Good morning everybody.
I know that it's not easy to be, you know, next, the day after the gala dinner,
but we need to start, you know, we still, we have so many,
uh, interesting sessions, and we are going to start now with uh the lymphatic surgery
session, something that still is new in uh in the world of the breast surgery.
But I must tell you that personally, this is for me the most fascinating part of the breast
cancer related um surgery.
I would like us to add to be co-chairing this session.
And the first speaker is Andrea Moreira.
She's going to talk about the prevention, surgery cost,
time, Altons, benefits, everything.
Thank you, Andrea.
Thank you, Jaime. Thank you Ed good morning everyone after the
party. So, um, I'm going to talk a little bit about,
um, prophylactic lymphatic surgery, um.
This is a field that is evolving and uh I still think we need a lot of
Um, good research over time, but there are a few things that we can actually discuss about
it. So the first thing I want to mention is that
there is a trend, at least in the United States, to a decreased axillary lymph node dissection.
And as you can see in this graph, that uh number of axillary dissections dropped from
2004 to 2014 to 16% actually affects resident training because they don't see as
many. And of course, if you see less axillary
dissection, you are going to have less problems with lymphedema.
So we know that the cancer, breast cancer-related lymphedema,
you know, it might happen with a lymph node biopsy in 4 to 10% of the cases,
um, with an axillary dissection up to 21%, and that number is so variable that goes to
5 to 50% over time, happens between 3 months and 3 years in general,
and we know that radiation, obesity, lymph node dissection, and the smokers um have an
increased risk for lymphedema.
So, treatment for lymphedema is expensive and it requires a lifetime commitment.
Um, as we, we know that these patients, they have up to 120% out of pocket,
um, increased cost for the treatment of lymphedema and there is really a last impact
not only on their savings but also productivity. Some of them are very limited in what they can
do. Um, when you look at the studies, in general,
a patient with lymphedema has an out of pocket cost from the insurance about $3000 to
$3500 per year in the US, so it's a lot of money.
And uh if we can do something that can minimise and mitigate lymphedema,
why not, right?
We, the reasons to perform um preventive lymphatic surgery will be pretty much to try to
reduce the sever the severity and the incidence of lymphedema over time after a mastectomy and
and uh lymph node dissection.
And, uh, you know, it's cost effectiveness over time, allowing for patients to
stop all the conservative management that it can be very onerous over time as,
as, as I mentioned before.
Um, so, we previously looked extra water efficiency and coordination of care on patients
undergoing, um, lymphatic surgery in our institution, and we look at 93 patients who had
axillary dissection.
Axillary reverse mapping, we do that for all the patients that are going to have axillary
dissection and lymphatic preventive surgery.
Um, 43% of our patients were unilateral, 34 bilateral, 60%,
they had breast conservation surgery, and 7% only had a mastectomy.
And what we're able to find is that surgeons' training and coordination is essential and that
gets better over time. We look at our data, uh,
and we follow up for about 4 years at that time and while in the beginning when you're doing
lymphatic surgery, that takes time and that you actually need to train not only breast,
but plastic surgeon. Personnel how to be efficiency on these cases,
but when we look at the surgical time, there was a significant decrease between
2016 and 2019 it just tells you that is a learning curve and we get better over time and
if we can reduce our surgical times we save money for those patients,
right? And again.
And again, when you look at the trend, there was an increase in the number of um
prophylactic uh lymphatic surgeries that we did and also an increase in the number of
lymphatics that we connected um and that a decrease on the time to perform these
procedures and that's a uh a cost saving issue.
I really love this slides. This was a dissection done in one of our
lymphedema courses by Iro Swami, and that points out exactly the lymphagic drainage of
the arm. You're gonna see a big blue lymph node and an
anticubbi so um.
Area, but you see, most of those lymphatics will drain to one or two lymphatics in the
axilla. So, if we map the arm, we can preserve in most
of the cases that lymphatic. We know that in general,
the lymphatic that's draining the breast and the lymphatic that's draining the arm,
in general, they're not the same.
And uh in this case, you can see the blue node draining all the dye.
These dissections are absolutely gorgeous. Um, it takes a long time to be done.
So, in most of the time, you can preserve um those those lymph nodes if you do a reverse
mapping. So, our protocol at the clinic, we offered,
um, uh, you know, lymphatic preventive surgery to all patients who are undergoing um lymph
node dissection that we knew they're undergoing lymph node dissection.
There's a lot of counselling that goes with it since it's not a um.
Gold standard procedure quite yet.
Um, we send our patients to preoperative PT. We wanna make sure that we get all the
measurements before surgery. We wanna, uh,
evaluate patients for possibly primary lymphedema once in a while you see one of those
and, uh, they get all their postoperative exercises and management preoperatively.
Um, so I think by doing that we increase our rate for success and uh all
our breast surgeons were trained on the reverse mapping.
Um, I think it's really important to do it right and we find that we're able to find the
lymph node draining the arm, you know, 86% of the cases,
um, with the reverse lymphatic mapping.
So our protocol and decision making was, was pretty much,
it was very simple.
Um, you need a vein to do your uh LVAs, right? So, if we're able to find a recipient veins for
that lymphatic, we would proceed if we, we didn't, we would abort the procedure.
You know, we look at lymphatic availability.
There was one or multiples, we changed our technique.
If there are multiple lymphatics, we do the interception technique and multiple LBAs.
However, um, if it was just one for a size discrepancy, we still do the interception or
end to end or end to side and ostomosis and re verify the patency with the ICG.
Um, just to show a case, this is actually one of my patients who Is it
moving? OK. Who underwent bilateral mastectomies,
pre-op chemo, the lymph node was positive, um before surgery,
they couldn't see it after, um, the last MRI.
