According to the case report, conducted by K KN et al. (2020) a 28-year-old patient complained of swelling in the right leg for 4 years which worsened in the last 3 months. The examination was conducted on the leg which stated that it was edematous and hyperpigmented plaques were present. Blood examination was positive for Wuchereria Bancrofti. After medical treatment the lymphedema did not resolve due to which surgery was performed. The patient responded well to treatment and had no complications for 2 years (K KN et al. 2020). This shows that the surgical intervention was a requisite where medical management could not help the young adult lead a normal and healthy life.
In another study conducted to evaluate the usefulness of standardized clinical classification of hydroceles in Lymphatic Filariasis endemic countries for their surgical management concluded that Standardized Clinical Classification of Hydroceles based on the Stage of enlargement of the scrotum and the Grade of burial of the penis appears to be a useful tool to guide the decision about the level of care and the surgical technique required (Capuano GP, Capuano C. 2012). The debulking surgeries are performed more in advanced cases of Lymphatic Filariasis with Grade 4 Lymphedema with nodules, ulcers and warty growths (i.e., Elephantiasis). The core principles of these surgeries were to augment the lymphatic drainage and debulk the lymphedematous & lymph producing surface thereby reducing the load. These procedures help reduce the lymphedema and improve the function of the limbs (Servelle 1987).
In a study VLNT (vascularized lymph node transfer) along with excisional procedure was performed in advanced LF patients and clinical efficacy was evaluated. This was performed on 17 patients with Grade 2 or Grade 3 Lymphedema in India. Swelling which resolves with elevation, pressing on may leave an impression & the swelling that does not resolve with elevation, pressing on which doesn’t leave any impression correspond to Grade 2 and 3 respectively. They underwent excessive soft tissue removal and the supraclavicular lymph node was transferred to the dorsum of foot. After the procedure the patients reported reduction in heaviness of leg (p<0.005) and episodes of acute lymphangitis. The study concluded that combination of VLNT and excisional procedures are a safe and reliable approach to patients with advanced Lymphatic Filariasis (Chilgar et al. 2019).
The trial of 75 patients regarding the lymphonodovenous shunt was conducted to determine the factors associated with unilateral filarial lymph edema developed among patients while considering the gender, duration, adenolymphagitis, venous reflex as well as operative impression of lymphatic nodules. Postoperative complications were found amongst the patients in minimal percentages such as 8.5% as wound hematoma, 13.6% as wound infection and decreased the volume of edema upto 46.7% and in some cases 50%. The surgical intervention was reported to be presented with best results among patients with great amount of lymphatic drainage edema and it was further elucidated that increased occurrence of adenolymphangitis episodes depicts optimal working of lymphonodovenous shunt surgical intervention (Rao et al. 1999).
In another study, twenty patients with early lymphedema due to Filariasis and twenty-four patients with Elephantiasis of the lower limb were subjected to Lymph nodo-venous shunt (LNVS) and Charles operation respectively. This study concluded that while excisional surgery such as Charles operation (subcutaneous and deep fascial excision followed by full-thickness grafts) becomes necessary for late stages of lymphedema which progressed to elephantiasis, Lymphnodo-venous shunt alone is sufficient to relieve early stages of lymphedema due to Filariasis (Dandapat et al. 1986).
Grade 4 lymphedema patients with lack of treatment options surgically or any other way were selected for nodovenous shunt which would be led by the reduction surgery to produce the optimal outcome for patients to increase the viability of patients. Victor et al. conducted a study to determine the outcomes of such procedures with retrospective study design. They reported that 16 patients from 2010 to 2019 were treated surgically for this condition which mainly consisted of nodovenous shunt followed by debulking surgery and resulted in more than 5 cm reduction in the circumference of limbs after the operation which indicate significant consequences of this intervention. Shunt of the nodular venous region that is followed by reduction surgery of lymphedema is the best treatment option available to increase the quality of life as well as decrease the morbidity or secondary complications of lymphedema (Victor et al. 2021).
Limitations
The lack of previous research on the topic along with missing data from randomized control trials limits this study with recommendation of further trials and studies - observational and cohort. A combination of these surgical techniques should be applied on a case-to-case basis to further improve the clinical outcome, with an extended follow up period to battle the long-term complications adequately and without delay.