By Alex Ramsden at the Oxford Lymphoedema Practice
To explain lymphoedema it is really necessary to start with the lymphatic system and what it does, which will help to explain why cancer treatment can upset this system and cause lymphoedema.
Everyone has a lymphatic system. Fluid is normally lost from the circulation as it passes through the smallest blood vessels of a limb. This fluid is lymphatic fluid or lymph and keeps the tissues protected and wet. However, it gets taken back up by tiny lymphatic channels, passes through the lymph nodes and eventually returns back into the bloodstream to start the process all over again. In an average person approximately three litres of lymphatic fluid is processed like this every day.
Lymphoedema occurs when there is disruption in the drainage of the lymphatic fluid away from a limb. Lymphoedema symptoms can be any or all of the following: excessive swelling, restricted movement, pain, recurrent episodes or infection (cellulitis) or leaking of lymphatic fluid through the skin (lymphorrhoea). It is a common disease with over 125,000 people affected in the UK. The most common cause of lymphoedema in the UK is the treatment of lymph nodes affected by cancer, by either surgery or radiotherapy. Up to 40% of patients treated for breast cancer are estimated to suffer with lymphoedema.
There are a variety of conventional treatments for lymphoedema, also called conservative treatments but there are also a range of surgical options for the treatment of lymphoedema.
Being active and keeping fit is one of the best things someone can do if they suffer from lymphoedema. Additional weight puts an added pressure on the lymphatic system, and activity moves the lymphatic fluid around the body. Keeping fit can be tricky if you suffer from lymphoedema but it is worth the extra effort. If you feel self-conscious about exercising in front of other people, try and find activities where you can keep fit on your own or find out when places such as gyms or swimming pools are quieter and less busy.
Conservative treatment consists of meticulous skin care, self-massage, compression garments, bandaging, manual lymphatic drainage (MLD), pneumatic compression and kinesio taping. These have short term effects but once stopped the lymphoedema symptoms return, often very quickly, as they don’t address the underlying cause of the lymphoedema (the obstruction to the outflow of lymphatic fluid from the affected area). These methods don’t stop the lymphoedema progressing over time.
There are now a number of surgical options for the treatment of lymphoedema. All the modern approaches to lymphoedema surgery have undergone numerous trials and are no longer experimental but have proven results (despite what any insurance company may say!).
Multiple Lymphaticovenular anastomoses (LVA) is supermicrosurgery. Microsurgery describes surgery undertaken that is beyond the limits of human sight and microscopes are required. Supermicrosurgery takes this one step further and specialist microscopes are required as vessels are joined together that are between 0.2 and 0.8mm in diameter. Sutures are used that are thinner than a human hair. LVA seeks to join the lymphatic channels to the veins. This allows the lymphatic fluid to bypass the obstruction and clears the lymphatic fluid away naturally. Not only is LVA an effective treatment for established lymphoedema, it is also highly effective at preventing lymphoedema in those people who are considered high risk for developing lymphoedema. LVA also vastly reduces the number of cellulitis attacks (over 90% reduction) and can also stop lymphorrhoea.
Lymph Node Transfer (LNT) or Vascularised Lymph Node Transfer involves transplanting healthy lymph nodes from an unaffected area unto the area with the swelling. The transplanted lymph nodes do a number of things; they release growth factors that help stimulate function and link up with the surrounding lymphatic channels, they can help to repair the damaged lymphatics in that area, and they can help drain the lymphatic fluid. It is better to take the lymph nodes that are to be transplanted from either the base of the neck or the abdomen as these areas are less risky areas for causing additional lymphoedema.
Liposuction for lymphoedema or Suction Assisted Protein Lipectomy (SAPL) is very good for when the lymphoedema has progressed to a stage where the tissues in the limb have undergone changes and have been replaced with a fatty tissue. This is when there is less of an issue with the fluid and more with fatty and fibrous tissue. This surgery should not be confused with cosmetic liposuction and any surgeon offering this should be specifically trained in liposuction for lymphoedema. There should also be very close follow up undertaken with both the surgeons and a specialist lymphoedema nurse as correct fitting of garments post op is crucial.
Any lymphoedema care should be offered by skilled and trained therapists or surgeons and it is vitally important to ensure that the care being offered is of top quality. Registered practitioners are likely to be members of the BLS (British Lymphology Society) and can be found on the BLS website under the members directory (www.thebls.com). Surgeons should be highly trained and have undertaken a significant number of surgeries. They will need to have travelled internationally to train. Results for LVA and LNT are better if there are two surgeons operating but ensure that both surgeons are trained, not just one. Don’t be afraid to ask for results, any good surgeon should audit their outcomes and be happy to share. Don’t accept anecdotal evidence, ask for exact figures. If the surgeons are good, they will be happy to share their data.