Providing a lymphoedema service

www.perfuse.net vascular surgery @ amnch
Starting a Lymphoedema ServiceStarting a Lymphoedema Service
Professor Sean TierneyProfessor Sean Tierney
Consultant Vascular SurgeonConsultant Vascular Surgeon
Tallaght HospitalTallaght Hospital

Vascular Surgery in Tallaght
Peripheral
arterial
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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..
praecox
65-80%
0- 35 years( typically during puberty)
females> males (*4)
unilateral (70%)
tarda
10%
>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 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

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

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 elevation
Early skin changes
Extensive swelling
Severe skin changes
Recurrent infections
or 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 garments
Issues
• 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 limbs
Badger CM A, Preston NJ, Seers K, Mortimer PS
Cochrane 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

“…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

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

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

Providing a lymphoedema service

Providing a lymphoedema service

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