En-Wei Liu, M.D.
Plastic & Reconstructive Surgery, China Medical University Hospital
A 46-year-old female from Taichung was found to have contracted breast cancer three years ago. After undergoing surgical removal of the focal loci and 18 sessions of chemotherapy, she has successfully beat the cancer into remission. However, while fighting the disease, she developed the lymphedema complication and experienced limb swelling, numbness, and even pain, which bothered her a lot. The discomfort of the limb swelling manifested on and off 8 months after the surgery. She had to be given medication or rehabilitation routinely in order to maintain her normal living and could not ignore the condition. She could not even rock her beloved niece to sleep, and her quality of life was significantly impacted by these symptoms.
Another woman, 60 years old and retired, who is also a breast cancer patient, underwent surgery to remove the tumor, radiotherapy, a few sessions of chemotherapy, target therapy, etc. She encountered the obvious swelling in the limbs three years after the cancer diagnosis was made and treated. The signs and symptoms were more significant at night and made her feel like she was continuously getting shocked with electricity. When she met with friends and family, they would often ask, “Why are your hands swelling like this?” The problem made getting dressed inconvenient, and she stopped her hobby of gardening, which negatively impacted her and pushed her away from the happy life she should have been enjoying.
Both of the aforementioned patients were diagnosed with lymphedema by Dr. En-Wei Liu, Plastic & Reconstructive Surgery, China Medical University Hospital and underwent minimally invasive lymphaticovenous anastomosis. During their one-year and six-month follow-up periods, respectively, big progress was made without any recurrence.
What is lymphoedema? What does it do?
Post-surgery cancer patients are in the high risk group to be afflicted by lymphedema, especially patients with breast cancer, cervical cancer, and other gynecological cancers, who make up a higher proportion among patients with this symptom. According to the statistics from many different studies around the world, about 15~40% of breast cancer patients may experience lymphedema in their lifetimes. “Lymphoedema” is a kind of limb swelling caused by the impaired circulation of the lymphatic system. The lymphatic fluid congests between tissues to make the limbs swell like sponges with water fully absorbed. The root cause of the symptom may be congenital or acquired. Patients frequently contract other infections and deformations. Some severe cases may even have the consequence of elephantiasis due to thickening skin after recurrent instances of inflammation.
One common cause of acquired lymphedema is tumor treatment (including surgery, post-surgical radiation treatment, chemotherapy, etc.) and the circulation block of the lymphatic vessels that it induces. For lymphedema patients, swelling of arms, feet, external genital organs, head and neck, or the body caused psychological stress, and the inconveniences to daily life can be even more impactful to their lives than the cancer surgery itself. Taking a breast cancer patient as an example, swollen arms cannot be hidden because they cannot wear their old dresses; more swelling and heavier limbs will influence patients’ body and mind, making them unwilling to go out and causing them to hide from other people.
The latent phase of lymphedema may be months or years, even several years. Since the initial signs and symptoms of lymphoedema are not obvious, patients usually lose the opportunity to treat it early. Therefore, the first critical step to treating lymphoedema is early diagnosis and confirming the issue.
Lymphaticovenous anastomosis and super microscope
The second critical factor is precise therapy. The traditional lymphoedema surgical treatment usually waits until the symptom is very severe, then removes a huge area of skin and proceeds with skin transplantation; this is a very destructive approach and results in poor appearance of the surgical area.
A new approach involves applying lymphaticovenous anastomosis via a minimally invasive approach (only a 2-centimeter incision is required) and builds many physiological drainages for the suffering limbs so that the post-surgery recovery period is short (the patient can get out of bed on the same day of the surgery), as is the hospitalization period (around 3-5 days). The procedure is implemented by connecting the isolated lymphatic vessels from the suffering limbs with the veins in the surrounding area to rebuild the alternative pathway for lymphatic fluid returns (similar to the concept of bypass surgery) to allow the retentive lymphatic fluid in the swelling limbs to return to the venous system due to the pressure differences, thus improving the limb swelling conditions. This is the physiological reconstruction of the lymphatic return.
This technique has become more advanced since the super microscope was invented because the precise locations of the obstructed lymph and the connections between the lymphatic vessels and veins need to be positioned through super microsurgery. The radius of the lymphatic vessels in the suffering limbs is around 0.03 to 0.08 centimeter so the common microscope cannot support surgery that requires such a high power of magnification. Relying only on a super high power microscope and fine professionally handmade instruments, the surgical team can proceed with super microsurgical sutures that are thinner than hair to complete such a difficult task to bring substantial benefits to cancer patients.