Lymphovenous Microsurgical Shunts in Treatment of Lymphedema of Lower Limbs: A 45-year Experience of One Surgeon/One Center.

Dec 2012

Olszewski WL.

Source

Department of Surgical Research & Transplantology, Medical Research Center, Polish Academy of Sciences, 5 Pawinskiego Str., 02-106 Warsaw, Poland. Electronic address: wlo@cmdik.pal.pl.

Abstract

RATIONALE:

The use of microsurgical lymphovenous shunts is one of the generally accepted treatments for limblymphedema.

AIM:

The 45-year personal experience of one surgeon in indications, technique and results of lymphovenous shunt operations in lower limb lymphedema of varying etiology is presented.

MATERIAL:

One thousand three hundred patients were followed up in the period 1966-2011. Patients were classified into groups according to the etiology of lymphedema as postinflammatory/posttraumatic, postsurgical, idiopathic and hyperplastic. Decrease in limb circumference, heaviness and pain, and increase in joint flexing were evaluated.

RESULTS:

The most satisfactory results, reaching 80-100% improvement, were obtained in the congenital non-hereditary hyperplastic lymphedema group, with large lymphatics not previously damaged by infection. Results were also satisfactory in the group of cancer patients after iliac lymphadenectomy, reaching 80%. A less satisfactory outcome was observed in the postinflammatory group, not exceeding 30-40%. In idiopathic lymphedema results were satisfactory in only a few cases.

CONCLUSIONS:

Patients with lymphedema with local segmental obstruction but still partly patent distal lymphatics and without an active inflammatory process in the skin, subcutaneous tissue and lymph vessels present satisfactory results.

ESVS

Can I Prevent Lymphedema?

Can I Prevent Lymphedema?

It seems to be quite “fashionable” lately for website to put out pages on “How to Prevent Lymphedema.” As a lymphedema patient of almost 60 years, I find it somewhat dishonest (to say the least) for anyone to be claiming a way of doing this. It simply is not true. There is absolutely no scientific or medical evidence to support that claim and it gives false hopes to people who are desperate for some type of hope and help.

You can not absolutely prevent lymphedema if your lymphatic system has been damaged or compromised and you are at risk. The only way to “prevent” lymphedema is to have the lymph systemm regrown or repaired where it has been damaged. But there are certain steps you can take that can that can lessen your chances of getting it or will help lessen the severity of it should it happen.

While it is not possible to prevent lymphedema, you can and should take steps to lesson the possibility and/or to lessen its impact.

Pat

My Life with Lymphedema and Lymphoma

Risk Factors for Lymphedema

Who is at risk for lymphedema? Anyone who has one or more of the following factors can acquire lymphedema.

• Lymph node removal for biopsies

• Serious infections that include Lymphangitis, cellulitis or erysipelas

• Deep invasive wounds that might tear, cut or damage the lymphatics

• Radiation treatments, especially ones that are focused in areas that might contain “clusters” of lymph nodes

• Morbid obesity can cause secondary lymphedema by “crushing” the lymphatics

• Serious burns, even intense sunburn

• Infection of the microscopic parasite filarial larvae, though this is more common in tropical countries

• Trauma injuries such as those experienced in an automobile accident that severly injures the leg and the lymph system.

• For primary lymphedema any person who has a family history of unknown swelling of a limb
  
  

  Eighteen Steps to Prevention of Lymphedema

  1. Absolutely do not ignore any slight increase of swelling in the arm, hand, fingers or chest wall (consult with your doctor immediately).

  2. Never allow an injection or a blood drawing in the affected arm(s).

  3. Have blood pressure checked in the unaffected arm.

  4. Keep the edemic arm, or “at-risk” arm spotlessly clean. Use lotion (Eucerin, Nivea) after bathing. When drying it, be gentle, but thorough. Make sure it is dry in any creases and between the fingers.

  5. Avoid vigorous, repetitive movements against resistance with the affected arm (scrubbing, pushing, pulling).

  6. Avoid heavy lifting with the affected arm. Never carry heavy handbags or bags with over-the-shoulder straps.

  7. Do not wear tight jewelry or elastic bands around affected fingers or arm(s).

  8. Avoid extreme temperature changes when bathing, washing dishes, or sunbathing (no 1sauna or hot tub). Keep the arm protected from the sun.

