b'reaches the rib area, and closely monitor the genitaliaphysiological surgery, which re-establishes the for signs of worsening. If adverse signs do appear, thedisrupted lymphatic system with microsurgery. pump should be discontinued. One reason the pumpKoshima et al described and popularized the concept does not work for all is that the pump is trying to bringof performing microsurgical lymphovenous bypass the fluid up from the genitals into the lower abdomen(LVB) or lymphovenous anastomosis (LVA) between a anteriorly, and this is often the least efficient way tofunctional lymphatic vessel and a recipient vein withmove fluid. Gravity may assist in returning the fluid toa diameter 0.8mm 65 . Since then, LVB/LVA has the genitals. Elastic tape can be used on the trunk butbecome the gold standard of treatment for patients should never be used on the skin of the genitals, for with early-stage secondary lymphedema.it could lead to irritations or sores on the skin. HCPsTraditionally, lymphovenous bypass is indicated in treating GLE may also need to address or refer out forpatients with MDACC (M.D. Anderson Cancer Center) other conditions related to GLE, such as incontinence,ICG (Indocyanine Green) lymphedema stage 1 or 2. On pelvic pain, prolapse, and hormone imbalances.the ICG lymphography, these patients demonstrate The ingrained belief that one should not discusspatent lymphatic vessels with patchy (stage 1) or genitalia needs to be suppressed for HCPs to dermal backflow segmental (stage 2), which are ideal treat patients with GLE successfully. From clinicaltargets for LVB. The ICG lymphangiography is experience, the genitals will respond favorably performed for mapping of lymphatic channels, and with early appropriate intervention from HCPs LVBs are typically performed at the areas distal to the and compliance with a robust home program.region of dermal reflux using incisions 2-cm in length. Including GLE in more studies, courses, and books orSubdermal lymphatics and venules are anastomosed in educational materials will assist in reducing the stigmathe end-to-end or side-to-end manner using an 11-0 or around GLE and support HCPs in delivering the most12-0 nylon suture. The patency of the lymphovenous appropriate evidence-based interventions to QOL bypass is confirmed using the blue dye and ICG dye. of patients with GLE. Koshima et al have demonstrated that patients who underwent LVB have an average decrease in arm SURGICAL MANAGEMENT OF circumference by more than 4 cm. In addition, Chang LYMPHATIC DISEASE et al have shown that patients who underwent LVBs had a 96% subjective improvement with a 42% volume A. SURGICAL METHODS ADDRESSING THEreduction at 1 year postoperative 66 .TREATMENT OF PRIMARY LYMPHEDEMA While the efficacy of lymphovenous bypass in Author: Min-Jeong Cho, MD secondary lymphedema has been widely studiedHistorically, surgical treatment of primary lymphedemaand accepted, there are limited studies on its efficacy was limited to debulking procedures such asin primary lymphedema. In a systematic review by liposuction or direct excision due to an abnormalFallahian et al, they found a total of ten studieslymphatic system in these patients. However, there (254 patients with primary lymphedema) who under-has been increased evidence on the efficacy ofwent physiological surgeries67. 88% of these patients physiological surgeries such as lympho-venous bypassunderwent lymphovenous bypass, and they had a and lymph node transfer in these patients. It is critical,statistically significant improvement in lymphedema. however, to note that primary lymphedema is anYoshida et al found that LVB was more effective in umbrella term that represents a wide variety ofolder patients with early-stage bilateral lymphedema conditions caused by several different pathologicalthan younger patients with late-stage unilateral mechanisms responsible for lymphatic dysfunction. lymphedema 68 . These findings agree with current As such surgical interventions may not be successful findings on the efficacy of lymphovenous bypass on in all cases (e.g., in cases where venous incompetencesecondary lymphedema. In addition, Demirtas et al such as lymphedema distichiasis or poor uptake by found that reduction of edema was similar between the initial lymphatics in Milroys lymphedema (seeprimary and secondary lymphedema 69 .primary lymphedema section) but may be appropriateVascularized Lymph Node Transplant (VLNT)in others. Vascularized lymph node transplant (VLNT) wasLymphovenous Bypass (LVB) first described in the 1960s, and it has become the Previously, surgical treatment for lymphedema treatment of choice for patients with moderatewas limited to non-physiological surgeries such asand advanced stages of lymphedema 70,71 . VLNT liposuction or excisional procedures. With theprocedure involves harvesting lymph nodes from one emergence of super microsurgical instruments andlocation and transferring them to the affected area technological advances in microscopes, surgicalusing microsurgical anastomosis. Currently, there are treatment of lymphedema has evolved to includediverse indications and timing of VLNT amongst | Standardized Approach for the Diagnosis and Management of Lymphedema (LE) and Lymphatic Diseases (LD)|24'