Tweets from ESL (5) – How does Microsurgery work?

[LVASurgeon]

@Oxford OLP

Sep 26

Lymphatic occlusion pressure is around 80mmHg. That is how we get flow from lymphatic to vein ‪#Lymphedema‬‬ ‪#Microsurgery‬‬ ‪#ESL‬‬ 2014 Genoa

Success of ‪#microsurgery‬‬ for ‪#lymphoedema‬‬ depends on number of anastomoses - need multiple surgeons like at Oxford Lymphoedema Practice

Sep 27

Microsurgery seems to be the best way to prevent ‪#Lymphedema‬‬ Need to start ‪#screening‬‬ after ‪#breastcancer‬‬ and other ‪#cancer‬‬ treatment

How does microsurgery work is a very important question! In order to answer it, we need to know about the function of the lymphatic system. Each day, around 3 litres of fluid is lost from our blood stream by being filtered out in our capillaries. These are the tiny blood vessels that are found in every part of our body. The fluid has an important function – to deliver oxygen and nutrients to every cell in our body, quite simply it keeps us alive.

However, we only have around 5 litres of blood in our body, so we can’t simply lose this 3 litres per day into our tissues, we need a way of returning it to the bloodstream. This is what the lymphatic system does. It absorbs this fluid, and actively pumps it back up your arm or leg, through bigger and bigger channels, until it reaches a vein in your neck, where it releases the fluid back into the bloodstream.

I am sure everyone will remember from schooldays, that for fluid to flow in a particular direction, there must be a pressure gradient. Think of the weather maps you see on TV, the wind always blows from an area of high pressure, to an area of low pressure. It is the same with lymphatic fluid flowing into the blood – the normal lymphatic pressure is higher than the normal venous pressure, allowing the fluid to be returned to the bloodstream.

In secondary lymphoedema, there is a problem with this system, usually caused by surgery or radiotherapy to the lymph glands. This causes a blockage in the system, and increases the lymphatic pressure further. Lymph fluid tries to find a different route out of the limb, but this is not so efficient, and fluid therefore builds up. I find it helpful to think of cars travelling on a motorway. If there is a crash, and the motorway is closed, cars start to back up, and then they will start to leave the motorway and travel on the A roads and B roads to reach their destination. This journey is not as efficient as if the motorway was still open.

However, when thinking about microsurgery, we must keep in mind what the destination is – the blood stream. What if we could build a bypass around the blocked motorway, that lead straight to our destination? Wouldn’t that be fantastic? Well, that is what microsurgery for lymphoedema achieves. We perform LVA (lymphaticovenular anastomosis) that joins the lymphatics just under the skin to tiny veins found near the lymphatics, returning the fluid to the blood stream without it having to go past the blockage.

Jean-Paul Belgrado from Brussels, demonstrated with a transparent tourniquet and ICG lymphography that the occlusion pressure of lymphatics is around 80mmHg – this is much higher than venous pressure at around 10mmHg.

It was also emphasized in this session that for microsurgery to be effective, multiple bypasses should be completed. This makes sense – the more bypasses you open up, the better the relief of the congestion. It is also likely that some of the bypasses will fail for technical reasons. If you only have a few bypasses and some of them fail, this could be critical to the outcome of surgery. However, if you have a lot of bypasses and some of them fail, there might well be more left open to do their important job. For this reason, I would always recommend choosing a team of experienced surgeons for your microsurgery operation – more surgeons equals more bypasses in the same amount of time, critical to success. This is one of the reasons single surgeons can struggle to make microsurgery work in the treatment of lymphoedema.

If you would like to follow me on Twitter, please search for @OxfordOLP.

There is also a lot of information available on our website olp.surgery

[Rebec]

I understand the work you and surgeons like you are trying to achieve in order to tryand improve people's lives, but I wonder whether there shouldn't also be a way in improving cancer treatments so that the lymphatic system won't have to suffer in the first place.

[Athinakay in reply to Rebec]

I agree! My surgeon and her MDT decided for me to have surgery first although my tumour was large (51mm).In retrospect, if I had neoadjuvant maybe the one lymph node that was positive would have cleared and the tumour would have shrunk so the surgery would not have to be so invasive and I would not have had 29 lymph nodes removed although only one was positive. I was told that I was going to have clearance I and without my knowledge or concent, I had clearance II. When I asked about it, she said, well it is only 20% more. Yes, 20% more impearement!That was the attitude towards my lymph nodes especially on the left side which controls the majority of the clearance to my body...

