A 60-year-old female patient was referred to our lymphedema clinic with a 12-year history of chronic, acquired, right lower extremity lymphedema. The patient had a history of right breast cancer, which was treated with right mastectomy and axillary lymph node dissection and chemoradiation therapy. The patient had right upper extremity lymphedema (International Society of Lymphology late stage 2), and first noticed signs and symptoms of numbness and tingling sensation in her right hand affecting the thumb, index, and middle fingers since the symptoms of lymphedema worsened.
The patient underwent electromyography and the nerve conduction study showed moderate CTS in both hands and that the right hand with lymphedema was worse than the unaffected hand. The results of the median sensory nerve conduction test from the middle finger to the wrist showed latencies of 4.6/5.6 and 4.9/5.9 ms, respectively. The bilateral median motor and sensory responses showed prolonged latencies and low amplitudes. In addition, the needle electromyography showed polyphasic motor unit action potentials with reduced recruitment patterns in the bilateral abductor pollicis brevis muscles. The patient also complained of severe right upper extremity heaviness, pain, infection, and intermittent sepsis that required hospitalization. She underwent medical treatments including decongestive physiotherapy for years, daily manual and mechanical lymphatic drainage, and wore compression garments. However, the lymphedema symptoms waxed and waned and were refractory to nonsurgical management.
A milliliter of indocyanine green (ICG) mixed with 2% lidocaine was injected subcutaneously at the second web space of the affected extremity at the bedside. After two hours, fluorescence images of lymphatic vessels were obtained with a near-infrared camera (Moment K; IANC&S, Seoul, Korea) and showed confluent dermal backflow in the forearm and few patent lymphatic vessels were visualized on the right upper extremity with severe lymphedema. However, magnetic resonance lymphangiography identified functioning vessels in the wrist and forearm. Therefore, we planned simultaneous carpal tunnel release and LVA to treat the severe lymphedema that the patients experienced for more than ten years. Lymphoscintigraphy and magnetic resonance lymphangiography were also performed before surgery (Fig. 1).
The circumference of the affected and unaffected upper extremity was measured at baseline, follow-up, and the last visit using a standardized tape. The circumference of the affected and unaffected extremities was measured in six places, 15 cm above the elbow, 10 cm above the elbow, at the elbow (using the antecubital crease as a reference point), 10 cm below the elbow, 15 cm below the elbow, and at the wrist. The circumference difference ratio was calculated according to the formula: (circumference of affected extremity – circumference of unaffected extremity) / circumference of unaffected extremity x 100. In addition, the volume of the extremity was calculated based on the circumference measures. The volume segment was measured according to the formula of a truncated cone: V = π x h x (R2 + r2 + Rr) / 3, where π is a constant, h is the height, R is the radius on base, and r is the radius on top [7, 8]. The circumferences of extremities measured at 10 cm above the elbow and 10 cm below the elbow was used to calculate the volume of the segment. The volume of the unaffected extremity was also measured and the volume difference ratio was ultimately calculated according to the formula: (volume of affected extremity – volume of unaffected extremity) / volume of unaffected contralateral extremity x 100 .
Release of the transverse carpal ligament (TCL) was performed first, followed by LVA. Under general anesthesia, the patient was placed in the supine position and a tourniquet was used. Incisions were made along the palmar crease line. After making an incision in the TCL, the median nerve was identified, dissected, and the TCL was completely released. Subsequently, four lymphatic vessels (two at the wrist, one at the medial forearm, and one at the antecubital fossa) distal to the areas of dermal backflow were marked for microsurgical anastomosis to adjacent small veins for LVA. Intraoperatively, 3-cm-long longitudinal incisions were made under a surgical microscope were made according to the magnetic resonance lymphangiography. After a superficial fascia incision, functioning lymphatics were identified deep in the superficial fascia and one to two functional lymphatic vessels were anastomosed to the adjacent veins using 11 − 0 nylon sutures (Fig. 2). Functional drainage was confirmed by the washout of venous blood in the anastomosed vein.
Antibiotics were administered to prevent cellulitis and infection postoperatively. The right arm was compressed and elevated immediately postoperatively and postoperative compression bandage therapy with 35 to 40 mmHg pressure was instituted following surgery.
The circumference difference ratios before surgery were 27, 26, 25, 22, 18, and 17% 15 cm above the elbow, 10 cm above the elbow, at the elbow (antecubital crease), 10 cm below the elbow, 15 cm below the elbow, and at the wrist. The ratios was decreased to 20, 17, 15, 13, 12, and 8% at these six levels, respectively. The volume difference ratio was also decreased from 51 to 31%. The patient had significant circumference and volume reduction of the right hand (Fig. 3). The CTS and lymphedema symptoms have decreased following synchronous TCL release and LVA surgeries.