So this is our breast surgeon doing the lymphatic mapping.
We do 3 CCs of all the isosoone glue on the inner aspect of the arm,
and um.
You know, you, you really go superficial, but I also like to go a little bit into the fat
tissue, especially if the patients are obese.
Um, I think it helps you to map that lymph node, um, and you'll be able to see here the blue
node localised.
Unfortunately for this patient, this was the same node that we are able to map with the
probe, uh, with the lymphocytigraphy, so it had to be removed.
Um, I am there on the beginning of the case because I wanna make sure that I see the veins
and I actually protect them because the worst thing that can happen and you get after the
axillary dissection is done and you can't find anything to hook up those lymphatics,
and you can see the lymphagic um there and the lymphagic connected here.
So, um, it does require more training. It does require super microsurgery sometimes.
So we look at our cases and we had in two years about a 5.3% rate of lymphedema on the
patients who had prophylactic lymphatic uh surgery.
This is very similar to what is found in the literature.
I like to point studies that have done a longer follow up.
Uh, we see Gemma, um, and how many studies here that's, uh,
accepted, hopefully accepted for publication soon, and they had a 4% lymphoedema rate for 41
months and, uh, you can see that even longer studies.
The rate of lymphedema on patients who had Lympha is,
is, is definitely shorter. Some of these studies don't have a longer
follow up, so we have to wait on that.
I do want to point out this study.
This is the NIH trial on uh Lympha that is going on in the US,
and their data in 5 years showed 3.
15% rate of lymphedema on the patients who had lympha but this study is a different study.
So not all the lymphatics were actually connected.
They were just approximating the lymphatics to a vein.
It was done mostly by breast surgeons, so without the expertise of micros I think that
kind of uh might have affected the results.
So, if you ask me if Lympha is worth it, I think it is,
right? We do have to consider patient selection,
um, surgical expertise does matter. This is not a procedure that doesn't have a
learning curve. It does and is steep, um, and you have to
provide an individualised care because every patient is gonna be different.
Every lymph node dissection is gonna be different, um,
and you wanna be able to try to standardise as much as you can.
Um, and that you really have to balance cost and investment with potential long-term
benefits for patients and health care.
If you can control lymphedema, you're saving years, years of magical abuse and physical
therapy, and many of these procedures are not, at least in the US,
covered by the insurance.
So patients are really um affected by this.
And, and of course, there are several challenges.
There is the expertise that is required, so we need training.
Um, there is an infrastructure in the hospital. You need a good microscope so you can see those
little vessels. You need instruments that allow you to do the
procedure. Um, you need to have a very good coordination
between plastic surgery, breast surgeon, and physical therapist.
And, um, you know, there is a lot of variability in outcomes,
and I think at some point we need to figure it out how to cut down that.
Uh, insurance coverage is an issue in US and when they cover,
it's not very well reimbursed.
So I think there's several factors that we need to, to study.
In terms of cost effectiveness, I think the major takeout from this talk is that you are
going to. Save cost in a long term for the patient.
You can't pinpoint the value of prophylactic lympha right now.
There's not a cost effective study that I am aware, but I'm pretty sure they're gonna happen
in the near future, and I think they're gonna be really important.
And, uh, you know, there were, you guys heard yesterday um when,
when JP talked about innovations, you heard about the money,
so there will be new technologies that are gonna make this procedure a lot more popular
because it's those are enabling technologies.
Um, ultrasounds are much, much, much better and with AI I'm sure we're gonna be able to either
save those lymphatics or reconstruct them in a much easier way.
Um, and, uh, you know, there's a lot of area for improvement,
and, uh, if you're interested, I think, um, all of us can,
can discuss a little bit more about it.
Thank you so much. Moving on
to uh the next speaker, um, talking about um the comparing the microsurgical versus
conservative management for breast cancer lymphedema.
Doctor Cassos. Thank you, Ed.
Uh, good morning, everyone. Thank you for showing up that this early.
So I have no conflicts of interest to disclose.
The previous speaker, Andrea already told you, it's still quite frequent that we see patients
suffering from breast cancer, lymphedema, and of course prophylactic surgery would be ideal.
Also de-escalation is a big thing, so hopefully in the future it will be less,
but there are still many of our patients suffering from this chronic disease.
And so far across the globe still the gold standard is really the conservative treatment.
And this um is composed of uh of different things, manual lymphatic drainage,
compressive therapy and physical exercise and skin care.
But this of course is uh purely symptomatic and uh therapy has to be continued for most
patients uh lifelong.
So we know that we have these microsurgical options and with the help of ICG
we can stage our patients and then indicate and then indicate the right treatment for them or a
combination of different microsurgical approaches.
This is mostly lymphavenous anastomosis as you see on this picture or
in further progressed cases, lymph node transfer.
Both LBA and BLNT have been suggested to be effective.
There is increasing evidence to both of these techniques.
Um, but there's only very few and many single centre RCTs on the subject,
and they usually have a very small sample size.
There's also a large variation of quality of life questionnaires that are used,
and I'm just going to show you some examples. This is probably the most famous one by Dimmy's
group from Dey's group in Thessaloniki.
Their primary outcome was quality of life and volume reduction,
but it was just a single centre with a with a small group,
only comparing VNT and conservative treatment.
And then there's another more recent one, they also showed uh several uh results when
comparing microsurgical treatment, but again, a small sample size and just one centre.
Um, here they only compared LVA and CDT.
Those were actually two different centres, uh, but only 6 months uh follow up.
So there are, as I said before, promising results for these two microsurgical approaches,
but there is still insufficient high level evidence, which is why the procedure,
as Andrea also mentioned, is not covered in many places.
