Form and Function: approaches to the management of secondary lymphoedema

Lymphoedema management is a challenge for both the health care professional and the patient. Access to NHS treatment can be patchy, leading to long waiting times and deterioration of limb function, and private therapists are expensive. It is a chronic condition requiring life-long management.

What is lymphoedema?
Lymphoedema is an external or internal manifestation of lymphatic insufficiency and deranged lymph transport [1]. This causes an accumulation of protein-rich interstitial fluid, leading to distention, proliferation of fatty tissue and progressive fibrosis.

It is generally classed as either primary (hereditary), related to congenital malformation of the lymphatic channels, or secondary, resulting from disruption to the lymphatic system [2]. In developing countries, lymphatic filariasis is the major cause of lymphoedema [3].

Surgical intervention
While surgery to ameliorate the effects of lymphoedema (swelling, loss of function, risk of cellulitis) has been used for decades, poor outcomes and the advent of conservative debulking techniques such as manual lymphatic drainage (MLD) (either alone or as a component of decongestive lymphatic therapy (DLT) (Box 1), rendered it largely a ‘last resort’ option.

However, in the last 20 years or so, techniques have improved and surgery is being used as a management option for intractable lymphoedema.

Cornier, summarising her 2012 systematic review [4], suggests that four categories of surgical approaches are used: excisional procedures, liposuction, lymphatic reconstruction and tissue transfer procedures.

Excisional procedures
This is the removal of excess skin and subcutaneous tissue (debulking). Complications include skin/flap necrosis, infection and excessive scarring. It is the most commonly used approach, and was the earliest surgery for debulking.

Liposuction

Liposuction for chronic lymphoedema involves the removal of subcutaneous adipose tissue and accumulated lymph fluid via several small incisions in the limb [5] Cannuli, inserted via small incisions in the affected limb are connected to a vacuum pump and lymphoedematous fat tissue is removed. Post-operatively, a compression bandage is applied to control bleeding and to minimise the development of oedema. The patient will be required to wear custom-made compression garments for life.

Since the early 1990s, much of the pioneering work on the use of liposuction has been undertaken in Sweden (Dr Hakan Brorson) and Dundee (Dr Alex Munnoch, using the Swedish model), and the current Nice guidance draws heavily on Dr Brorson’s work [6]. Brorson suggests that while DLT may work in limbs containing only accumulated lymph, it will be less effective in limbs dominated by adipose tissue [7] as that cannot be broken down by massage. It is shown that:

• Chronic non-pitting arm lymphoedema of up to 4 litres can be removed using liposuction and pressure garments, without further reduction in lymph transport [8]
• No recurrence of arm swelling at long-term (15 yr) follow-up [7]

Lymphatic reconstruction/microsurgery

Lymphatic-venous anastamoses for the treatment of lymphoedema (in canines) was described in the literature as early as 1969 [9]. Improvements in micro-surgery over subsequent years have enabled its use in the drainage of trapped tissue fluid into the lymphatic basin or venous circulation [10]. Techniques include:

• Lymphatico-venualr bypass: subdermal lymphatic vessels are anastomosed to adjacent venules – the pressure in the subdermal venules is lower than that in the deep, larger veins, thus less venous backflow, resulting in improvement in lymphoedema [10]
• Indocyanine green (ICG) fluorescent lymphography: to visualise lymphatic vessels before, during and after surgery
• Vascularised lymph node transfer: soft tissue, including lymph nodes, are transferred to the lymphoedematous limb to promote growth of new lymphatic vessels [11]

Conclusion

Lymphoedema is a long-term, chronic disease. While conservative management (where available) is the first management option, this requires a life-long approach which includes daily massage and wearing of compression garments for life. Surgical techniques, particularly liposuction, appear to offer an alternative, although pressure garments are still required for life, even after liposuction, the most effective option.

If you would like to comment on any of the issues raised by this article, particularly from your own experience or insight, Healthcare-Arena would welcome your views.

Box 1: Components of Decongestive Lymphatic Therapy (NHS Choices 2014)

References

1. International Society of Lymphology. The Diagnosis and treatment of Peripheral Lymphedema.Consensus Document. Lymphology. 2009. 42:51-60
2. International Lymphoedema Framework. Best Practice for the Management of Lymphoedema – 2^nd Edition. Surgical Intervention. A position document on surgery for lymphoedema. 2012. http://www.lympho.org/mod_turbolead/upload//file/Resources/Surgery%20-%20final.pdf Accessed August 2015
3. Narahari SR, Ryan TJ, Vivekananda K, Brantus, P. Compression therapy in Indian villages. In: International Lymphoedema Framework: Best Practice for the Management of Lymphoedema – 2^nd Edition. Compression Therapy: A position document on compression bandaging. ILF. 2012. Chapter 7. http://www.lympho.org/mod_turbolead/upload//file/Resources/Compression%20bandaging%20-%20final.pdf Accessed August 2015
4. Cormier JN. The evidence base for surgery. In International Lymphoedema Framework. Surgical Intervention. A position document on surgery for lymphoedema. 2012. page 10 http://www.lympho.org/mod_turbolead/upload//file/Resources/Surgery%20-%20final.pdf Accessed August 2015
5. National Institute for Health and Care Excellence. Liposuction for chronic lymphoedema. NICE interventional procedure guidance [IPG251]. 2008. http://www.nice.org.uk/guidance/ipg251. Accessed August 2015
6. National Institute for Health and Care Excellence. Summary of key efficacy and safety findings on liposuction for chronic lymphoedema. Nice, 2008. http://www.nice.org.uk/guidance/ipg251/resources/liposuction-for-chronic-lymphoedema-interventional-procedures-overview2 Accessed August 2015
7. Brorson H. From lymph to fat: Liposuction as a treatment for complete reduction of lymphedema.Int J Low Extrem Wounds. 2012. 11; 1: 10-19. Available at: http://www.lymphnet.org/resources/vol-28-no-1-2014-best-career-investigator-award-from-lymph-to-fat-liposuction-as-a Accessed August 2015
8. Brorson H, Svensson H, Norrgren K, et al. Liposuction reduces arm lymphedema without significantly altering the already impaired lymph transport. Lymphology. 2008 31 (4): 156–172. Cited in Brorson H, Damastra R. The role of Circumferential Suction Assisted Lipectomy (liposuction) and compression in limb lymphoedema. International Lymphoedema Framework. Best Practice for the Management of Lymphoedema – 2^nd Edition. Surgical Intervention. A position document on surgery for lymphoedema. 2012. Chapter 4. http://www.lympho.org/mod_turbolead/upload//file/Resources/Surgery%20-%20final.pdf
9. Yamada Y. The studies in lymphatic venous anastomosis in lymphedema. Nagoya J Med Sci. 1969. 32:1-21. http://www.med.nagoya-u.ac.jp/medlib/nagoya_j_med_sci/pdf/v32n1p1_21.pdf Accessed August 2015
10. Suami H, Chang DW. New developments in microsurgery. In: International Lymphoedema Framework. Best Practice for the Management of Lymphoedema – 2^nd Edition. Surgical Intervention. A position document on surgery for lymphoedema. 2012. Chapter 5. http://www.lympho.org/mod_turbolead/upload//file/Resources/Surgery%20-%20final.pdf
11. Becker C, Assouad J, Riquet M, et al. Postmastectomy lymphedema: long-term results following microsurgical lymph node transplantation. Ann Surg. 2006. 243:313-31. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1448940/ Accessed August 2015