  9. Avoid any type of trauma (bruising, cuts, sunburn or other burns, sports injuries, insect bites, cat scratches).

  10. Wear gloves while doing housework, gardening or any type of work that could result in even a minor injury.

  11. When manicuring your nails, avoid cutting your cuticles (inform you manicurist).

  12. Exercise is important, but consult with your therapist. Do not overtire an arm at risk; if it starts to ache, lie down and elevate it. Recommended exercises: walking, swimming, light aerobics, bike riding, and specially designed ballet or yoga. (Do not lift more than 12 lbs.)

  13. When traveling by air, patients with lymphedema must wear a compression sleeve. Additional bandages may be required on a long flight.

  14. Patients with large breasts should wear light breast prostheses (heavy prostheses may put too much pressure on the lymph nodes above collar bone). Soft pads may have to be worn under the bra strap. Wear a well-fitted bra that is not too tight and with no wire support.

  15. Use an electric razor to remove hair from axilla. Maintain electric razor properly replacing heads as needed.

  16. Patients who have lymphedema should wear a well-fitted compression sleeve during all waking hours. At least every four to six months see your therapist for follow-up. If the sleeve is too loose, most likely the arm circumference has reduced or the sleeve is worn.

  17. Warning: If you notice a rash, blistering, redness, increase of temperature or fever, see your physician immediately. An inflammation or infection in the affected arm could be the beginning of lymphedema or a worsening of lymphedema.

  18. Maintain your ideal body weight through a well-balanced, low sodium, high-fiber diet. Avoid smoking and alcoholic beverages. Lymphedema is a high protein edema, but eating too little protein will not reduce the protein element in the lymph fluid; rather this will weaken the connective tissue and worsen the condition. The diet should contain protein that is easily digested, such as chicken and fish.

  
  

  See also: Lymphedema Risk Reduction Practices

  National Lymphedema Network

Lymphedema Strategies for Investigation and Treatment: A Review

Lymphedema Strategies for Investigation and Treatment: A Review

Oct/Dec 2012

Pankaj Tiwari MD 
Michelle Coriddi MD 
Susan Lamp BSN, RN, CPSN 

Plastic Surgical Nursing

**For information only.  There is much controversery regarding surgical treatment for lymphedema**

Abstract

The goal of this article was to define lymphedema as a disease entity, to introduce the American Lymphedema Framework Project, and to summarize current surgical strategies on the horizon in the surgical treatment of lymphedema.

LYMPHEDEMA DEFINED

Alongside the arterial and venous vasculature, the lymphatic system is a part of the circulatory system. Lymphatic channels primarily regulate the flow of fluid in the interstitium (Ellis, 2006). Under normal conditions, venous capillaries reabsorb 90% of the fluid in the tissues, and lymphatic channels absorb the remaining 10% of lymph fluid, proteins, and other molecules (Warren, Brorson, Borud, & Slavin, 2007). Lymphatic fluid passes to regional lymph node basins. Ultimately, the lymphatic fluid is transported back into the subclavian vein to enter the venous system via the thoracic duct.

Lymphedema is an external or internal manifestation of lymphatic insufficiency and deranged lymph transport (International Society of Lymphology, 2009). This insufficiency causes an accumulation of protein-rich interstitial fluid, leading to distention, proliferation of fatty tissue, and progressive fibrosis. Skin changes such as thickening and hair loss may occur. Progressive lymphedema without adequate management can lead to functional impairment, compromised quality of life, and deformity. Clinically, lymphedema is noted as swelling of the involved extremity. The head and neck, breast, or genitalia may also be affected (McWayne, & Heiney, 2005; Rockson, 2010; Smeltzer, & Stickler, 1985).

Lymphedema is generally classified as either primary or secondary. Primary lymphedema (hereditary) is related to congenital malformation of the lymphatic channels. Secondary lymphedema results from disruption to the lymphatic system. Primary lymphedema can result from any one of a number of disorders that may be sporadic or hereditary. Syndromes such as Milroy's disease and Prader-Willi syndrome have lymphedema as an element of their clinical manifestations to varying degrees. The estimated prevalence of primary lymphedema is 1.15 in 100,000 persons under the age of 20 years Milroy's Disease (Smeltzer & Stickler, 1985). In children, the two main causes are Milroy's disease and lymphedema distichiasis (International Society of Lymphology, 2009).