So there is this knowledge gap. Does the microsurgical treatment that we are
offering our patients, is it really superior to the conservative treatment that is currently
still the gold standard?
So this is why we came together with many of you also and created the lymph trial,
which is a multi-center randomised superiority trial comparing microsurgical treatment of
chronic breast cancer related lymphedema with the conservative therapy.
It's called uh it's a pragmatic real world trial, meaning that there's no standardisation
of the procedure, but there is very detailed documentation.
And this will hopefully allow us to then translate the result directly into a routine
clinical care.
In the end, we need to randomise just below 300 patients.
We have over 32 sites involved worldwide, and the trial is completely funded by the Swiss
National Foundation and some two different foundations.
So just to go a little bit dig a little bit deeper in how we're going to do this,
the primary endpoint is patient reported outcomes.
It's the lymph ICF upper limb, but of course we also included the objective measurements like
the arm volume and adverse events, frequency of lymphatic drainage and economic assessment,
not just for the prophylactic approach, but of course also for the therapeutic surgical
approach. It's very important to prove to the For the
insurance coverage that it's actually superior to just the conservative treatment.
The primary endpoint will be measured at 15 months after randomization.
This is a compromise between wanting to follow the patients as long as possible in a way to
the primary, but on the other hand, not prolonging the treatment too long for the
conservatively randomised group. So it's 15 months,
and there will be an extended follow up of 10 months, but after 15 months,
the patients in the conservative groups, they are offered the surgical option as well.
So this is the different sites. I didn't list all of them,
but some of them are Group and they are in there, many of you in the
in the audience as well, and so far the recruitment is actually going fine,
but we need of course the different centres as those of you who have already run these large
international trials know it's quite challenging to open these international sites.
We have a great team in Basel.
They're very professional. I couldn't do it without them.
The project management team, um, but yeah, it's challenging.
It always takes longer than you think, but we have included um actually not 47 but 49
patients, but today the two were randomised yesterday and hopefully we'll reach for accrual
with the help of everyone.
So the goal of this trial is really to implement lymphatic reconstructive microsurgery
as part of the gold standard across the globe, and I agree with Andrea that the role of
robotics and prophylactic lymphatic surgery will be very important in the future.
Hopefully someday we will be able to avoid patients suffering from this chronic disease,
but so far there are still many that need our help with this surgical option.
And then of course, uh we should focus on the quality of life uh for our patient and uh do
everything to be able to help them.
So thank you very much for your attention and uh come visit us in Basel.
Excellent. Uh, next speaker is, uh, Kuro Milan is going to
talk about the non-surgical therapy for lymphedema.
Hi, I would like to begin by paying tribute to the patent named Pepita,
my oldest patent. According to the World Confederation of
Physical Therapy, is one of the best pillars of therapy that medicine used
to cure, prevent, and rehabilitate patients.
According to the APTA guide, use responsibility of the physiotherapy,
evaluate avoiding complication, training sequel and functional limitation,
recovering the passing autonomy, controlling edoema, avoiding the formation of band,
avoiding pressure user, muscle and jaw balance, posterior care,
and early mobilation.
The competition of physiotherapy according to the ATA is conservative prayer
during and post treatment.
No, I would like to explain the protocol that we carry out,
uh, colour detail, diagnodiagnosis, integration, treatment, and maintenance.
We start with the diagnosis with clinical analysis, inspection,
palpation, early phobia, go steer, asymmetric and rigid and fibrosis.
Um. Also, and this is icosocial
family economy that is the edoema for the patent in this aspect.
They continue I, uh, with a body analysis scan post are functional photometry,
body thetry, segmental theometry, and volumetry.
Uh, multi-frequency by impedance.
Segmental analysis, the mass analysis, fat analysis estafear and intraar water.
Lymphocytegraphy is a gold standard test of lymphatic system.
And this is very important.
Uh, I see lymphography gives us very valuable information that will help
us know the real state of the lymphatic system.
It is safe, simple, and minimally invasive. A long early diagnosis of secondary lymphedema
at a clinical stage.
Lymph transport capacity is a critical function that maintains fluid circulation and
also show us the possible speed of the lymphatic system to evaluate the function of
the lymphedema pump.
The ultrasound and theography is simple and very fastest that help us
know the amount of infra fluid this time from the
dermis to the fascia and tissue density.
Oh Lymphedema may be associated
with other pathology, obesity, chronic venous influenza in sufficiency,
lymphodystrophy ass associate with medication, lipo lymphedema,
idiopathic thick edoema, system dysfunction, and sedentary lifestyle.
The intervention is a is appropriate therapy for the patient according to symptoms,
functionality, risks, age, vitality, desire, psychology, impact,
and economic assessment.
Depending on the result, the patient will undergo surgical or
conservative treatment.
Many patients go directly to physiotherapy and the diagnosis explained above is important
because it helps to make an early diagnosis from reconstructive surgical treatment.
Pre-training is important for diagnosis and surgery, preparing the tissue and reducing the
volume to maximum.
This is reducing 5 days.
50, 63 centimetres, and 12 kilogrammes.
This is a pattern of Doctor Macia, uh, it's got lymphedema.
2 days after the salary changed their life.
This is Pattern of the term Masato is is a reduction
of edoema pressures.
But, but the conservative conservative, uh, training is,
is important, the maintenance.
And the, the first is manual therapy in 1936.
Mother, uh, described the, the technique of, of manual derena.
The objective conservative training is control the evolution in in initial stage.
Recover functionality, reduce symptoms, reduce volume, educate and support to
patients and maintain results over time.
