients. Objectively, volume changes showed a significant improvement in 83%, with an average reduction of 67% of the excess volume. Of those patients followed-up, 85% have been able to discontinue the use of conservative measures, with an average follow-up of more than 7 years and average reduction in excess volume of 69%. There was a 87% reduction in the incidence of cellulitis after microsurgery. Microsurgical lymphatic-venous anastomoses have a place in the treatment of peripheral lymphedema and should be the therapy of choice in patients who are not sufficiently responsive to nonsurgical treatment. Improved results can be expected with operations performed earlier at the very first stages of lymphedema.

Is there a role for microsurgery in the prevention of arm lymphedema secondary to breast cancer treatment?

The secondary lymphedema of the upper limb (post-mastectomy lymphedema) has an incidence, in patients who underwent axillary lymphadenectomy for breast cancer, between 5 to 25%, up to 40% after radiotherapic treatment. We studied 50 patients treated for breast cancer. The patients were divided in two groups of 25 each, comparable for age, sex, pathology and treatment and followed up to 5 years after operation for breast. One group of 25 patients was controlled only clinically (physical examination, water volumetry) at 1-3-6 months and 1-3-5 years from breast cancer treatment. The other group of 25 patients was followed also by lymphatic scintigraphy performed pre-operatively and after 1-3-6 months and 1-3-5 years from operation. In the first group, followed only clinically, lymphedema appeared in 9 patients after a period variable from 1 week to 2 years, with highest incidence between 3 and 6 months. In the second group of 25 patients, the preventive therapeutic protocol allowed to have a clinically evident arm lymphedema only in 2 patients. The comparison of the two groups of 25 patients proved a statistically significant difference in the appearance of arm secondary lymphedema (p = 0.01, using Fisher's exact test). The diagnostic and therapeutic preventive procedures allow to reduce the incidence rate of lymphedema significantly, in comparison with patients who did not undergo this protocol of prevention.

[The role of endorectal echography for determining the extent of an operation]. / Rol' éndorektal'noi ékhografii dlia opredeleniia ob''ema operatsii.

The paper discusses the usefulness of endorectal echotomography and adenolymphoscintigraphy--two new diagnostic methods which allow surgeons to know preoperatively tumor extension beyond the rectal wall and lymph nodes involvement. Though the statistical data presented are not numerous, it is hoped that, using these two diagnostic methods in cases of rectal tumors, surgeons will be able to choose better between local excision and abdominoperineal resection thus avoiding unnecessary and mutilating operations.

Experience with local rectal cancer excision in light of two recent preoperative diagnostic methods.

This study analyzes the usefulness of two diagnostic methods: endorectal echotomography and adenolymphoscintigraphy. Echotomography is an important means for determining the extent of a tumor beyond the rectal wall, whereas lymphoscintigraphy is useful in demonstrating the metastatic locations in lymph nodes. These two modes of evaluation may permit an evaluation of the extent of the tumor and the possible involvement of regional lymph nodes before a surgical operation. Although the case material is limited, the statistical data can lead one to believe that, in the near future, a reasoned choice will be possible between local excision and abdominoperineal resection. The study includes 60 endorectal echotomographies and 26 lymphoscintigraphies (20 with 99mTc colloid and six with 201-Tl colloid).