In a normal person fluid is recycled back to the venous part of the circulation by a system called the lymphatics. Lymphoedema is where an excess of fluid builds up in the limbs, usually because of impairment to the outflow of lymphatic fluid from an affected area causing excessive swelling, restricted movement, pain, recurrent episodes of severe infection (cellulitis), and subsequently a greatly decreased quality of life for the patient. Up to 60% of patients treated for breast cancer and 60% of patients treated for gynaecological cancer are estimated to suffer with lymphoedema.
Lymphoedema may be classified as primary or secondary, based on underlying cause. Primary lymphedema is caused by abnormal development of the lymphatic system. It can be present at birth, or develop later in life. Most commonly in the UK, lymphoedema develops secondary to damage to normal lymphatics. The most common causes of lymphedema are lymphatic damage from surgery (axillary or groin lymph node dissection), or radiotherapy.
Conventional treatment for lymphoedema consists of meticulous skin care, self-massage, and specialist compression bandaging. This is performed by lymphoedema specialist nurses and therapists and can control the swelling, but it fails to address the cause - an obstruction to the outflow of lymph fluid from the affected region. Furthermore, lymphoedema of some areas, for example the head or the scrotum, is not amenable to compression therapy. Recent developments include:
Supermicrosurgery. Lymphovenous anastemosis
LVA - pioneered in Japan and developed further in Europe. Damaged lymphatic vessels are joined to a functioning vein to bypass the blockeage in early lymphoedema. Its diverting a blocked flow to where there is a good flow. This gives the lymphatic fluid an alternative route to escape from the affected area, effectively bypassing the area of damage to the lymphatics.
The problem is that lymph vessels are so small that visualising them is difficult to join up lymphatics. Professor Baumeister in Munich has performed lymphatic grafting or transplantation instead of joining lymphatic vessels to vein he has demonstrated significant improvement in limb volumes.
Lymph node transfer
This aims to kick-start the lymphatic system and involves microsurgical transfer of lymph nodes with their own blood supply from one part of the patients body to the limb with lymphoedema. As soon as the transferred lymph nodes are connected, they start releasing substances that encourage the growth of new lymphatic vessels as well as the old pathway to open. This has been performed on patients with arm oedema due to breast cancer by Anne Dancey, a plastic and reconstructive surgeon at the Queen Elizabeth Hospital in Birmingham and has been successfully used to reverse swelling and reduce or eliminate infections resulting from lymphedema
Whilst no cure exists for lymphoedema in 2008 the National Institute for Health and Care Excellence (NICE) recognised liposuction as an appropriate method for managing and alleviating the symptoms. Liposuction is a technique that removes fat through small metal cannulae. It is important that patients have minimal pitting oedema, are fully compliant with conservative therapy techniques and are wearing compression garments. Postoperatively, patients have to wear garments 24hrs a day for life. This technique has replaced the old fashioned debulking techniques that caused significant scarring and is much better cosmetically.The National Institute for Health and Care Excellence (NICE) states that liposuction for chronic (long-term) lymphoedema appears to be safe, and may be effective in the short term. However, NICE says there is not enough evidence of its long-term effectiveness and safety.
Conservative therapies remain the appropriate treatment for most lymphoedema patients. Surgery (liposuction and other techniques) may only be appropriate for some patients, and should only be undertaken in a multi-disciplinary environment, with appropriate follow up and auditing of results.