They are soft and low techniques that have pressure in common.
30 and 140 mini minimum of mercury.
Which is the best?
The best is uh in the learning curve, the relation
relationship between skill and time of experience.
In this uh review, the article reported conflicts results,
and we are often limited by methodological uses.
There is some evidence to drainage, manual drainage in the early stage of breast cancer
surgery may help prevent progression to clinical lymphedema.
Male lymphedema, uh, manual lymphatic drainage may also provide.
Additional benefit of volume reduction, moderate to severe lymphedema
may not provide additional benefit when not combined with compression therapy.
The clinical rarity is that manual drainage lose compression has significant
clinical residue.
Uh, in, in the astrology, uh, the technology has advanced a lot,
and now we have a new associate techniques to improve results and maintain better.
Shockwaves, for example, they are very useful for the training of lymphedema,
not only for the reduction of volume, but especially for the treatment or
fibrotic fibrotic area.
Arm move. It's a simple passive mobilisation therapy.
It is active in the muscle pump, helping the re reabsorption and mobilisation
of life.
Theoelectric magnetic energy regulation is a system that improves all vascular tissue,
deep oscillation, and the effect of manual drainage are intensified.
By depositation, help the initial drain mechanisms, adds a collagen fibre
of the superficial structure and anchoring filaments.
And dermotherapy, uh, functional problem, the scar and fibrosis problems,
post-radiotherapy prevent addition, reduce pain, decompression of axillary vein,
reduction area of tissue hypertension, and great defibrosin active.
This is Pepita.
Remember the of the first picture, a breast cancer survivor who,
after surgery, radiotherapy and chemotherapy developed lymphedema at the age of
8C.
After going to the several specialist physiotherapy service and not getting results,
she become depressed about longing, losing her functional independent duty to lymphedema.
She come to our service.
At the age of 85.
After going to Intensive training.
Yes. Yes ma'am.
What is Brian.
Well, the first fast is reduce the volume.
In the second phase is maintained treatment with axillary discompression,
manual drainage, physical agents, uh, possibly passive mobilisation
compression, 1 session per month or every few months, improving and maintaining
the result for 10 years.
She's total, totally involved in the training of her lymphedema.
And as you can see in the video performance, she vanished every night of the
year and during the day, she was her compression girl.
It's very difficult.
We have In this moment 95 years.
And she also has one fundamental therapy for this patient,
family support.
She is under control and improve them everyday functional and now very happy
celebrating her 95th birthday.
Objective, a clock shift.
Thank you. Is that him?
Fantastic, fantastic results, uh, last speaker for the session,
uh, one of my colleagues from, uh, NB Anderson, Doctor Mark Charen was speaking about novel
flaps for, uh, lymphedema surgery, yeah.
Uh, good morning, um.
Thank you very much to Marlene and Sheen for running such a a great meeting.
Um, and I just want to tie together a lot of the themes that we've heard,
uh, And how we use those to treat a specific patient that has lymphedema.
Um, it's a little early in the morning, but um, can I see a show of hands for those that are
doing therapeutic lymphedema surgery?
So a minority, OK, so um.
Uh, I have a book, but I don't accept royalties or payment.
So, um, The reason why uh the preoperative evaluation is so important is because.
Around 25% of the patients that we see in a general lymphoedema clinic won't actually have
lymphoedema. They'll have other causes of limb swelling.
There's also no one test that's 100% sensitive or specific for lymphoedema
diagnosis and therefore you need a multimodality approach to accurately diagnose
the patient with lymphoedema.
And this includes limb volume, measurement extracellular fluid,
lymphatic imaging, and patient reported outcomes.
It's very important to take the time, uh, to take a,
a thorough history and clinical examination, and there are many subtle signs that will lead
you towards a diagnosis.
ICG lymphography really is the mainstay for, you know,
as a diagnostic tool, it's available, um, it's portable, and there are many staging
scales. We use the MD Anderson scale, which has been
demonstrated to be reproducible and this uses a quantitative and qualitative approach
to um ascertaining the severity of lymphoedema and therefore diagnosing.
The appropriate treatment modality, also looking at the pattern of dermal backflow,
which also needs to be considered.
The more patients that I see and treat, the more emphasis I have on evaluating the
vein. So, um, the same treatment that has caused the
lymphedema also impacts the vein.
90% of the tissue fluid drains through the vein and therefore it's very important to have a low
pressure venous system in order to have an effective lymphatic drainage.
And so this should be scrutinised and if necessary treated before you embark on
lymphoedema surgery.
It's also very important to select patients well.
So uh it's important to have a um uh a standardised uh diagnosis in your centre.
So, uh, uh, usually this is by, uh, you know, diagnostic threshold measurements confirmed by
lymphatic imaging, and that patient is potentially a candidate for surgery.
It's also important to understand that we can't treat every patient surgically and indeed,
uh, many patients uh can be very well managed uh non-surgically,
and those are with um.
Untreated or unstable, uh, cancer, uh, that have untreatable venous insufficiency,
those that are medically unfit or, um, with the very high obesity classes,
um, and those actively receiving cytos of chemotherapy, because this can have an impact
on the lymphatic pumping.
Um, the, the role of physical therapy cannot be minimised, and it's really important,
that is the central aspect of an individualised multidisciplinary patient care pathway.
We term this rehabilitation.
It's individualised. Every patient has different needs and so you
have to, you know, find out what those are and manage them.
We like patients to be compliant with, um, optimised, uh,
conservative therapy for at least 3 months before surgery.
Uh, this, uh, moves patients into the maintenance phase.
It lowers inflammation and uh we see better outcomes by doing this.