Secondary lymphedema is a consequence of removal or damage to lymph nodes, fibrosis of the nodes (postradiotherapy), and trauma or infection secondary_lymphedema Rockson, 2010). Upper extremity lymphedema is commonly associated with the treatment of breast cancer. The degree of lymphedema has been well recognized to correlate with the number of lymph nodes that have been removed and the extent of radiotherapy to the axillary region. Lower extremity lymphedema is most often seen in survivors of uterine and prostate cancer, as well as melanoma and lymphoma survivors (Meneses & McNees, 2007). Most cancer survivors develop lymphedema within 3 years of treatment (Petrek, Senie, Peters, & Rosen, 2001).

In addition to cancer ablation, side effects of advanced diseases such as congestive heart failure, neurological and liver disease, and end-stage renal disease can cause chronic edema. An increase in the bariatric population has also seen an increase in lymphedema incidence. Lympedema caused by the parasite wucheria bancrofti and transmitted by mosquitoes remains the most common cause of lymphedema worldwide. Unfortunately, no strategies employed to prevent the onset of lymphedema have proven fruitful to date. The term chronic edema has been adopted by European investigators to define a population of patients with long-standing edema (>3 months). Prevalence estimates for chronic edema are between 1.3 and 1.5 per thousand.

New clinical data suggest that some patients may have a primary disposition to lymphedema but that this first becomes clinically evident after a secondary eliciting event (Rockson, 2010). Lymphedema tarda is defined as debut after the age of 35 years. It is often associated with an eliciting factor such as trauma or an inflammatory reaction (Kerchner, Fleischer, & Yosipovitch, 2008).

Complete text:

Nursing Center

Microsurgical Techniques for the Treatment of Breast Cancer-related Lymphedema: a Systematic Review.

Dec 2012

Penha TR, Ijsbrandy C, Hendrix NA, Heuts EM, Voogd AC, von Meyenfeldt MF, van der Hulst RR.

Source

Department of General Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands.

Abstract

Background 

Upper limb lymphedema is one of the most underestimated and debilitating complications of breast cancer treatment. The aim of this review is to summarize the recent literature for evidence of the effectiveness of lymphatic microsurgery for the treatment of breast cancer-related lymphedema (BCRL).

Methods 

A search was conducted for articles published from January 2000 until January 2012. Only studies on secondary lymphedema after breast cancer treatment and those examining the effectiveness of microsurgery were included.

Results 

No randomized clinical trials or comparative studies were available. Ten case-series met inclusion criteria: (composite) tissue transfer (n = 4), lymphatic vessel transfer (n = 2), and derivative microlymphatic surgery (n = 4). Limb volume/circumference reduction varied from 2 to 50% over a follow-up time ranging from 1 to 132 months. Postoperative discontinuation rates of conservative therapy were only reported after composite tissue transfer, ranging from 33 to 100% after 3 to 24 months. Clear selection criteria for lymphatic surgery and lymphatic flow assessment were absent in most studies.

Conclusion 

We identified important methodological shortcomings of the available literature. Evidence acquired through comparative studies with uniform patient selection is lacking. Consistent positive findings with regards to limb volume reduction and limited complications are reasons to further explore these techniques in methodologically superior studies.

Thieme

The effect of mechanical lymph drainage accompanied by heat

The effect of mechanical lymph drainage accompanied with heat on lymphedema.

Nov 2012

Mariana VF, de Fátima GG, Maria Pde G.

Source

Associate Professor, Godoy Clinic, Paulista University, São Jose do Rio Preto, Brazil.

Abstract

KEYWORDS: Thermotherapy, Lymphedema, Mechanical Lymph Drainage

BACKGROUND:

Thermotherapy has been indicated by some researchers as a treatment for lymphedema. A study comparing temperatures demonstrated that a temperature of 40°C significantly increased the transportation of lymph compared to other temperatures assessed. The aim of this study was to evaluate the possible benefits of mechanical lymph drainage accompanied with heat in the treatment of lymphedema of the lower limbs.

METHODS:

In a cross-over randomized study, the effect of heat on lymph drainage was evaluated in the treatment of leg lymphedema. The study, performed in the Godoy Clinic in São Jose do Rio Preto, Brazil, involved seven patients (two males and five females) with leg lymphedema. The patients' ages ranged from 18 to 79 years old with a mean of 48.5 years. The subjects underwent a total of 38 assessments including 19 evaluations of mechanical lymph drainage alone and 19 combined with thermotherapy. Heat was applied using an electric blanket which was wrapped around the legs of the patients. The volume of legs was evaluated by water plethysmography before and after treatment sessions. The paired t-test was used for statistical analysis with an alpha error of p = 0.05 being considered as acceptable.

