Providing a lymphoedema service

www.perfuse.net vascular surgery @ amnch

Starting a Lymphoedema ServiceStarting a Lymphoedema Service

Professor Sean TierneyProfessor Sean TierneyConsultant Vascular SurgeonConsultant Vascular Surgeon

Tallaght HospitalTallaght Hospital


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

SurgeryHyperhidrosis

Foot Protection

Clinic

LymphoedemaLymphoedema


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?


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..

praecox65-80% 0- 35 years( typically during puberty)females> males (*4)unilateral (70%)

tarda10%>35y"Meige disease"


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


Pathophysiology

Lymphatic dysfunctionAccumulation of protein rich oedema

In subcutaneous tissue

Inflammatory reaction

Fibrosis

skin thickens ("peau d'orange") scaling, warty verrucosis

Cracks and furrowsulceration (lymphorrhea)

Recurrent cellulitisUlceration

(rarely) lymphangiosarcoma


Therapeutic window

Lymphatic dysfunctionAccumulation of protein rich oedema

In subcutaneous tissue

Oedema & Inflammatory reaction

Fibrosis

skin thickens ("peau d'orange") scaling, warty verrucosis

Cracks and furrowsulceration (lymphorrhea)

Recurrent cellulitisUlceration

(rarely) lymphangiosarcoma


Diagnosis

• Clinical assessment primarily

• Consider in all cellulitis (esp >1)– >20%– non pitting– no other cause

• Skin changes usually absent (mild-moderate)


Assessment


Assessment

??


Exclude venous/secondary


Grading

Mild

Moderate

Complications

Severe

<20%↑Pitting↓On elevation↓no skin changes

I

II

III

20-40%↑Pitting & Non-pitting⇔On elevationEarly skin changes

Extensive swellingSevere skin changesRecurrent infectionsor ulceration

www.lympho.org


Treatment

Mild

Moderate

Complications

Severe

•Self directed•Lifelong•Support when required

•Lifelong•Multidisciplinary•Proactive

•? Inpatient treatment•? Surgery


Mild lymphoedema

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


Mild Lymphoedema

Skin care• Wash & dry daily• Regular emolients

– 50:50– Emulsifying ointments– Avoid steroids– Avoid topical antibiotics


Mild Lymphoedema

Cellulitis• Early oral antibiotics

– Gram positive

– Ciprofloxicin

– Clarithromycin

• IV antibiotics• Elevate


Mild Lymphoedema

Compression• Grade 2 or 3• Below knee may be

sufficient• Early refit• 3 monthly• ?full length• ?custom


Mild Lymphoedema

Exercise• daily• with stockings• weight loss

Elevation


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


Multilayer bandaging (MLB)

• Full length

• Short stretch• Standard application• ? Digits• Daily (? 2-3 days)

• Duration 2-6 weeks







• 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)


Manual Lymphatic drainage

• Vodder technique etc.• Sequential∀ ± MLB• Compression garmentsIssues• Repeated• Limited availability• Cost

www.mldireland.com


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


Sequential Air compression


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


Drug Therapy

• Diuretics

• Benzo-pyrones

• Paroven etc

Benzo-pyrones for reducing and controlling lymphoedema of the limbsBadger CM A, Preston NJ, Seers K, Mortimer PSCochrane 2004


LLLT

• Unproven• Usually combined

with physio/message


Surgical treatments

• Excisional– Excisional Surgery– Liposuction

• Reconstructive– lymphatic microsurgical anastomosis– tissue transfer




Evidence based medicine

www.cochrane.org


Excisional surgery

Surgical Tutor

Historical interest only

? Severe soft tissue infection

Poor outcomes


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.


Liposuction – the evidence

lymphoedema.org/News/Story73.asp

www.perfuse.net vascular surgery @ amnchlymphoedema.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…”


“… 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.…”


“…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… ”


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


Surgical treatments

• Excisional– Excisional Surgery– Liposuction

• Reconstructive– lymphatic microsurgical anastomosis– tissue transfer


Lymphatic microsurgery


Lymphovenous reconstruction

• 8 trials (none randomised)• N=9-100

– except Genoa, >1000)

• Combined with compression• 2-60% reduction in limb

volume• unproven


Tissue transfer

• Transfer of lympatic rich tissue to limb

• 4 studies (<60 patients)

• Variable results

• Unproven


Integrated care


Integrated care


Integrated care


Lymphoedema

• Life-long chronic condition

• Empowerment• Preventative

– skin care– antibiotics– compression

• MLD/MLB• Surgery rarely

appropriate

Providing a lymphoedema service

Health & Medicine

vascular clinic

amnchvascular surgery

amnchprevalence vascular

lymphoedema servicestarting

prevalence of lymphoedema

peau dorange scaling

warty verrucosiscracks

wound management