It also helps identify those patients that just cannot do this programme,
um, and identify those barriers so that we can overcome them and,
and develop a pathway for them to be able to to uh comply with their their non-conservative
therapy. Some of our patients have very severely
restricted range of motion and so getting into the axilla for lymph node transplant can be
very challenging. And so sometimes that requires intensive uh
physical therapy, perhaps intramuscular botox injections to get the range of motion.
Weight management is really now a central theme of lymphedema surgery,
and particularly with the the new medications, um, there's really an opportunity here to get
patients down to more favourable weight classes whereby they can respond better to our
surgeries, and those that have frequent episode of cellulitis may require perioperative
antibiotics for a period of time beforehand to allow an operative opportunity because an
infection in the early stages can be severely detrimental to the efficacy of surgery.
We've heard about this already, but um uh you know CTD is is really uh vital.
This is two phases, reduction and maintenance reduction being uh bandaging uh specialised uh
reduction garments, and then we typically have our patients,
not always, but typically into customised compression garments and if necessary into
pneumatic compression pump.
So, having done all that, how do we decide what we do?
Well, we predominantly use the ICG and so where there are patent linear lymphatics,
and the patients are presenting early, those are potentially candidates for lymphana bypass.
The majority of patients that I see though fit into this advanced category that needs.
lymph node transplant, about 80% of my patients get a lymph node transplant,
um, and then a minority with a fibro adipose excess will exclusively get um uh liposuction
debulking but then they may become then candidates for physiological surgeries,
uh, once that, um, adipose uh component is removed.
Uh, it's important to have a range of lymph node transplant options in your armamentarium
because patients are different in their presentations, their previous surgeries,
their scars, their body habits, and so, and also, uh,
you know, we we place these transplants in different places.
I'll come to in a moment, and some are more bulky than others and more suitable for
proximal transfer than distal.
Uh, and all of these, uh, options, uh, have advantages and disadvantages.
There's no ideal, uh, uh, lymph node transplant without those considerations.
So It's important to have an algorithmic approach uh with those options to determine
where to place them, um, either placing them approximately where they are more bulky or
distally where they are more discrete.
Now I hear all the time that it's not important, the cosmesis,
but it really is. The patient doesn't want uh mild improvement of
their affected arm. They really want an arm that looks like their
other arm or the arm before they were treated. So, you know,
cosmesis is is really important in these patients just like any others.
So, uh, when a patient um presents with a, a scar contraction in the axilla,
which is the majority of patients after an axillary lymphadenectomy and radiation,
it's very important to take the the care to do a thorough scar,
lysis, uh, removing all that scar. There are sometimes constricting bands around
the vein that you can release that that uh uh can have a significant impact on the uh
lymphatic drainage.
Uh, and so I have a very, very low threshold for going proximally on these patients even if
I intend to go distally as well.
The deep flap and composite groyne uh lymph node transplant is really a mainstay in in many
centres, uh, and so, uh, we take the lymph nodes composite uh with with the deep flap.
I'll typically do this as a bipedicled flap, and then also anastomos the vessels are
separately in the axilla.
It's important that you do some form of reverse lymphatic mapping because er commonly uh those
nodes uh that we want to utilise uh are involved in drainage of the lower extremity.
And so we can get 3 dimensional imaging so that we can plan this uh pre-optivity to make sure
that we, we know where the nodes are that we want to take and we can avoid those that we
don't. The omentum really is becoming popular for,
for lymphedema now just because it is so accessible and there's not a risk of donor
extremity lymphedema.
Um, and, uh, it has lymph nodes, it also has lymphatic tissue,
and it can also be divided into multiple flaps, which makes it really ideal,
uh, you know, for lymphoedema, where often the whole limb is affected.
We can harvest this laparoscopically and robotically with minimal abdominal morbidity
and scars, and this has made such a big difference compared to the many laparotomy
approaches that we used to use.
And uh It is typically divided into two parts so that the bulkier part
is placed into the axilla, that's really for um 3 dimensional volume obliteration to prevent
recurrence of the scarring, and then a component is placed in the volar forearm.
This is typically reserved for those patients that have lymphedema reflecting the whole um
extremity up to the wrist level and and maybe the hand.
The lateral thoracic flap is a flap that I'm very fond of,
uh, we are basically utilising level one of the axilla.
So, uh, we're reverse mapping, very similar to what we've just heard,
and um we are um.
Uh, uh, uh, utilising, uh, uh, those nodes, uh, it comes with a,
a skin paddle as well, so it's very useful for lower extremity,
uh, where you're not placing pressure on those lymph nodes.
Um, and it's also possible to, uh, uh, base it on dual pedicles,
you can divide it into two flaps.
Um, I redesigned it to be, uh, uh, a more acceptable curvilinear,
uh, scar in the female patient, so it can be, uh, hidden within the scar,
uh, within the, um, the bra line.
It's very important to transfer this flap with respect to the lymphatic drainage which you map.
Um, many of these flaps whereby we take skin paddles, it's very important to have that that
iso um lymphatic drainage pathway preserved in the axiality of where it's
being transplanted to.
Uh, if we are going, uh, ortho topic, we will typically also perform lymph nodes bypasses in
the forearm where there are obstructed lymphatics.
Uh, we use conventional techniques, so identifying obstructed lymphatics by ICG
imaging, um, and then, uh, we use a variety of techniques depending on what we find.
The relationship between the number of lymphatics and the veins calls for specific
techniques for those circumstances, particularly favouring multi-barrelled or
multiple end to side approaches.
So what about those patients that require distal transfer?
Well, Marlene asked me to talk about new flap, so I,
I thought we would touch on this. This was one that I very much enjoy doing
genital mesenteric flap, and I actually came across this in a Kinmoth's textbook,
Kimmoth who used to be at um Saint Thomas's.
