I first developed an interest in the field of lymphedema during my fellowship in Canada, where I started to research the possibility of lymphnode transfer as a treatment of lymphedema. I was surprised at the level of interest my research generated in the scientific community. I was fortunate and humbled to receive several awards for my work in this field and also completed my MD thesis on this topic.
Since then I have continued to improve my experience in this field with scientific work, presentations at national and international meetings and visiting several centers around the world that are specialized in the treatment of lymphedema in order to obtain the latest knowledge and clinical experience.
- 1 Lymphedema in Hamburg
- 2 What Is Lymphedema?
- 3 What Are The Clinical Signs Of Lymphedema And Its Progression?
- 4 What Are The Risks Of Developing Lymphedema?
- 5 Conservative Measures To Treat Lymphedema
- 6 Why Is Screening For Lymphedema Important?
- 7 How To Screen For Lymphedema?
- 8 What Is Indocyanine Green Lymphography (ICG)?
- 9 What To Expect At Your First Lymphedema Consultation?
Lymphedema in Hamburg
Lymphedema affects people in many different ways and can be an extremely debilitating and distressing experience. Listening to patient stories has made me realize that lymphedema patients are generally neglected by the medical community and have difficulty gaining access to accurate up to date information and specialized services. In this regard, I hope to bring my experience in lymphedema surgery to patients in Hamburg and surrounding areas.
What Is Lymphedema?
Lymphedema is a progressive and debilitating condition associated with dysfunction of the lymphatic system. In the developed world lymphedema commonly occurs after lymph node dissection and/or radiotherapy to lymph nodes for the diagnosis or treatment of breast cancer, malignant melanoma, sarcoma or gynecologic cancers. This is known as “Secondary Lymphedema”.
Less commonly, lymphedema occurs as a result of congenital causes known as “Primary Lymphedema”. Regardless of the initiating event, its onset is often a distressing experience and is reported as having a negative impact on the quality of life.
What Are The Clinical Signs Of Lymphedema And Its Progression?
Clinical lymphedema results from the abnormal accumulation of protein rich fluid in the affected limb due to interruption of the normal lymph return to the circulation. In the early stage, the swelling is due to excess pooling of lymphatic fluid and is characterized clinically by a pitting edema, which is soft to palpate. This is the fluid phase of the disease process and the edema is potentially still reversible at this stage with adequate treatment, but if neglected or inadequately treated, the chronic buildup of inflammatory cells is believed to subsequently produce scarring and gradual fatty tissue deposition.
Further tissue fibrosis, blistering and skin breakdown acts as a vicious cycle which ultimately leads to worsening of the condition and paves the way for the onset of a more chronic and less reversible stage characterized by a non-pitting solid lymphedema. The time frame for this transition from fluid to solid can vary considerably between patients.
Much of the challenge in managing lymphedema is the inconsistency in the diagnostic standards. Therefore timely diagnosis remains a barrier to optimal treatment for many patients. This can be a complicated undertaking aggravated by lymphedema’s frequently sudden onset. While some patients develop dramatic swelling soon after the initial insult, more commonly this swelling is transient without any permanent consequences. Many patients can be free of any lymphedema for many years before they experience the first symptoms.
What Are The Risks Of Developing Lymphedema?
Patients who undergo lymph node removal or irradiation are at risk of developing lymphedema. This risk increases directly as treatments become more aggressive and anatomically disruptive. Each patients ‘at risk’ territory depends on the area drained by the lymph nodes involved in the treatment. For example breast cancer patients are solely at risk in the axillary region on their affected side, including the hand, arm, breast, and upper truncal quadrant.
On the other hand patients treated for gynecological cancers potentially have a much more extensive territory at risk because their pelvic lymph nodes as well as deeper seated nodes around the aorta which are responsible for draining both legs and feet, lower truncal quadrants and genitalia may have been resected and irradiated. Therefore treatment of gynecological cancers potentially places the entire lower half of the body at risk for developing lymphedema.
Obesity is another important factor to consider as it has been proven to increase the risk of lymphedema progression and rendering it more resistant to conventional therapies.
Uncontrolled collections of lymphedema fluid can be painful and prime the limb for recurrent soft tissue infections, which leads to scarring that can further compromise the lymph drainage and ultimately leads to worsening of the lymphedema and ultimately the development of “elephantiasis”. On the other hand, medical conditions, including diabetes, hypertension, heart failure, and autoimmune conditions, have not been implicated in lymphedema despite considerable scrutiny.
Studies have shown that activities requiring repetitive use of the arm also do not appear to increase lymphedema risk in breast cancer patients. In fact advice against exercise or other repetitive activities have potentially adverse consequences for patients’ quality of life as well as their general wellbeing.
Conservative Measures To Treat Lymphedema
Conventional treatment options for lymphedema include an initial course of “complex decongestive therapy” administered by a lymphedema physical therapist. This is achieved by the application of external compression including manual lymph massage, compression bandages and garments, in addition to skin care. The objective of these approaches is to ‘milk’ the interstitial fluid and lymph through the lymphatic system to decongest the affected limb.
