April-June 2012: Surgery in Lymphedema

By: Janice N.Cormier MD, MPH,  

UT MD Anderson Cancer Center , Houston TX 

Q:  Will insurance companies pay for surgical procedures to treat LE?

A:  The surgical treatment of lymphedema is still widely considered “investigational” by most insurance companies in the United States. Therefore, insurance coverage to pay for the procedure is widely restricted. Medicare, which provides medical insurance for people over the age of 65, does not currently provide coverage for lymphatic venous bypass or lymph node transplantation. The majority of private insurance companies in the United States have reimbursement policies that follow Medicare guidelines, but there have been a few reported cases in which individual insurance companies were successfully petitioned to cover such procedures. These individual cases required case-by-case analysis with supporting published data pertaining to the risks and benefits of an individual procedure. Unfortunately, the available data from published articles and case studies supporting the surgical treatment of lymphedema patients treated in Europe is weak. Without insurance coverage, surgical procedures for the treatment of lymphedema are often restricted to wealthy individuals who can afford to pay the costs out of pocket. The cost for these procedures ranges from $20,000 to $40,000 for surgery alone. When the cost of postoperative hospitalization (if needed) and rehabilitation are considered, the total cost is often prohibitive.

Q:  How do doctors learn to perform lymphedema surgery and what should I look for in terms of surgeon qualifications?

A:  The majority of procedures performed for the surgical treatment of lymphedema are performed by plastic surgeons. The minimum requirement for surgeons should be certification by the American Board of Plastic Surgery.  In addition to basic training in plastic surgery, surgeons performing microvascular procedures, which are done under a microscope, such as lymphovenous bypass should have received additional training, usually an additional year, in a microvascular fellowship.  Most surgeons get very little training on the specifics of these procedures, as surgery for lymphedema is not commonly performed in the United States.  Often surgeons read about the procedures or travel abroad to observe and learn from more experienced surgeons and then teach their colleagues and students.

Q:  I’ve been battling repeated bouts of cellulitis; would any of the lymphedema surgical procedures reduce my infection risk?

A:  In general, reducing the magnitude of limb swelling often decreases the frequency of future episodes of cellulitis.1 This is a general phenomena and not specific to surgery for the treatment of lymphedema, as controlling the swelling using complete decongestive therapy can achieve the same outcomes.2  In addition to complete decongestive therapy, prophylactic antibacterial therapy, most commonly penicillin, is often recommended for patients experiencing repeated cellulitis (defined as three or more episodes). The majority of patients surgically treated for lymphedema require ongoing compression therapy.  Although infrequently reported, there is a risk of developing infection at the surgical site following surgical attempts to treat lymphedema.

Q:  Does removing nodes from a donor site put me at risk for lymphedema in that area?

A:  One of the limitations of the currently available published literature is that very few studies report or document complications associated with the procedures. In addition, many of the studies report on results at short follow-up times (months rather than years) and do not follow the affected or associated donor-site limb using objective measures. There is one study of 14 patients treated with microsurgical lymph node transplantation that reported that 2 patients (14%) developed lymphedema at the donor site.3  The investigators noted that the donor site lymphedema improved significantly with complete decongestive therapy and the use of compression garments. 

Another source of information that may be informative are the reports related to the incidence of lymphedema following sentinel lymph node biopsy.  There are a number of studies in patients with breast cancer that report on average an 8% incidence of lymphedema following sentinel lymph node biopsy.4 Data are also emerging from prospective melanoma studies.  It has been reported that the incidence of lymphedema following sentinel lymph node biopsy in the groin may much higher (up to 25%), particularly as patients are followed longer using objective measurements for limb volume.5

References

1. Foldi E. Prevention of dermatolymphangioadenitis by combined physiotherapy of the swollen arm after treatment for breast cancer. Lymphology 1996;29(2): 48-49.

2. Feldman J. The challenge of infection in lymphedema. Lymph Link 2005;17(4): 1-3.

3. Felmerer G, Sattler T, Lohrmann C, Tobbia D. Treatment of various secondary lymphedemas by microsurgical lymph vessel transplantation. Microsurgery 2011.

4. Velanovich V, Szymanski W. Quality of life of breast cancer patients with lymphedema. Am J Surg 1999; 177(3): 184-187.

5. Cormier JN, Chiang Y, Hyngstrom J, Xing Y, Taylor S, Lee J, Gershenwald J, Armer J, Ross M. Prospective assessment of lymphedema following lymph node surgery for melanoma. In: International Conference of Lymphology; 2011; Malmo, Sweden; 2011.