Um, and this was devised around the time of the mental flap and,
and it went out of favour because like the pedic called a mental flap,
there's a significant abdominal morbidity to it.
Um, but it was, it was highly effective, and so, um, we,
uh, do a lot of supercharged adjunal flaps and MD Anderson.
And so, uh, with my colleague, uh, former colleague Jessie Selba,
uh, we devised an approach taking uh the lymph node packet that you find at the root of the
misentry um and uh and and transferring that. We've done other studies demonstrating the
lymphatic capabilities. This is incredibly rich lymphatic tissue,
obviously it has a nutritive function, um, and it it it has a very discrete flap,
it's just a bunch of lymph nodes on a pedicle.
Um, and the nice thing about it, it's incredibly discreet,
uh, for distal transfer, so it really, uh, does meet all those requirements we were outlining
before. Another flap I'm very fond of is the sub mental
flap. I didn't design this.
This is really a credit to Ming Wei Cheng, but I did refine it because one of the issues is
that it can cause quite a significant donor defect and also recipient site defect.
So with some modifications you can design a very discrete flap with a very acceptable scar
and a very acceptable donor site and because we can.
Because it's such a discrete flap, you can place it very distally towards uh really where
the problem is, um, and so that's a flap that I use uh very commonly.
So do these surgeries work? Well, obviously we're very much looking forward
to seeing the results of the lymph trial.
There is now quite a bit of data comparing surgery to conservative therapy,
demonstrating that there does seem to be a benefit to these surgeries.
Uh, we performed a prospective study, uh, with 2-year follow-up at MDNist on 134 patients,
and we saw, uh, a significant improvements in, uh, uh,
limb volume, um, extracellular fluid, and patient reported,
uh, quality of life.
We also saw improvements in limb volume and extracellular fluid LDE score in 90% in patient
reported quality of life in 95%, and we saw a 98% reduction in infections.
Now we subsequently followed this up. We did a patient reports and we found that this
incidence is a little lower than that, right about 85%,
but still, that's quite remarkable given that these patients are getting frequent episodes.
episodes of cellulitis.
We also found interestingly the flat type wasn't important,
and so it does seem to be more of a of a field effect rather than specific to the to the flap.
We had no flap losses and many of the patients were able to discontinue or reduce their
compression garments. We really guide that you cannot rely on the
patient to be a reliable guide as to when they should stop wearing their garments.
So with that, thank you. Good.
Excellent. Now it's time we have nearly 15 minutes for
discussion. We can start a little bit going to this
prophylactic surgery, Andre.
And uh what do you think just a common question. What do you think it's better to work in
prophylactic surgery in a two teams approach it means breast surgeon doing the axillary
clearance and then jumping to the um plastic surgeon to do this axillary
LBA so probably it will be better that one only one single surgeon.
Do the the axillary clearance and then obviously the LBA.
I think that would be ideal, right?
Um, but I don't think we are at that point yet at at in US in general,
the axillary dissection is done by the breast surgeons, um,
and, uh, so far they're very interested on doing the lymphatic mapping.
But I think in terms of expertise to do the lymphovenous bypass they're not doing that now,
um, it is tricky though because usually I go there first.
I map all the veins that I wanna use, then they go in and I come back and everything is gone,
uh, so then I usually try to take one branch from the thoraco dorsal and see if I can do an
end to site sometimes that works there are like several little um vessels there.
But it can be very frustrating because you go, you have all these plans and it's all disrupted,
but um.
I think it's very important to dissect those veins before and mark them.
If you have a good person operating with you, they will preserve the veins.
Another option is to do what Wei does at the clinic, which he doesn't do um
a lymphatic prophylactic surgery, the axilla, he brings the patient's back later and he does
it at the level of the elbow.
Um, I think the major issue for that is that he doesn't have to wait for the breast surgeons to
finish and it doesn't have to deal with the lack of recipient veins on the chest wall
that that happens.
um, it would be great if we could do the whole procedure, but,
but it's not the way that legally we are advised in the US.
You'll probably have a different experience here, and there is any question,
any comment from the audience regarding to this prophylactic surgery?
Honestly I believe that this is the the real.
Treatment for lymphedema because one the lymphedema is established we can try to do
something but it's very difficult you know to get uh stable and and good results but on the
other hand, when I see all these different techniques about lympha different groups you
know there is a big difference on the technique and and for me it's very difficult to trust in
some kind of implantation techniques.
Especially 5 years ago in Boston in a roof uh meeting, I remember
that uh this um breast sergeant American Susan Klimber, she,
she told that it seems that I don't know where in the United States they were doing this kind
of lympha technique only with uh loops and using, you know,
60 switches.
Yeah, so that's, and the funny thing is that's the on the trial.
That's on the trial because the clinic is part of the trial and we had to watch the videos.
So it was, the trial was designed by the breast surgeons and what they were doing,
they're finding the lymphatics, finding the vein, and just put a 6 of a stitch to bring
them closer.
So there was not You know through anastomosis, and I think that that's probably why there's so
much variability on that study. I don't know if you have anything to add to
that because I think you're.
Yeah, I mean, I'm uh proud to say that she works in Texas with Doctor Shavrin and I,
so we're very proud of this but um I think it comes from the uh difficulty of always
obtaining a plastic surgeon.
I think uh Doctor Masa's situation is ideal where the plastic surgeon performs much of the
axial dissection, so the two components that you need is a recipient vein and a lymphatic.
Uh, we work very closely with our breast surgeons, so they've gotten very good at
preserving veins and the lymphatics for us.
