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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
www.perfuse.net vascular surgery @ amnch
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
www.perfuse.net vascular surgery @ amnch
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?
www.perfuse.net vascular surgery @ amnch
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"
www.perfuse.net vascular surgery @ amnch
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
www.perfuse.net vascular surgery @ amnch
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
www.perfuse.net vascular surgery @ amnch
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
www.perfuse.net vascular surgery @ amnch
Diagnosis
• Clinical assessment primarily
• Consider in all cellulitis (esp >1)– >20%– non pitting– no other cause
• Skin changes usually absent (mild-moderate)
www.perfuse.net vascular surgery @ amnch
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
www.perfuse.net vascular surgery @ amnch
Treatment
Mild
Moderate
Complications
Severe
•Self directed•Lifelong•Support when required
•Lifelong•Multidisciplinary•Proactive
•? Inpatient treatment•? Surgery
www.perfuse.net vascular surgery @ amnch
Mild lymphoedema
• Advice– skin care– early antibiotics– compression– elevation– exercise– weight loss
www.perfuse.net vascular surgery @ amnch
Mild Lymphoedema
Skin care• Wash & dry daily• Regular emolients
– 50:50– Emulsifying ointments– Avoid steroids– Avoid topical antibiotics
www.perfuse.net vascular surgery @ amnch
Mild Lymphoedema
Cellulitis• Early oral antibiotics
– Gram positive
– Ciprofloxicin
– Clarithromycin
• IV antibiotics• Elevate
www.perfuse.net vascular surgery @ amnch
Mild Lymphoedema
Compression• Grade 2 or 3• Below knee may be
sufficient• Early refit• 3 monthly• ?full length• ?custom
www.perfuse.net vascular surgery @ amnch
Mild Lymphoedema
Exercise• daily• with stockings• weight loss
Elevation
www.perfuse.net vascular surgery @ amnch
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
www.perfuse.net vascular surgery @ amnch
Multilayer bandaging (MLB)
• Full length
• Short stretch• Standard application• ? Digits• Daily (? 2-3 days)
• Duration 2-6 weeks
www.perfuse.net vascular surgery @ amnch
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 garmentsIssues• 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
www.perfuse.net vascular surgery @ amnch
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
www.perfuse.net vascular surgery @ amnch
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
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Surgical treatments
• Excisional– Excisional Surgery– Liposuction
• Reconstructive– lymphatic microsurgical anastomosis– tissue transfer
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Excisional surgery
Surgical Tutor
Historical interest only
? Severe soft tissue infection
Poor outcomes
www.perfuse.net vascular surgery @ amnch
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.
www.perfuse.net vascular surgery @ amnch
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…”
www.perfuse.net vascular surgery @ amnchlymphoedema.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.…”
www.perfuse.net vascular surgery @ amnchlymphoedema.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… ”
www.perfuse.net vascular surgery @ amnch
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
www.perfuse.net vascular surgery @ amnch
Surgical treatments
• Excisional– Excisional Surgery– Liposuction
• Reconstructive– lymphatic microsurgical anastomosis– tissue transfer
www.perfuse.net vascular surgery @ amnch
Lymphovenous reconstruction
• 8 trials (none randomised)• N=9-100
– except Genoa, >1000)
• Combined with compression• 2-60% reduction in limb
volume• unproven
www.perfuse.net vascular surgery @ amnch
Tissue transfer
• Transfer of lympatic rich tissue to limb
• 4 studies (<60 patients)
• Variable results
• Unproven
www.perfuse.net vascular surgery @ amnch
Lymphoedema
• Life-long chronic condition
• Empowerment• Preventative
– skin care– antibiotics– compression
• MLD/MLB• Surgery rarely
appropriate