Editorial Message: Should Old Become New Again?

“All you have learned from history is old ways of making mistakes. There is nothing that history can tell you about what we must do tomorrow. Only what we must not do.”   ~ Edwin H. Land (1909-1991), scientist and inventor Dear Readers:   We live in an age of technology and rapid advancement in just about every field. We are always looking for the newest and the best for our patients, because we have been told that half of all medical information will be obsolete within 5 years.¹ We know this is not always the case, as in the revival of the use of honey in the treatment of wounds.² But some therapies have come and gone that should remain of “historical interest only.” Recently, I read an article describing an operative procedure I think should remain in that category but, unfortunately, is being resurrected.   Chronic lymphedema is a devastating disease that can cause significant morbidity and affect an individual’s quality of life. Before we understood the pathophysiology of lymphedema and how to best manage it, surgeons devised an operative procedure, reductive therapy, to treat the disease. This involved excising the lymphedematous tissue on the extremity down to the fascia, and replacing the excised skin and subcutaneous tissue with split-thickness skin grafts. The basic technique was described in 1912 by Sir Richard Henry Charles³ and modified by others.^4,5   This was a big procedure fraught with complications, the least of which were infection, failure of skin grafting, and significant disfigurement of the extremity. It is telling that there have been reports of only 122 patients undergoing operative therapy for lymphedema in the past 50 years.⁶ Doscher and colleagues⁶ report that recent results with the procedure justify this approach because “consideration of disease severity and refinement of technique in the modern era of surgical care can support the use of excisional therapy.” I think that, even with modern surgical care, the procedure rarely can be justified.   Interestingly, there is no evidence in Doscher et al’s⁶ report that most of the patients mentioned were given the benefit of modern, evidence-based lymphedema therapy prior to operative intervention. The photos of the patients who underwent operative therapy strongly resemble photos of patients I have seen treated successfully with modern compression, and other therapies, including manual lymphatic drainage and exercise therapy. There is no mention of the involvement of physical therapists, wound centers, or other lymphedema experts in the care of these patients prior to their operations.   One of Doscher and colleagues’⁶ statements is especially telling, and should give rise to objections: “Conservative, nonsurgical, management of lymphedema is often the first line treatment. However, it cannot address the changes that arise in the setting of severe, end-stage disease typified by chronic fibrosis.”⁶ Consider the recent information from Adams et al⁷ on the exciting finding of the improvement of lymphedema function with the use of compression therapy. This restoration of lymphatic flow has been demonstrated by new lymphatic visualization techniques. With this information, more effective compression and other therapies are being utilized to treat these desperate patients without operations.   I agree with Doscher that it may be difficult to find practitioners trained in the latest lymphedema therapies, but I know they are out there, and have no doubt they could successfully manage the patients presented in Doscher et al.⁶ This brings us to another question: Why can’t we, as the wound care community, get the message out that these patients can be treated without risky, potentially disfiguring operative procedures?   We must find ways to band together with lymphedema societies, wound care societies, and individuals providing modern lymphedema therapy, to educate all healthcare providers about the benefits of modern lymphedema treatment. Until we do, it appears the view that “Radical surgical management is often the only option for these patients …”⁶ may continue to be seen as true.

References

1. Emanuel E. A Half-life of 5 Years. Can Med Assoc J. 1975;112(5):572. 2. Treadwell, TA. Honey’s Healing History. WOUNDS. 2007;19(9):2. 3. Charles R. Elephantitis Scroti. In: Latham AC, English TC, eds. A System of Treatment. London: Churchill, 1912:504. 4. Homans J. The treatment of elephantitis of the legs--a preliminary report. N Engl J Med. 1936;215:1099-1104. 5. Macey HB. A surgical procedure for lymphoedema of the extremities: a follow-up report. J Bone Joint Surg Am. 1948;30A:339-346. 6. Doscher ME, Herman S, Garfein ES. Surgical management of inoperable. lymphedema: the re-emergence of abandoned techniques. Jour Am Coll Surg. 2012;215(2):278-283. 7. Adams KE, Rasmussen JC, Darne C, et al.Direct evidence of lymphatic function improvement after advanced pneumatic compression device treatment of lymphedema. Biomed Opt Express. 2010;1(1):114-125.