I think uh Doctor Klimburg's concept, it worked in pigs,
so I think that is why she thought it would work in humans,
but you know, even though we're in Texas, we're a little bit larger than most people like pigs
and humans are very different, so you cannot assume that just putting two vessels in close
proximity is actually gonna work.
Um, I think, uh, I learned this, uh, from Doctor Masil also.
I think the direct intima to intima coaptation is critical.
I also personally have a bias against doing an inter susception technique as well,
so we will do a true sort of end to end anastomosis, um,
trying to get the intima into my approximation.
And I think for the audience, um, in general, if you map that lymph node going to the arm,
I'm sorry. You're gonna find 56 lymphatics going to the
same lymph node.
So you know that's draining the arm.
So, if you do a reverse mapping, uh, with ICG on the chest,
well, many times you can separate where are the nodes draining the chest or draining the arm,
so you can actually leave that node intact.
Sometimes that's difficult for breast surgeons because they're doing a lymphadonectomy,
they, they feel like they have to take everything.
But you know, studies have shown that probably what 75% of the time these nodes are not
draining the same areas so it's OK to preserve. I, I fully agree.
I think that is the concept, you know, prophylactic lymphoma surgery is not doing
LBA's in the axilla is doing a more anatomical and conservative way to do the
axillary. Clearance, you know, for years I remember when
I was in training the objective of the of the axillary clearance was just remove as many
lymph nodes preserving some nerves and avoiding bleeding or what they say wrongly
seroma, but it was not seroma it was lymphoa.
But just doing this approach, you know, you need you need you can avoid damaging,
you know, some of the non unnecessary removal, you know,
pieces of the axilla.
And, and this is the key point. The thing is we need to to stop thinking that
if it's my field or is your field, we need to start going back to the new approach on DeL and
probably we can avoid more than 50% of the potential LBAs and
and I'm sure that uh if we do well, the axillary clearance,
the incidence of lymphedema that now more or less is about 30%.
It can be about 8% then you know from this 8%
maybe only a few that can really need these LBAs.
But I mean I think there's kind of thinking the same thing.
Also the breast surgeons and the gynaecologists, they all want to de-escalate axillary surgery,
so I think it's really the right time to do this together and everyone kind of adds what we
can and in the end there will be a minimum number of patients suffering from this.
I think it would be difficult I can only speak for Central Europe to try to do the axillary
clearance even though we might be able to do it and preserve of course those vessels because
it's really in the hands of gynaecologists and breast surgeons and if you're trying to tell
them that we can do that better, it will only lead to them not wanting to touch the area at
all. So I think we really just need to show the
evidence that. This prophylactic approaches that they're
actually better than not doing it and then they will happily let us do it because it's in their
interest that the patients don't get the lymphoedema.
Probably due to this the escalation of the surgery at the end in a very close future maybe
there should be only a specific few reference unit for axillary clearance or for any
lymphatic, you know, surgery.
Because if they do, you know, once every 2 months, one axillary clearance,
never they can do in their in the good way and, and the impact once it established of the
lymphedema is extremely painful for the patient and it's really costly for the society.
And I think the future is going to reduce who can do the axillary surgery and do
very well trained specific units and in a country like Switzerland,
I don't know how many patients you have but probably if there is per year 100 axillary
cleaners they may focusing one unit for all the country would be good if that would be the
future. Good.
No more comments about this topic.
Let's go to move, move to the next one.
That it's uh more or less about that is a fantastic, you know,
topic how we can get, you know, objective data about what they are doing in lymphedema because
when I saw this the presentation of Mark, you know, he talked about everything.
I was expecting Nobel flaps, but it was about everything.
And, and 20 years after, you know, working in lymphedema, I still,
everything is on the, on the, on the, on the, on the table.
And the only way is that because comparing good studies to compare what we are doing.
Because I really believe that in Lymphedema something works but not everything is working
and now everybody wants to put a name with a new flap with a new technique with a new
algorithm that you need to take some pills to read the algorithms because it's like a
nightmare, you know. Uh, uh, uh, and that is important.
What I think what you are doing is extremely, extremely important and necessary.
I mean, I couldn't do it with all of you because it's just,
uh, as you mentioned, Switzerland is a small country and so we really need all the patients
and it's also really the surgeons thinking that they really want to randomise the patients
because it's not in our nature. I mean usually we get those referrals and we
really very convinced that we know what's best for them,
so we just want to operate on them. So to me I really had to change how I
approached the patient because really the evidence is.
Not there yet. I didn't go into so much detail,
but I really feel that the patients actually don't have a disadvantage entering the trial
because the patients that we include they can both one randomised to the
surgical treatment, they get kind of a fast access to surgery because we would like the
centres to do the surgery within 3 months, which is much faster than most of us can do it.
The waiting list that we have, so you have this 50% chance of a fast track approach to the
lymphatic surgery, and if you're in the conservative arm,
you wait these 15 months and then you're kind of almost in getting it at the time you would
if you weren't in the trial and then you're following both both groups regularly,
as you know, if there's any sign of worsening of the disease in the conservative arm,
they have the possibility of a of a group switch so also they are ethically.
Um, and also this I didn't mention it, but the trial was really developed with patients,
so with patient advocacy groups, and one of the, one of my uh PIs,
she's really a breast cancer survivor herself, also a professor of uh of nursing,
so they were involved from the beginning making sure that it would be would be fine from a
patient perspective. I think this has also led to the funding
getting us the whole funding because it's kind of yeah.
