A review of the current issues in management of lymphoedema in ireland

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Starting a Lymphoedema ServiceStarting a Lymphoedema Service
Professor Sean TierneyProfessor Sean Tierney
Consultant Vascular SurgeonConsultant Vascular Surgeon
Tallaght HospitalTallaght Hospital

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Vascular Surgery in Tallaght
Peripheral
arterial
disease
Medical
Endo
Open
Abdominal
Aortic
Aneurysm
Surveillance
Surgery
Endo
Open
Surgery
Surveillance
Carotid Artery
Diagnosis
Endo
Open
Surgery
Vascular access
Venous
Ulcers
Endo
Open
Surgery
Hyperhidrosis
Foot
Protection
Clinic
LymphoedemaLymphoedema

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Classification of lymphoedema
• Primary
– congenital lymphedema
– lymphoedema praecox
– lymphoedema tarda
• Secondary
– breast cancer
– Wuchereria bancrofti
– VV Sx (or any surgery - peripheral vascular surgery, lipectomy,
burn scar excision)
– Burns
– insect bites?

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Classification of lymphoedema
• Primary
– congenital lymphoedema
– lymphoedema praecox
– lymphoedema tarda
Congenital (inc Milroy’s)
10-25%
evident at
females > males (*2)
Lower> upper (*3)
Bilateral in 66%
may ↓ with increasing age..
praecox
65-80%
0- 35 years( typically during puberty)
females> males (*4)
unilateral (70%)
tarda
10%
>35y
"Meige disease"

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Prevalence
• Vascular OPD
• 2.6% among 460 patients
• 36% hx of cellulitis
• Significant impact on QOL
– physical functioning
Gethin et al. Prevalence of lymphoedema and quality of life among patients attending a
hospital-based wound management and vascular clinic. International Wound Journal
2011

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Pathophysiology
Lymphatic dysfunction
Accumulation of protein rich oedema
In subcutaneous tissue
Inflammatory reaction
Fibrosis
skin thickens ("peau d'orange")
scaling, warty verrucosis
Cracks and furrows
ulceration (lymphorrhea)
Recurrent cellulitis
Ulceration
(rarely) lymphangiosarcoma

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Therapeutic window
Lymphatic dysfunction
Accumulation of protein rich oedema
In subcutaneous tissue
Oedema & Inflammatory reaction
Fibrosis
skin thickens ("peau d'orange")
scaling, warty verrucosis
Cracks and furrows
ulceration (lymphorrhea)
Recurrent cellulitis
Ulceration
(rarely) lymphangiosarcoma

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Diagnosis
• Clinical assessment primarily
• Consider in all cellulitis (esp >1)
– >20%
– non pitting
– no other cause
• Skin changes usually absent (mild-
moderate)

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Assessment

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Assessment
??

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Exclude venous/secondary

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Grading
Mild
Moderate
Complications
Severe
<20%↑
Pitting
↓On elevation
↓no skin changes
I
II
III
20-40%↑
Pitting & Non-pitting
⇔On elevation
Early skin changes
Extensive swelling
Severe skin changes
Recurrent infections
or ulceration
www.lympho.org

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Treatment
Mild
Moderate
Complications
Severe
•Self directed
•Lifelong
•Support when required
•Lifelong
•Multidisciplinary
•Proactive
•? Inpatient treatment
•? Surgery

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Mild lymphoedema
• Advice
– skin care
– early antibiotics
– compression
– elevation
– exercise
– weight loss

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Mild Lymphoedema
Skin care
• Wash & dry daily
• Regular emolients
– 50:50
– Emulsifying ointments
– Avoid steroids
– Avoid topical antibiotics

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Mild Lymphoedema
Cellulitis
• Early oral antibiotics
– Gram positive
– Ciprofloxicin
– Clarithromycin
• IV antibiotics
• Elevate

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Mild Lymphoedema
Compression
• Grade 2 or 3
• Below knee may be
sufficient
• Early refit
• 3 monthly
• ?full length
• ?custom

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Mild Lymphoedema
Exercise
• daily
• with stockings
• weight loss
Elevation

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Moderate lymphoedema
• Advice
– skin care
– early antibiotics
– self help networks
• Specific interventions
– multilayer bandaging (MLB)
– manual lymphatic drainage (MLD)
– pneumatic compression devices (SAC)
– (custom) compression garments

