Learn More About Lymphoedema & The Wide Range Of Surgical & Support Services We Offer ...

Lymphoedema

Lymphoedema is a chronic progressive condition that results in excessive accumulation of protein-rich fluid in the tissues. This is caused by transport failure in the lymphatic system.

Types Of Lymphoedema

Lymphoedema is classified as primary or secondary lymphoedema. Primary lymphoedema is caused by a developmental problem with the lymphatic system and is often inherited. Secondary lymphoedema however is caused by damage to the lymphatics by a disease or surgical treatment and is the most common type of lymphoedema.

Primary Lymphoedema (rare)

  • Milroy's disease (congenital lymphedema). This disorder begins in infancy and causes lymph nodes to form abnormally.
  • Meige's disease (lymphedema praecox). This disorder often causes lymphedema around puberty or during pregnancy, though it can occur later, until age 35.
  • Late-onset lymphedema (lymphedema tarda). This occurs rarely and usually begins after age 35.

Secondary Lymphoedema

  • Surgery - lymph nodes can be affected by cancer spread and surgery is often required to remove the lymph nodes to treat the cancer, especially breast or gynaecological cancer and melanoma. Removal of lymph nodes can cause blockage of the lymph drainage and result in lymphoedema.
  • Radiotherapy. Radiation treatment (radiotherapy) is often used to treat cancer either on its own, or in addition to surgery to a lymph node basin such as the armpit (axilla), groin, neck etc. Radiation causes tissue fibrosis (stiffening) and scarring which results in blockage of the lymphatic vessels, causing lymphoedema.
  • Cancer. Some types of cancer spread is via the lymphatic vessels and into lymph nodes and this cause blockage of lymphatic vessels which causes lymphoedema.
  • Infection. Filariasis is a parasite infection which causes "elephantiasis" or lymphoedema due to the damage it causes to the lymphatic vessels. This condition is more common in tropical countries. Other recurrent infections such as cellulitis can also lead to lymphatic damage and lymphoedema.

Symptoms Of Lymphoedema

  • Constant dull ache or severe pain
  • Burning and bursting sensations in limb
  • General tiredness and debility
  • Sensitivity to heat, cramps, pins and needles
  • Skin problems- dehydration, flakiness, weeping
  • Excoriation and breakdown
  • Immobility of patient leading to obesity and muscle weakness
  • Backache and joint problems
  • Cellulitis

Diagnosing Lymphoedema

Lymphoedema in most cases is diagnosed clinically based on signs and symptoms. You may be at higher risk of Lymphoedema in some instances such as having had prior or recent cancer treatment, especially involving lymph node biopsy or clearance surgery, or radiotherapy to lymph nodes.

In some cases, certain imaging tests are required to make the diagnosis of Lymphoedema. The gold standard test is Indocyanine Green (ICG) Lymphography which not only helps us in confirming the diagnosis of lymphoedema but is also invaluable to the patient, their lymphedema therapist and surgeon in planning conservative and surgical treatment options based on the condition of the lymphatic vessels and the drainage patterns.

Other imaging modalities such as CT, MRI, radionuclide lymphoscintigraphy are sometimes also utilised.

At PRSM we have a holistic approach to ICG mapping which includes the patient, therapist and treating physicians and surgeons in the process in order achieve optimal treatment outcomes. Please refer to the ICG mapping menu on our approach to ICG Mapping below.

ICG Lymphatic Mapping

The gold standard method of assessing your lymphatic vessels is to have a ICG Lymphography test to map the lymphatic vasculature to understand the degree of lymphatic abnormality and to allow accurate decision making about the treatment options available to your lymphoedema specifically.

Dr Prasad performs this test in the rooms at a separate consultation and will provide you with an immediate view of the lymphatics in your affected limb, and for comparison always performs the same test in the unaffected limb at the same time. This test is recorded in real time and you are provided with a copy of the lymphatic mapping test to take home.

Lymphoedema Surgery

Aims of Lymphoedema Surgery

  • Prevent progression of lymphoedema
  • Symptom relief – reduction in limb volume and episodes of cellulitis
  • Free from Compression garments (possible in 5-10% of patients)

Depending on whether the affected limb is predominantly fluid or fat determines which lymphoedema surgical procedure is optimal for the patient. Supermicrosurgical or Microsurgical procedures are performed when the limb is predominantly fluid in nature. Super microsurgery is anastomosis of vessels smaller than 0.6mm in diameter. Size of lymph vessels in LVA surgery is usually between 0.3-0.5mm in diameter.

Liposuction is performed when the affected limb is predominantly composed of fatty tissue.

  • Lymphaticovenous Anastomosis – LVA (Anastomosis of lymph vessel to a vein)
  • Lymph Vessels/Nodes Transfer
  • Liposuction

Lymphaticovenous Anastomosis

Lymphaticovenous Anastomosis is an extremely specialised and time consuming procedure that requires high levels of surgical expertise.

The lymph vessel is bypassed to a nearby vein restoring the lymph flow back to the venous system. Surgery is performed under high magnification (x35). The patient is usually able to return home the following day after surgery.

Typically 2-3 LVAs are performed per limb.

When is LVA Surgery offered?

  • When there is pitting oedema present in the limb from lymphoedema
  • When the patient / therapist has demonstrated compliance with therapy and compression bandaging
  • When the patient has been optimised with lymphoedema therapy with the use of compression garments, massage and lasers preoperatively
  • The compression garments must not be more than 6 months old - Garments change with time and for correct post op compression a relatively new, well-fitting set of compression garments is essential to ensure adequate limb compression
  • No change of garment size for at least 2 months - This demonstrates that the condition is stable and that the amount of limb swelling is not fluctuating

Lymph Node Transfer

Lymph nodes may act as a sponge to absorb lymphatic fluid and direct it to the blood vessels. Lymph nodes are harvested (usually from the axilla, groin or neck) and these are used to replace the damaged lymph nodes. Transferred nodes may induce growth of new lymphatic vessels in 12-18 months.

Is there a risk of developing lymphoedema after lymph node transfer?

Reverse Lymphatic Mapping is utilised to prevent lymphoedema of the donor limb after lymph node harvest. Lymphoscintigraphy (nuclear medicine scan) is performed to identify lymph nodes draining the donor limb. These lymph nodes are preserved in lymph node harvest, thus preventing lymphoedema of the donor limb.

Liposuction

In Lymphoedema, excess limb volume without pitting oedema equates to excess fatty tissue. Conservative treatment and microsurgical procedures cannot remove excess fatty tissue.

Excess fat can be removed by liposuction to restore the form and function of the limb. Lifelong use (23.5 hours/day) of custom-made compression garments is mandatory for maintaining the effect of surgery.