The utility of surgical and conservative combination therapy for advanced stage lymphedema

Background: In the treatment of lymphedema, a plastic surgeon carries out only surgical treatment, whereas a therapist performs only complex physical therapy. Therefore, a combination treatment strategy is not performed in most cases. Our institution combines a lymphaticovenular anastomosis (LVA) operation with complex physical therapy during the same hospitalization. Methods: From advanced cases of lymphedema of stage II or higher, we included patients who were hospitalized for 2 weeks or more for combined LVA and complex physical therapy. Of the 28 cases studied, 26 were secondary lymphedema and two were primary lymphedema. There were seven upper limb cases and 21 lower limb cases. The mean length of hospital stay was 12 days (7-14 days). We performed a multisite LVA in all 28 patients. The mean number of anastomoses in each case (the side with the most edema for bilateral cases) was 3.96 (2-6). During hospitalization, lymphatic therapists who were familiar with complex physical therapy for lymphedema were trained to provide total care for lymphedema. The content of the education was applied according to the individual patient's status, and an emphasis was placed on development of a treatment regimen that patients could perform continuously by themselves after discharge. Results: The average volume reduction in seven patients with upper limb lymphedema was 15.1%; the average in 18 patients with lymphedema of the lower limbs was 13.1%. The average volume reduction in eight patients at stage II was 14.1%; stage II late was 13.0%, and stage III was 14.7%. The other three cases had suffered an exacerbation, and the mean exacerbation was 3.2%. Among the 12 patients who had cellulitis preoperatively, an episode of cellulitis was detected in only two patients during follow-up postoperatively. These two patients were those at late stage II and stage III. The frequency of onset decreased in these two cases. Conclusions: In this study, combination therapy was administrated for lymphedema. We obtained good results in the diseased limbs, including volume reduction and prevention of cellulitis. Therefore, combination therapy might be useful for lymphedema cases at advanced stages.