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Multilayer bandaging (MLB)
• Full length
• Short stretch
• Standard application
• ? Digits
• Daily (? 2-3 days)
• Duration 2-6 weeks

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Multilayer bandaging (MLB)

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Multilayer bandaging (MLB)

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Multilayer bandaging (MLB)
• Full length
• Short stretch
• Standard application
• ? Digits
• Daily (? 2-3 days)
• Duration 2-6 weeks
Evidence weak 0
5
10
15
20
25
30
35
Volume reduction @ 18 weeks
MLB+ Hosiery
A Randomized, Controlled, Parallel-Group Clinical Trial Comparing Multilayer Bandaging
Followed by Hosiery versus Hosiery Alone in the Treatment of Patients with Lymphedema of the Limb.
Badger, Peacock, Mortimer. Marsden (online)

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Manual Lymphatic drainage
• Vodder technique etc.
• Sequential
∀ ± MLB
• Compression garments
Issues
• Repeated
• Limited availability
• Cost
www.mldireland.com

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Manual Lymphatic drainage
Physical therapies for reducing and controlling
lymphoedema of the limbs
Preston NJ, Seers K, Mortimer PS
Last updated February 20 2008
Very few high quality trials
Cochrane

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Sequential Air compression

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Sequential Air Compression
• Grade 1 >Grade 2-3
• Secondary > primary
• Multi-chambered gradient > single-chambered, non-gradient pumps.
• Effects variable
• Probably best combined with massage and compression garments),
• Regular retreatment required
• May shift the lymphoedema elsewhere
Limited application in selected patients guided by
multidisciplinary team input

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Drug Therapy
• Diuretics
• Benzo-pyrones
• Paroven etc
Benzo-pyrones for reducing and controlling lymphoedema of the limbs
Badger CM A, Preston NJ, Seers K, Mortimer PS
Cochrane 2004

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LLLT
• Unproven
• Usually combined
with
physio/message

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Surgical treatments
• Excisional
– Excisional Surgery
– Liposuction
• Reconstructive
– lymphatic microsurgical anastomosis
– tissue transfer

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Evidence based medicine
www.cochrane.org

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Excisional surgery
Surgical Tutor
Historical interest only
? Severe soft tissue infection
Poor outcomes

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Liposuction – the evidence
• Five studies
– (3 from one centre, Brorson et al., Malmo)
– 109 patients
– non-randomised
– Significant ↓ in limb volume (esp arms)
– Complications include bleeding, infection,
pain and ulceration
– Effectiveness versus compression unknown
– Long effectiveness unknown.

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Liposuction – the evidence
lymphoedema.org/News/Story73.asp

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lymphoedema.org/News/Story73.asp
“…Liposuction should only be considered in
those with significant excess volume in a limb,
where conservative measures have failed to
bring about further reduction and there is no
pitting oedema, in a compliant patient…
…This surgery is completely different to that
undertaken for cosmetic purposes…”

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lymphoedema.org/News/Story73.asp
“… 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.…”

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lymphoedema.org/News/Story73.asp
“…all lymphoedema practitioners to think
carefully before referring patients to
surgeons who do not have the appropriate
experience to perform this (or any other)
technique… ”

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ILF conclusions
“…Liposuction (CSAL) is a well researched, effective
and safe procedure for end- stage lymphoedema
that has been unresponsive to conservative
treatment….
CSAL should be embedded in a integrated
lymphoedema service protocol…”
www.lympho.org/resources.php

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Surgical treatments
• Excisional
– Excisional Surgery
– Liposuction
• Reconstructive
– lymphatic microsurgical anastomosis
– tissue transfer

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Lymphatic microsurgery

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Lymphovenous reconstruction
• 8 trials (none randomised)
• N=9-100
– except Genoa, >1000)
• Combined with compression
• 2-60% reduction in limb
volume
• unproven

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Tissue transfer
• Transfer of lympatic rich tissue to limb
• 4 studies (<60 patients)
• Variable results
• Unproven

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Integrated care

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Integrated care

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Integrated care

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Lymphoedema
• Life-long chronic
condition
• Empowerment
• Preventative
– skin care
– antibiotics
– compression
• MLD/MLB
• Surgery rarely
appropriate