RESULTS:

No statistically significant differences were evidenced between mechanical lymph drainage alone and lymph drainage combined with thermotherapy.

CONCLUSIONS:

There was no obvious synergic effect in the immediate post-treatment period when heat was combined with mechanical lymph drainage in the treatment of lymphedema. 

Journal of Research in Medical Sciences

Lymphedema Strategies for Investigation and Treatment: A Review

Lymphedema Strategies for Investigation and Treatment: A Review

Pankaj Tiwari MD 
Michelle Coriddi MD 
Susan Lamp BSN, RN, CPSN 

Plastic Surgical Nursing
October/December 2012  
Volume 32 Number 4 
Pages 173 - 177

Abstract

The goal of this article was to define lymphedema as a disease entity, to introduce the American Lymphedema Framework Project, and to summarize current surgical strategies on the horizon in the surgical treatment of lymphedema.

LYMPHEDEMA DEFINED

Alongside the arterial and venous vasculature, the lymphatic system is a part of the circulatory system. Lymphatic channels primarily regulate the flow of fluid in the interstitium (Ellis, 2006). Under normal conditions, venous capillaries reabsorb 90% of the fluid in the tissues, and lymphatic channels absorb the remaining 10% of lymph fluid, proteins, and other molecules (Warren, Brorson, Borud, & Slavin, 2007). Lymphatic fluid passes to regional lymph node basins. Ultimately, the lymphatic fluid is transported back into the subclavian vein to enter the venous system via the thoracic duct.

Lymphedema is an external or internal manifestation of lymphatic insufficiency and deranged lymph transport (International Society of Lymphology, 2009). This insufficiency causes an accumulation of protein-rich interstitial fluid, leading to distention, proliferation of fatty tissue, and progressive fibrosis. Skin changes such as thickening and hair loss may occur. Progressive lymphedema without adequate management can lead to functional impairment, compromised quality of life, and deformity. Clinically, lymphedema is noted as swelling of the involved extremity. The head and neck, breast, or genitalia may also be affected (McWayne, & Heiney, 2005; Rockson, 2010; Smeltzer, & Stickler, 1985).

Complete article:

Nursing Center.com

How to Cure Lymphedema

How to Cure Lymphedema

Yet another “new” item that seems to be showing up in regards to lymphedema is the claim that you can cure lymphedema.

Use this lotion - take this potion!

In the days of the old West, we always hear the stories of snake oil salesmen traveling through the countryside with their wagons hustling “magical cures” for all ailments.

We are much more sophisticated today, now we use the internet to sell the snake oil.

Please understand that as of this date (Dec. 31, 2011) there is absolutely no “cure” for this condition. Don't be misled by someone who claims to have such cure. Certain techniques that claim to cure lymphedema is exercise and/or microsurgery, lymph node transplant. First, there is absolutely no evidence to support the claim the early intervention and exercise can cure LE. Microsurgery does hold promise and some have had initial good results. However, that is still considered as experimental and there are no studies out showing the long term results (10 years).

Lymph node transplant is also very very early in its use and is considered quite controversial and is very much experimental. Also, because there is mounting evidence that anyone who gets secondary lymphedema was born with a defective lymph system. Yanking out nodes in these individuals to put elsewhere is simply transferring the locale of the potential start of lymphedema. We need honest, clear independent clinical research on outcomes that cover not simply a couple years or even five years, but much further out to include 10 years and 20 years.

Why is there no cure?

The understanding of this, rests in the pathophysiology of lymphedema. Lymphedema is caused by either trauma/damage to the lymphatics and/or being born with a malformed lyhmp system. Those born with it may also be missing lymph nodes throughout their body. This is why I had LE from birth. I am missing critical inguinal lymph nodes as demonstrated by a lymphangiogram I had back in 1966,

The only way to cure lymphedema is to have that lymph system repaired (healed) or to have any missing nodes regrown.

There is no way of doing that, at the moment. There IS promising research going on, but we are still a long way off.

Believe me, if anyone would hope for a cure for this rotten condition it would be me. Mine started from birth some 50 years ago and presently I am having to cope with many complications, some of which includes lymphoma (a lymphatic cancer) and had massive pleural effusions.

Continued:  How to Cure Lymphedema