However, the maintenance therapy and the ongoing use of compression garments required afterward must be continued indefinitely in many cases in order to remain effective. In some patients and despite optimum conservative measures there is worsening of the lymphedema after a period of stability maintained by such measures.
Suction assisted lipectomy
In chronic lymphedema due to fluid stasis and the inflammatory process, there is usually a gradual accumulation of fatty tissue in the affected extremity. Suction assisted lipectomy can remove large volumes of fatty tissue deposits that can be aspirated from the lymphedema-affected limb after lymph fluid has been maximally treated by conservative measures. More significantly, the incidence of dangerous cellulitis can be reduced by up to 75% as a result.
Despite these improvements it is important to emphasize that this operation does not address the underlying pathophysiological case of lymphedema nor does it restore the continuity of the lymphatic system. It is best performed in addition to reconstructive microsurgical or supermicrosurgical procedures. Otherwise a successful outcome requires commitment to a life-long regimen of complex decongestive therapy and custom fitted compression garments to prevent renewed buildup of excess lymphatic fluid.
Supermicrosurgery methods to treat lymphedema
Surgical procedures to treat lymphedema have existed for over a century. However, more recently and due to advancements in medical technologies including better microscopes, finer surgical instruments and newer less invasive imaging technologies that have made it possible to visualize lymphatic vessels in real time and perform accurate mapping of their course, have prompted the introduction of sophisticated microsurgical techniques that make it possible to operate on delicate structures such as lymphatic vessels.
Surgical interventions should however be reserved for patients who have failed to respond to conservative treatment measures or in cases where the initial positive effects are no longer capable of maintaining disease progression and there is worsening of the lymphedema. Better results are generally obtained if surgical interventions are applied in earlier stages of the disease course.
Vascularized lymph node transfer
A free tissue flap containing lymph nodes can be harvested from donor sites such as the groin, chest wall, or neck along with their nourishing blood vessels and are transferred to the lymphedema-affected arm or leg, where these vessels are microsurgically connected to local vessels to reestablish blood circulation that is crucial to the survival of the transferred lymph nodes.
There are several possible recipient sites for lymph nodes in the affected limb. For example, in the upper extremity, the axilla can be the most arduous recipient site for nodes because of scarring and irradiation changes to the tissues. The elbow and wrist on the other hand tend to be healthier recipient sites. The same is true for the lower limb where the groin tends to be the most scarred region.
Therefore according to the most recent studies the best symptomatic improvement is seen when the nodes are transplanted to the more dependent sites where fluid tends to pool, such as the wrist or ankle.
These transferred lymph nodes act like suction pumps facilitating lymph clearance and restoring local immune response, thereby reducing the likelihood of infections. Clinically, the lymphedematous limb becomes softer, less heavy, with improved range of movement and skin wrinkling may start to appear in some cases within one week after surgery. The reported mean reduction rate in lymphedema following this procedure is between 40- 50%. This improvement appears to be sustainable over time because the transferred lymph nodes continue to work at shunting lymph fluid from an expanding area of the surrounding tissues to the venous system. This intervention has been successfully used in both congenital as well as primary lymphedema.
If it produces adequate outcome there is the hope that patients will no longer require conservative measures or at least to a much lesser degree.
The main disadvantage of the lymph node transplant procedure is the potential risk for donor site lymphedema. However more accurate mapping of the lymph node drainage region before the surgery helps to further reduce the chance of developing complications at the donor site.
There is not one procedure that can be used for all patients but rather the combined use of lymph node transfer, lympho-venous anastomosis (“LVAs”), lymph vessel transfer and suction assisted lipectomy based on the clinical stage of lymphedema and lymphatic mapping tailored to the individual needs of the patient in order to deliver a more successful treatment strategy. With this combination the aim is to render the lymphedema-affected extremity as normal as possible.
This selective application of the appropriate method to treat the fluid or solid phases of lymphedema greatly improves overall outcomes. Despite this fact, it remains important to perform reconstructive procedures while the lymphedema is still at an early stage, before the inflammatory process causes the condition to worsen over time with accumulation of fibrous fatty tissue and infections.
Lymphatic-Venous Anastomosis (LVA)
The introduction of better quality microscopes and ever-smaller sutures in addition to minimally invasive refined supermicrosurgical techniques have made it possible to perform lymphatic-venous anastomosis with significant improvement in limb girth. Tiny incisions are made, often less than 3 cm long to find lymphatic channels ranging from 0.1 to 0.6 mm in diameter just beneath the skin. These are then connected to adjacent veins allowing excess lymph fluid to bypass areas of obstructed lymph flow and drain directly into the venous system.
Lymphatic-venous anastomosis can result in significant improvement in limb girth, ranging between 42% to 83% in selected patients, as well as reducing or even eliminating the frequency of infections. Following lymphatic-venous anastomosis most scientific literature seems to recommend the continued use of complex decongestive therapy and compression garments following this procedure, but to a lesser extent and depending on response to therapy some patients may be able to discontinue conservative treatments.
