Department of Plastic Surgery, Ninewells Hospital, Dundee, United Kingdom
Prior to the development of suitable pressure garments and the various decongestive therapy techniques, the only option for patients with large lymphoedematous limbs was surgery. A variety of techniques were described in the early 20th century, with some still in use today (Charles & Homan’s procedures).
The draw back of these surgical excision procedures is the significant and unacceptable degree of scarring and cosmetic deformity which can result.
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hey i really have the feeling that world wide, more and more bypass and lymph node transplants are performed every year. they have shown good result in arms too...
From Alex Munnoch's article (link given by Jake52): 'Professor Campisi in Genoa has demonstrated significant improvement in over 1500 patients treated with this technique over the past 30 years. He joins lymphatics to veins in the proximal arm or leg, and has reported over 75% volume reduction in 83% of patients followed up for over 10 years, with many being able to dispense with pressure garments altogether.
Dr Koshima in Japan, however, prefers to perform supermicrosurgical anastamoses at multiple points within a limb through small incisions, often under local anaesthetic. He has demonstrated an average limb circumference reduction of 41% in over 82% of patients.'
As far as I can work out, In England, Alex Ramsden and Dominic Furniss in Oxford and Kelvin Ramsey at the Royal Marsden, London are using the Koshima technique. Campisi's technique involves one main larger incision and he connects some deeper, larger vessels as well as superficial ones. Does anyone have any links or experience as to which is better for hand and arm lymphoedema? (The reductions above are not comparable as far as I can see because Koshima's is limb CIRCUMFERENCE and Campisi's is VOLUME reduction).
My oncologist reviewed this procedure with me (I have lymphedema in my right leg), that's being done in the USA. However, my research showed that the positive results were not guaranteed and in some cases could make the lymphedema worse.
Report from Vicky who was operated on by Alex Ramsden and Dominic Furniss in Oxford:
Alex Ramsden and Dominic Furniss in Oxford
My arm is continuing to improve albeit slowly,but this was how the Surgeons explained it would happen and not to expect miracles.
The lower half is definitely less swollen and softer to touch,it also doesn't ache constantly the way it did! Obviously it is still more swollen the the other arm and I still limit doing anything that makes it swell.......silly things like cleaning,ironing etc,we all have to do these things,but I now do them little bit at a time and then stop.......
There isn't yet much change at the top of arm and I don't really think there will be,as having had the condition for such a long time,it turns to fat,which obviously can't drain away.....but won't give up just yet as its still very early days,and continues to improve over 3/4years!!
You will have to have a dye test to determine if you are a suitable candidate for the surgery,which involves injecting green dye into each side of both wrists which enables them to see both the working and non working lymph systems to see where the problem is?
You will then be told at that consultation if anything further can be done?
That procedure will cost £650 and if suitable for the surgery the costs are high.....Surgeons Fee is £10,000 plus £2,000 for day care room&theatre costs,so around £13,000 for the whole thing!!!
I had it done at The Nuffield Orthopedic Hosp in Oxford,and the surgeons were Mr Alex Ramsden and Mr Dominic Furniss who are both Consultant Plastic Surgeons,and both very nice and will explain everything in detail to you,nothing is too much trouble.
You can google both and read all about them.
The surgery is called Lymphaticovenular Anaestamosis which means they locate suitable lymph nodes and attach them into a vein enabling the lymph fluid to then drain away. It's very intricate surgery and depending on how many connections they can make can last hours. They did 3 on me and it took 6hrs.....all done under local anaesetic with you lying very very still.
A very fair report. I'm glad you found our service was good. One small point is that we don't find lymph nodes. We join lymphatic channels (which are the draining tubes that connect the skin to the lymph nodes and drain the lymph back to the blood stream) to small veins. Otherwise very accurate account of our treatment and service.
I have a post op report written by a lady called Marion, her surgery was performed by Dr Giacalone:for leg lymphodema. Should you wish me to email it to you, please forward your email address.
Great post. I can confirm we use Koshima's technique but also use elements of Campisi's i.e. operating on deep lymphatic channels. One of the problems for patients (and surgeons) in evaluating the techniques available is that everyone tends to use different measuring systems to monitor change in the limb. Circumference is related to volume. Koshima measures on 5 different levels on the limb and relates it to BMI to make an index. Broson (of liposuction fame) measures every 4cm up a limb to construct a volume. Other use a variety of different machines to measure volume. Most practitioners in the UK use the 4cm method to measure volume and fit garments.
At the recent meeting in Barcelona where Koshima, Brorson, Campisi, Dominic and I were present, we decided as a medical community to use a 4cm circumferential technique as a standard for measuring. Dom and I now both use this technique.
Measurement of success is difficult and it is not all about volumes. Softness of the limb is important as is heaviness. Pain is important for some people. For others it is all about hope and stopping everything getting worse and retaining some control over their disease. This elements of lymphoedema are important but difficult to measure. We have started using patient reported outcome measures to try an assess how successful surgery is. I think the surgical community and lymphoedema practioners have an important role to play in developing practical measures of outcomes so different treatments can be reliably measured to guide patients and trials. Unsuccessful treatments would be accurately assess and discounted. For example - kinesio taping has no objective evidence of improvement but some people swear it works. Maybe if it makes you feel better then why not??
