Treatment of post-lymphadenectomy and radiotherapy lymphedema of limbs by bypassing the lymph flow obstruction site with implanted silicone tubes

 
 
 

Treatment of post-lymphadenectomy and radiotherapy lymphedema of limbs by bypassing the lymph flow obstruction site with implanted silicone tubes

Waldemar L Olszewski, Marzanna Zaleska

Medical Research Center, Polish Academy of Sciences and Central Clinical Hospital, Ministry of Home Affairs, 02106 Warsaw, Poland  waldemar.l.olszewski@gmail.com

Introduction.

Patients treated for breast and uterine cancer, melanoma and seminoma are facing a life-time risk of developing lymphedema in at least  40% of this population. In advanced cases of lymphedema the main lymphatics become obstructed at their whole length and tissue fluid accumulates in the interstitial  spaces forming  fluid  “lakes” and “channels”. The only solution for fluid drainage would be creating artificial channels  for flow away to the non-obstructed edema fluid absorption regions.

We propose a novel method  of forming artificial pathways for edema fluid flow by  subcutaneous implantation of  silicone tubes into the swollen limb bypassing the obstruction site (1). As a complementary treatment stocking and long term penicillin were applied before and after surgery. Implantation was done only if that treatment didn’t bring improvement.

 

Implant characteristics

        Sterile silicone tubes medical grade o.d. 3mm and i.d. 2mm is used.  The tubes material is hydrophobic preventing ingrowth of connective tissue into the lumen and around them. Hydrophobic properties were tried previously  on rats proving easy pullout of the implanted tubes without resistance even months after implantation. The concentrity of tubes didn’t change and there was no reduction of ovality. Three tubes of  a length adjusted to  that of the limb were tied together and multiple lateral holes  were made at distances of 3cm. On a cross view a space was formed between the three tubes allowing fluid to accumulate. The accumulated fluid could move in the tubes as well as between them.

 

Implantation technique

     For upper limb, a  2cm long incision was made 2 cm above the radial-metacarpal joint, another above the internal aspect of arm above the elbow and the third one at the scapular region. For lower limb, a 6cm long incision was made in the groin, 2cm long above the medial ankle and 2cm in the hypogastrium.  A 1.5 cm wide and 100 cm long  slightly curved metal tube tunneling device was introduced deep under the skin  and bluntly  passed along the limb. The  tubes were passed  through the tunneler, after which  it was removed.  Fixing of tubes  to the surrounding tissues  was avoided to maintain the possibility of removing in case of any complication.

 

Pre and postoperative evaluation

Limb circumference and  volume as well as  tissue tonometry were done.  Moreover, tissue fluid movement was evaluated in a two-cuffs compression test. Ultrasonography and lymphoscintigraphy were done to show accumulation of edema fluid in and around the tubes and their patency (Fig. 1).

Patients reports included heaviness in the limb, easier  hand grip and flexing in elbow, as well as raising arm. In lower limbs this was easier flexing in ankle and knee joints.

 

Results

 

The first investigated group included  25  patients  with lower and 12 with upper lymphedema, stage III, with a follow-up from 6 months to 2-4 years.  A fast decrease of limb circumference was observed already during the first days after implantation  lasting for  2 weeks to become slower thereafter. In lower limbs circumference decreased in all patients within the first 2 weeks, differently at  various levels of the limb, by -3.2% to -3.9 % with a range from +3% to – 17% after 2 years (p<0.05). In upper limbs it was 10% in the mid-forearm and 5% in the mid-arm during week 1 to reach 15 and 10% after 6 months, respectively (p<0.05). Interestingly, after this rapid decrease of circumference and volume the ultrasonography, MRI and fluid movement plethysmographic test didn’t reveal any more mobile fluid. There was an evident decrease of skin and subcutis stiffness  observed already on the first week to proceed for another week and level off thereafter. On lymphoscintigraphy, the tracer filled up tubes  and/or space between tubes at their whole length giving a wide shadow. This could be interpreted as spread of isotope into the tissues surrounding implants (Fig. 1). 

Taken together, the implanted tubes brought about fast evacuation of excess tissue fluid, b) most decrease in circumference, volume and stiffness occurred in  first two weeks, c) less limb heaviness and easier hand grip, d) lymphoscintigraphy  tracer accumulated in tubes and  around them, e) free fluid  was seen on ultrasonography at both ends of tubes and in between , e) no postoperative  complications.

Conclusions.  We propose a multimodal method comprising implantation, limb compression to generate fluid pressure gradient for flow and prevention of inflammation by administration of long-term penicillin. Simplicity of  surgical procedure and lack of reaction to implant make the method worth applying in advanced stages of lymphedema in large cohorts of patients.

 

1.Olszewski WL and Zaleska M.  A novel method of edema fluid drainage in obstructive lymphedema of limbs by implantation of hydrophobic silicone tubes. J Vasc Surg: Venous and Lymphatic Disorders, 2015; 3:401-409