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Surgery
Surgical reduction of severe whole limb lymphoedema that interferes with mobility or causes severe deformity is often appropriate. In a small proportion of patients preoperative contrast lymphangiography discloses a proximal lymphatic obstruction in the ileoinguinal region with normal distal limb lymphatics.  These patients can be expected to benefit from some form of lymphatic bypass operation.
Lymphatic bypass
A number of methods have been used to reunite obstructed lymphatics with the venous system. Many of these techniques, such as the skin bridge devised by Gillies and the omental pedicle, both of which were sutured to the obstructed lymph nodes in the groin, are only of historical interest. Direct anastomosis of lymph nodes to veins was originally performed by Niebulowitz, but fibrosis and low flow rates resulted in a high failure rate. Degni used a specially designed needle to insert lymphatics into the lumen of the vein, but the imprecise nature of this procedure has prevented its widespread acceptance. The advent of the operating microscope has made it possible to divide obstructed lymphatics and directly anastomose them into the side of the vein. However, the results have generally been disappointing. At least three of four lymphatics should be attached to the femoral vein in the groin in the hope that one or two anastomoses will remain patent.
Kinmonth and his associates developed the mesenteric bridge as an alternative to direct lymphovenous anastomosis. This operation uses the copious submucosal lymphatic plexus and the mesenteric lymphatics to drain the lymph from obstructed nodes in the ileoinguinal region. About 5 cm of the terminal ileum is resected on its mesenteric pedicle, as for an ileal conduit, taking great care to maintain the lymphatic drainage. The small bowel is reanastomosed behind the pedicle. The isolated segment is then opened along its antimesenteric border and the mucosa is stripped off the submucosa by a combination of sharp and blunt dissection after injection of a solution of adrenaline in saline (1:400 000). The isolated pedicle is then brought down to the first normal group of lymph nodes below the level of the obstruction, and sutured over them after they have been bivalved. Connections develop between the divided nodes and the submucosal plexus and lymph drains up the pedicle into the mesenteric lymph nodes, and eventually into the thoracic duct.
This operation has been performed on over 40 patients at St Thomas' Hospital, London and has produced good results in more than half. Unfortunately there is no way of predicting those who will benefit from the procedure, although the careful selection of patients prevents inevitable failure. Young patients appear to fare better, and the distal limb lymphatics must still be functioning if a successful result is to be achieved. If limbs are too swollen resolution is poor, but swelling must be severe enough to justify major abdominal surgery. Perhaps for this reason surgery is appropriate for relatively few patients.
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