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Page 4 of 6 Chen et al. Plast Aesthet Res 2021;8:36 https://dx.doi.org/10.20517/2347-9264.2021.33

vs. 4.35% of general anesthesia, P < 0.05). But the reduction rate at 3-month follow-up were similar (4.33%
of local anesthesia vs. 5.07% of general anesthesia, P = 0.052). There were no perioperative complications in
both groups [Table 2].

DISCUSSION
Secondary lymphedema of the upper and lower extremities related to prior oncologic therapies is a major
cause of long-term morbidity in cancer survivors. Both non-surgical and surgical management strategies
have been used for volume reduction of the affected extremity, and improvement in patient symptomology,
as well as the reduction/elimination of lymphedema-related morbidities, including recurrent cellulitis.
Lymphovenular anastomosis or lymphovenous bypass, a surgical procedure where lymphatic vessels in a
lymphedematous limb are connected to nearby small veins or venules using microsurgical/super-
microsurgical techniques, is considered a promising solution. It allows the clearance of lymphatic fluid from
the affected limb, by utilizing the venous system back to the systemic circulation. A microsurgical
anastomosis is created between the overloaded lymphatic channels, proximal to the site of the lymphatic
obstruction, and nearby venules. Moreover, the procedure involves very little surgical site morbidity as the
incisions are localized to the affected limb and are less than 2 cm in length. However, this procedure usually
is performed under general anesthesia . In the past literature, there are two articles that mentioned that
[8]
[3]
LVA could be performed under local anesthesia. In 2004, Koshima et al. first described minimal invasive
lymphaticovenular anastomosis performed under local anesthesia for 52 lymphedema cases with a leg
[8]
circumference reduction of 41.8% in a 2-year follow-up. In 2014, Chan et al. also described local anesthesia
could be an option for LVA with low visual analogue scale of both intraoperative and postoperative pain.
But there is no series study in the patients with high ASA PS score.

Complex decongestive therapy, which is one of the physical treatments for lymphedema, can be effective for
advanced cancer patients who cannot tolerate general anesthesia. In 2018, Cobbe et al. , mentioned that 14
[9]
patients had a significant reduction of volume in 21 patients as 5.3% in the 3rd treatment and 9% in the 6th
treatment. In addition to the reduction of volume, CDT is also effective in decreasing skin thickness,
improving of volume changes, and increasing quality of life such as better function, improved limb
aesthetics, and less pain and tightness. In 2020, Qiu et al. showed the effectiveness of LVA with a
[10]
significant reduction in upper and lower limb circumference was observed in 52% of patients with a mean
decrease of 6% in a 24-month follow-up. LVA could not only improve limb circumference but also quality
of life in cancer patients. In our study, LVA under local anesthesia provides another option of lymphedema
treatment for these oncological patients who have poor responses to CDT. LVA is still effective for the
refractory patients of CDT (26/29; 89.7%). Although, our reduction rate of the circumference is 4.40% ±
3.67% of the preoperative excess length, less in comparison to previous studies (41.8%, Koshima in 2004);
however, similar to the results of Qiu et al. in 2020. The effectiveness of LVA will last for 2 years after the
[10]
surgeries. In our study, our patients were followed at 7.8 ± 0.85 months. Moreover, 21 patients have ongoing
oncological therapies while they received LVA. Three patients showed no improvement because of cancer
progressions and one patient was expired 3 months after LVA. As a result, LVA seems to have better
response rate for compression therapy in advanced cancer patients.

For most oncological patients, especially with higher ASA PS score, general anesthesia is a potential risk for
postoperative morbidities. The ASA PS classification system was first introduced in 1941. In 2015,
Hackett et al. described ASA PS was not only found to be associated with increased morbidity and
[4]
mortality, but independently predictive when controlling for other comorbidities. The postoperative
morbidities, including deep vein thrombosis, pulmonary embolism, reintubation, failure to wean from
ventilator, renal insufficiency, renal failure, coma, stroke, cardiac arrest, myocardial infarction, peripheral