Hope that helps but it may just muddy the water? The closer you look the more you realise we don't know!
What are the downsides of this surgery? Are you risking making your condition worse? From what I've read there only seems to be upside, either it works or it doesn't. Is that a fair analogy?
The advantage of LVA and one of the reasons I really like the treatment is that it is low risk. As with any cut through the skin there is a risk of infection and you will be left with scars. Infection rates are low but present. We give antibiotics at the time of surgery as we know lymphoedema patients are at slightly higher risk. Of the 35 patients we have operated on only 1 has infection and that person was on long term antibiotics already due to their multiple previous infections. So overall the risk of infection is low. We use a blue dye that is injected under the skin and persists for a few months as a stain that looks like a bruise for a few months. The risk of making the lymphoedema worse is very low and mainly theoretical. Other than those risks, the main thing people need to understand is that there is a risk that the operation doesn't work and there is no guarantee of improvement. In our experience 85-90% of patients have an improvement. We want to publish our early results now we have got up to reasonable numbers and present them at the BLS conference later this year.
I had surgery 6 months ago, for leg lymphoedema, where I had nodes transplanted from my neck to my groin.
Now it is too early to determine how successful the procedure has been, but my leg is a lot more responsive to compression treatments than before.
Going through this with my surgeon, there is apparently not enough clinical data to date to statistically announce how successful surgery is, in improving lymphoedema, however he suggests that the early evidence points towards the fact that these techniques are a clear benefit, because at worse there is no change in the affected limb. In fact it would seem that lymphoedema affected limbs stand up well to surgery, which goes against initial opinions. My surgeon is happy to see patients under the NHS, however he has said that he cannot publicly offer his services, because the demand is so great, he would not have time to see his other patients. Hence it will not be fair to advertise his services here, but, like me, research who performs the surgery, then contact them directly and ask if they will treat you, then get your PCT to fund it. Yes it is possible people and only when there is enough data
I live in London, but travelled to Essex for the treatment. I believe there has been significant work in the lymph field in the States, but worldwide they are still adapting techniques. If you feel like travelling, Japan seem to be leading it all
The reason we don't operate on patients from North America is that our medical defence bodies will not cover the insurance. Being sued in the US is just to expensive a risk to take for them and so they don't let us.
I did consider this procedure. However, the surgeon in the USA who performs this surgery (lymph node transplant) performed this procedure primarily on post-mastectomy patients, and had little or no experience with lower limb lymphedema patients.
It really seems that the UK has finally caught on to the potential of these microsurgeries.
It feels like we are on the cusp of something and I reckon in a few years time many hospitals will
offer surgeries like this. It makes total sense to me to provide an alternative route for the
trapped lymph, out of the arm or leg - such as happens in LVA microsurgery.
The physical and psychological problems that this horrid condition can cause could be greatly
alleviated by successful surgery. Will the NHS fully offer these services though? It would be logical
that they would, but my brief experience with this condition makes me pessimistic.
All the evidence I've seen,so far, points to the NHS using the cheapest approach that they can get away with (such as off the peg compression garments) and only providing additional therapies such as MLD or CDT when the condition has progressed and got worse. This is the very opposite of what the majority of lymphoedema practitoners seem to advise (ie catch it early and try various therapies to avoid it geting worse, because it is then more difficult to treat).
I have been reading a lot of forums and medical papers about the treatment of lymphoedema (particularly secondary lymphoedema, which I have) with LVA microsurgery and there does seem to be a general consensus between microsurgeons that these techniques can help patients at different stages of lymphoedema and that the very best results have occurred when surgery is performed on patients who haven't had the condition for long and are in the early stages. This is the polar opposite of how the NHS is approaching management/treatment of lymphoedema currently. Lots of info is given to cancer patients, such as myself to try to prevent lymphoedema developing in the first place, but once diagnosed, the only way that I can seem to access treatment through the NHS is for my condition to worsen.
the NHS is interested in the cold world of cost-benefit analysis i.e. how much would the NHS/society save in the long run by treating you with a high up front cost e.g. surgery. If they could keep you out of garments then they might consider it a good investment.
Unfortunately the NHS is trying to cut 5% out of it's budget each year by efficiency savings.........It is not keen to take on new services.
Thanks for your honest reply. Unfortunately it seems from what you say, that it is as I feared... What an irony-that after years of being a neglected group of patients, a really promising treatment arrives; but because the patients haven't had much in the way of resources so far, they'll probably be denied the hope of improvement that they've been waiting for so long...What a frustrating and ultimately tragic state of affairs.
lawstudent has been for a consultation with Campisi, but ended up having her surgery with Guido Giacolone in Belgium.
I have been in contact with Campisi's clinic numerous times. He has years of experience, great results and seems a genuinely lovely, helpful man. I would go to him like a flash if I had enough money!
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