Lymphatic-To-Lymphatic Bypass (“Lymph Vessel Transfer”)
First described in 1986, the method here relies on harvesting healthy donor lymph vessels, usually taken from the inner thigh, and transferring them to bridge the scarred or irradiated region in the groin or axilla. They are then sutured to patent lymph channels on either side of the scarred area, thus allowing lymph fluid to flow more easily through areas previously obstructed due to lymphatic destruction and scarring.
Improvement in the lymphedema and effective drainage of lymphatic fluid is clearly demonstrated early after surgery. A successful result is more likely in the arms than legs and is directly proportional to the number of vessels transferred. Meticulous technical expertise and careful harvesting of lymphatic vessels is critical for the success of the procedure and to avoid any complications.
Why Is Screening For Lymphedema Important?
Certain medical treatments such as surgery to remove lymph nodes, lymph node biopsies, radiation and chemotherapy, that are routinely used in the diagnosis or treatment of cancer put patients at a higher risk of developing lymphedema. In some cases this risk can be as high as 50% depending on the intensity and time line of the treatments.
Lymphedema is most likely to develop in these patients within the first three years following cancer therapy. Therefore lymphedema monitoring and treatment is critical during this period. We know from recent scientific findings that early intervention with supermicrosurgery can halt the progression of lymphedema or even prevent its onset altogether.
For patients, this means that the complications associated with lymphedema can be avoided. This is also true for conservative treatments of lymphedema. Early management can help to prevent progression and irreversible changes to the affected extremity. However it must be made clear that not all patients who undergo cancer treatments will develop lymphedema.
Therefore the aim is not to treat all patients prophylactically with supermicrosurgery, but rather to screen for early signs of lymphedema appearance and to monitor those changes, therefore helping to make a correct clinical decision.
How To Screen For Lymphedema?
Clinical examination and accurate circumference measurements are the most simple ways to monitor lymphedema. However, the early “subclinical” stages of lymphedema changes are too subtle to be detected by clinical methods.
Multi-Frequency Bioelectrical Impedance (L-Dex®), is a non-invasive method that accurately detects alterations in extracellular fluid volume and therefore allows early detection of lymph edema before the first symptoms arise. This measurement is quick to perform and can be repeated at intervals to monitor the progression of lymphedema or to detect the early onset of lymphedema.
Another and even more elaborate method to screen for lymphedema is the “Indocyanine Green Lymphography” (ICG). ICG is also superior to lymphoscintigraphy.
What Is Indocyanine Green Lymphography (ICG)?
ICG is a non-invasive accurate method to detect the onset and progression of lymphedema. In addition to lymphedema detection, this method performs complete lymphatic mapping of the extremity under examination allowing direct visualization of lymph flow pattern and helping to detect the exact area of lymph flow obstruction. Indocyanine Green is a fluorescent dye that has been used for over 50 years to measure blood flow in the heart.
For lymphatic imaging a low dose of this substance is injected under the skin where it binds to Albumin and is taken up by lymphatic vessels.
It moves with lymph fluid and an infrared camera can detect this movement seen as a black and white image on the screen, thereby helping to assess the function of the lymphatic vessels and quantify the lymph transport rate in the extremity under examination. This imaging method can be used in primary and secondary lymphedema patients.
In a normal patient, ICG is quickly taken up by the lymphatic system. Functional lymphatic channels are linear and propel the ICG swiftly by contracting and pushing the lymph through one-way valves that do not allow the lymph fluid to flow backwards.
In a lymphedema patient, the ICG is also taken up by the lymphatic system, however movement tends to be slower due to an existing obstruction to lymph flow, causing the lymph vessels to dilate, which destroys the one-way valves and leads to lymph backflow. Depending on the severity of the obstruction and duration of the lymphedema, the lymph can flow back as far as the microscopic lymph vessels in the skin to a variable degree. This is known as “dermal backflow” and is characteristic of lymphedema.
This pattern is seen in both primary and secondary lymphedema. However, in some cases of primary lymphedema when the lymphatic channels are severely underdeveloped, the ICG may just sit around the injection site indicating absence of functional lymph vessels.
What To Expect At Your First Lymphedema Consultation?
You will meet with our lymphedema specialist Dr. Dalia Sattler, one of the very few Plastic Surgeons in Germany who is trained in lymphatic microsurgery and supermicrosurgery. She is also an expert and tutor in the use of Multi-Frequency Bioelectrical Impedance (L-Dex®) and Indocyanine Green Lymphography (ICG).
Dr. Dalia Sattler will start by taking a full medical history and will examine you carefully, which will help to assess your edema and to find the best method of treatment for you. In addition to the detailed standard measurements Multi-Frequency Bioelectrical Impedance (L-Dex®) measurements of your edema will talk place to measure or detect existing lymphedema.
Depending on the findings of the initial investigation Indocyanine Green Lymphography (ICG) for a complete assessment of your lymphedema may also be necessary in some cases because it has the ability to map out the lymphatic channels and give a visual representation of lymphatic channels and their function which is important for any operative planning. The combined results of these investigations will lead to an accurate and objective diagnosis and will help to distinguish lymphedema from lipo-lymphedema and lipedema.
Only a handful of selected centers in Europe offer the above mentioned services which are crucial to formulate an individualized treatment plan in order to achieve the best results possible.