Discussion: Developing a Lymphatic Surgery Program: A First-Year Review.

Abstract

www.PRSJournal.com 986e A lymphedema affects over 250 million people in the world—5 to 10 million from the United States alone—it is a disease that has been largely neglected.1–4 However, over the past decade, there has been a tremendous increase in awareness of lymphedema and advances in lymphatic surgery. Consequently, lymphatic surgery is increasingly being offered in select hospitals throughout the United States. In 2016, Dr. Singhal and his team established a lymphatic surgery program at the Beth Israel Deaconess Medical Center.1 They developed a core team with a multidisciplinary approach to coordinate the diagnostic workup, management, and surveillance of patients. An electronic Research Electronic Data Capture (REDCap) database was established to monitor care delivery and facilitate future research. Their program has three arms, which constitute a “clinical triad”: (1) lymphatic surgery (plastic surgeon with a focus on lymphedema care); (2) lymphatic medicine (cardiologist with specialized training in vascular medicine and focus on lymphatic care); and (3) the lymphatic treatment clinic (certified lymphedema therapists). In addition, their program is supported by body and nuclear imaging. The lymphedema team meets bimonthly to discuss and formalize patient-specific care plans.1 Their experience has included patients undergoing immediate lymphatic reconstruction (e.g., lymphatic microsurgical preventative healing approach) or delayed lymphatic reconstruction (e.g. lymphovenous bypass and/or vascularized lymph node transplantation). Similar to ours and the experience of others, a majority of patients diagnosed with lymphedema had a history of breast cancer.1–6 Overall, Singhal et al. report seeing 142 patients for evaluation during the 1-year period, of which 40 patients were seen for immediate lymphatic reconstruction and 69 for cancer-related delayed lymphatic reconstruction.1 That nearly 30 percent of patients (40 of 142) were seen in consultation for immediate lymphatic reconstruction is notable.5 In our experience, integrating the lymphatic microsurgical preventative healing approach into surgical practice requires a close relationship between the breast surgical oncologist(s) and the reconstructive surgeons. Logistic challenges include coordinating scheduling, uncertainty regarding the potential need for axillary lymph node dissection, and insurance coverage. Furthermore, identifying the patients who are at highest risk for developing lymphedema continues to be a challenge that impacts treatment efficacy. However, Singhal et al. are apt to point out that patients referred for immediate lymphatic reconstruction require less workup before their surgery. Of the 102 patients presenting for delayed lymphatic reconstruction, only 49 patients underwent a presurgical workup. Patients were excluded because of poor surgical candidacy (47 percent), a desire to pursue conservative therapy (47 percent), or a diagnosis inconsistent with lymphedema (33 percent). Although it is unclear how patients were assessed for surgical candidacy, it is likely that overall the proportion of patients who merit a full presurgical workup will increase as patient and provider education improves within the referral network. Among the 53 patients who did qualify for presurgical workup (52 percent), Singhal et al. report performing surgery on 13 patients. Among the 13 patients who underwent surgery, two had lymphovenous bypass, seven had vascularized lymph node transplantation, and four had excisional procedures.1 Critical to providing surgical care for lymphedema patients is the need for long-term