D99. Debulk First and Bypass Later- Switching the Surgical Sequence in Advanced Fluid Predominant Lymphedema

PURPOSE: In advanced fluid predominant lymphedema, both debulking and physiologic procedures may be required. The conventional approach typically involves initiating treatment with a physiologic procedure such as lymphaticovenular anastomosis (LVA) to address lymphatic stasis, while disregarding concurrent fat deposits. Subsequent liposuction then requires a conservative and LVA sparing approach. Our observations of higher patient satisfaction with aggressive debulking and improved Indocyanine green lymphography (ICGL) post liposuction prompted us to switch the treatment sequence. METHODS: Patients who underwent staged debulking and LVA procedures in the same limb performed by the same surgeon, between January 2020 and June 2022, were included. Standardized outcomes tracking involving patient-reported symptoms, clinical examination, and ICG lymphography were implemented. RESULTS: Total 102 patients underwent liposuction debulking of upper/lower limbs and they all exhibited postoperative symptoms relief, limb volume reduction and ICGL evidenced improved lymphatic flow. In 9 patients, a physiologic procedure was additionally offered for reducing compression needs. LVA in the leg was performed 1.5 to 2.1 years following thigh (5/9) or leg (4/9) liposuction. In the 4 patients where LVA was planned within the previously debulked leg, multiple lymphatic channels could be successfully found for creating anastomosis. After LVA patients reported further symptoms alleviation and reduction of compression needs, corroborating with progressive ICGL improvement at 3 and 6 months. CONCLUSION: Prioritizing liposuction in moderately advanced lymphedema enables prompt limb debulking without reducing feasibility and efficacy of future LVA.