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Background Lymphedema is common in patients nearing the end of life. Lymphedema is defined as an accumulation of fluid in the interstitial space and is caused by the dysfunction of normal flow between fluid spaces.1 Its cause is multifactorial, including increased arterial capillary leakage, decreased venous capillary reabsorption, or a change in the constitution of the fluid such as hypoproteinemia.1 Treatments for this debilitating condition can be divided into two main categories: medicinal and mechanical. The most common medications used to treat lymphedema include diuretics and corticosteroids.2 Multiple mechanical approaches can be used to treat lymphedema including elevating the affected limb, manual lymphatic drainage, bandaging, exercise, and in specific situations, surgery, chemotherapy and radiotherapy.2 While these therapies, including compression bandaging, have been shown to be effective in treating lymphedema, the contribution of each individual therapy alone is not well understood.3 However, in palliative patients who are nearing end of life, these current treatments often fall short of decreasing the burden that lymphedema adds to their life. With these patients in mind, the procedure of reverse hypodermoclysis (or reverse dermoclysis) was developed to increase quality of life by reducing lymphedema. It is an adaptation of the more common palliative procedure, hypodermoclysis. Hypodermoclysis is performed via insertion of a subcutaneous needle (butterfly, cannula) to slowly introduce fluid into the interstitial space. It allows for parenteral medications or small amounts of hydration to be delivered in a patient where intravenous access is not established. Conversely, reverse dermoclysis allows for removal of interstitial fluid. Clein and Pugachev published a case series of eight patients in whom reverse dermoclysis was performed.4 The patients were predominantly male with significant edema of their legs and genitals, and it was suspected that several had partial obstruction of their inferior vena cavae, impairing lymphatic return. All of the patients had pelvic metastases, most were hypoalbuminemic, and three had hepatomegaly. Various techniques were used including making incisions, inserting penrose drains, and using subcutaneous butterfly sets. Seven of the eight patients drained a significant amount of fluid (1250-7000ml) and received meaningful symptom relief. A more recent case series of two patients was published by Jacobsen and Blinderman.5 Although the techniques varied somewhat (use of six IV catheters for skin puncture, followed by drainage into an ostomy bag), these patients also reported improvement in quality of life and actually proceeded to repeat the procedure. Despite the success of reverse dermoclysis in these case series and report, there has been no subsequent research on the procedure.

Lymphedema in palliative care – a case of reverse hypo- dermoclysis