I would like to ask a question, you know, according to these multi-center trials in
lymphatic surgery, I think one of the weak points and it has all been addressed already,
is how do you train your centres participating? How are the surgeons selected because we set
up a kind of trial like this in Belgium, and uh I was approached for that and I wanted to step
out because 3 of the part participating centres they supposedly did lymphatic surgery but there
was not one microsurgeon involved.
And I, I think this is a huge, huge, huge bias on the outcome of all these trials.
It's a very important question. I was discussing this with Mark yesterday,
and so we are actually stratifying by centre, which is kind of taking away the worry
of some centres and we are also of course selecting the people that participate in the
trial. On the other hand, We didn't want to exclude
per se, someone who is a specialised microsurgeon.
It's exclusively microsurgeons being the local PI specialised also in lymphatic surgery,
but it should be pragmatic because we didn't want to not show how it's done.
It should be like.
A picture of how the situation is now and we should be able to prove that it is working and
if in the end we cannot prove that it shouldn't be paid by the insurance companies because then
it might just be that people have to go to an Automark or you Uh,
and get the surgery, uh, but not at all the specialised centres.
So that's kind of the pragmatic trial design and it's,
it's quite novel, but to me it's convincing because it is a picture of how it's being done
in the specialised lymphatic microsurgery world if you want to say so.
And if you cannot prove it, it shouldn't be like part of the gold standard yet,
and we are not there yet, I think.
So there's a risk that we cannot prove it, but I'm pretty convinced that we will be able to.
Yeah, I, I, I just want to follow up on, on your point,
Jeremy. So I, I, yes, it's great, and some, we do,
a lot of us do some really fun sophisticated things, but.
We've really kind of really changed our approach and we are,
we are all in on prevention. Prevention is definitely better than cure and
so. We've done, we now have a programme we do.
59:56.320 --> 01:00:01.790 Immediate lymphatic reconstruction on all high risk patients lymphadenectomy for breast cancer.
01:00:01.830 --> 01:00:04.020 We're now doing groyne as well.
01:00:04.389 --> 01:00:07.540 And in the last 5 years we've done over 1300 patients.
01:00:07.550 --> 01:00:12.780 We did 320 last year, and we're following up prospectively, so we'll get some really
01:00:12.780 --> 01:00:14.179 interesting data from those patients.
01:00:14.510 --> 01:00:18.389 But absolutely, I mean, I think you don't have to look after these patients for long.
01:00:18.840 --> 01:00:24.179 To realise that, you know, just the importance of avoiding this disease at all is so important
01:00:24.179 --> 01:00:30.379 because this is a this is a lifelong um reminder of their cancer and and this is their
01:00:30.379 --> 01:00:33.399 long after their survivors of breast cancer, this is now,
01:00:33.409 --> 01:00:36.540 you know, their lifelong morbidity, the lymphoedema.
01:00:36.659 --> 01:00:42.500 So definitely I think we need to focus more on on prevention than trying to be more
01:00:42.500 --> 01:00:43.689 sophisticated with cure.
01:00:44.100 --> 01:00:47.550 Just before to close this session, I would like to ask the audience.
01:00:48.090 --> 01:00:50.889 Because in the audience, you have plastic surgeons, breast surgeons.
01:00:52.120 --> 01:00:58.760 Who now believe in uh lymphatic surgery. Can you raise the,
01:00:58.820 --> 01:01:05.550 the hands? About 40% of the audience,
01:01:05.770 --> 01:01:08.959 good, you know, very honest people.
01:01:09.649 --> 01:01:15.520 uh, and the second question is, you know, from the people obviously who believe,
01:01:15.729 --> 01:01:17.639 who will allow.
01:01:18.449 --> 01:01:24.840 To do to yourself or to your wife or to your sister, take a piece of
01:01:24.840 --> 01:01:31.199 momentum to do potentially, you know, the treatment of uh of a lymphedema.
01:01:31.239 --> 01:01:32.600 Can you raise the hands?
01:01:34.459 --> 01:01:38.909 It's uh about 40% of this 40%.
01:01:40.820 --> 01:01:46.100 That's good, you know, but you know that is a good thing we need to continue working and
01:01:46.100 --> 01:01:52.219 doing a lot of things because the patients are and we need us and uh I think little by little
01:01:52.219 --> 01:01:57.649 we are improving and just one just remark to uh Kurro who show.
01:01:58.520 --> 01:02:03.239 Amazing results reducing this kind of only with this conservative treatment.
01:02:04.290 --> 01:02:09.610 Um, from because you receive patient from everybody, you know,
01:02:09.729 --> 01:02:14.399 um, what do you think? You know, we, when the lymphedema is
01:02:14.399 --> 01:02:21.090 established. We do think that the surgery is can
01:02:21.090 --> 01:02:24.929 provide any real improvement or still the people they need,
01:02:24.979 --> 01:02:27.310 you know, the physiotherapist forever.
01:02:28.510 --> 01:02:31.790 I be honest, be honest, don't be afraid.
01:02:32.159 --> 01:02:39.000 No, I think in my English is very important, uh, I trade more
01:02:39.000 --> 01:02:41.750 patent. For a long time.
01:02:42.530 --> 01:02:45.449 Yeah, yeah.
01:02:46.060 --> 01:02:49.330 I have uh agreed for you.
01:02:50.709 --> 01:02:53.669 For the surgical technique.
01:02:54.979 --> 01:03:00.620 Change my my professional life and change the life of the patent.
01:03:01.540 --> 01:03:06.520 Because the therapy is, is a palliative treatment.
01:03:08.219 --> 01:03:15.000 Uh, the, I, I think the gold standard treatment for the lymphedema
01:03:15.649 --> 01:03:19.090 is is the surgical treatment.
01:03:20.770 --> 01:03:24.199 OK, thank you, thank you very much for this session.