The problem with care is that it is highly fragmented MDTs or not.

Nobody sees the side effects as their responsibility or something that can be avoided. I get the feeling that in their eyes we should be thankful we are alive and should put up with whatever the treatments leave us with. The only preson who showed any concern for side effects through my entire treatment was my oncologist. And I had two surgeries, chemotherapy and radiotherapy followed by hormone treatment so been around many blocks and clinics.

[Rebec in reply to Athinakay]

When I discussed the necessary treatment/s after my operation (I had all my nodes removed) with my oncologist, he showed me what a small percentage of people have their life extended having chemo and radiotherapy. At this stage nobody mentioned lymphoedema. I know that, following research, now not everyone, following breast cancer operation, has to have chemotherapy, and also radiotherapy has been reduced, I think only in some cases, from six weeks to only three. I was ready to go through a total mastectomy in oder not to go through radiotherapy. Women need to be made aware of the lifelong problems attached to having such an operation because of the treatments following it, and make them check themselves for lumps one of the most important routine in their life.

[Athinakay in reply to Rebec]

Radiotherapy is still 5 weeks for those of high risk. In regards to educating and informing, when I asked the senior breast care nurse ( after I developed cording ( Axillary Web Syndrome ) which is a warning sign for lymphedema, she said that they do not measure patients so that they do not think they will get lymphedema! Such is the denial and lack of understanding of lymphedema. If caught early ( even before it manifests itself ), it is much better and prepares yourself to what is to come...

[Rebec in reply to Athinakay]

That's true and this is what the surgeon above is trying, with fellow surgeons, to accomplish.

[Health1919 in reply to Athinakay]

I agree with - "Nobody sees the side effects as their responsibility or something that can be avoided. I get the feeling that in their eyes we should be thankful we are alive and should put up with whatever the treatments leave us with."

[bwatt1]

This is a really helpful explanation of the condition. Thank you! I am just wondering if you could explain why some patients with secondary lymphoedema are more receptive to your micro-surgery than others? Perhaps I have got confused with different surgery, but I thought I had read somewhere that this surgery does not suit everyone? If so, What are the criteria you are looking for which gives you the confidence to proceed to surgery?

Also, do you have lots of people you have successfully performed your micro-surgery on who can provide some feedback?

Many thanks for any info you can provide

[lovesradio]

Bwatt1 has said exactly what I was about to post!!! I wish this had been available when I went for breast cancer surgery in 2007!

[LVASurgeon]

Dear All,

Many thanks for the interesting discussion.

I agree that the majority of patients who I see feel that their "cancer team" underplay lymphoedema, and often have the feeling that they have successfully treated the cancer, so the patient should be grateful, and stop moaning about their lymphoedema. This is sad, as lymphoedema does affect quality of life, and early recognition and treatment can prevent complications and the effect on quality of life. If we get patients early (through screening or early presentation to us), we can reverse the early changes of lymphoedema, and prevent the need for conservative measures (compression, MLD etc).

There are some people on this forum who have had microsurgery performed by our team. I can't put you directly in touch with them as I have to respect confidentiality, but if you look around you should be able to find them. We have done the most cases in the UK (not up to the levels of Genoa or Tokyo, though!). There is definitely a learning curve (our patient selection has improved, and our surgical technique has finessed).

I would also say it is vitally important to have more than one surgeon operating on you, so that the maximum number of joins (anastomoses) are performed.

With regards to patient selection - ICG lymphography (olp.surgery/icg-lymphography) is vital to determine the anatomy of your lymphatics, and how well they are functioning. Don't go for surgery without having this done first. Despite this, we sometimes find very damaged lymphatics (sclerotic lymphatics) during surgery, that aren't really pumping much fluid. This means that despite joining them on successfully, we don't achieve such a good result. This can only be determined at surgery, though the ICG scan can give us some pointers. I estimate we only operate on around 1/3 to 1/2 of patients who come to our clinic.

I hope this is helpful, and do look out for further posts coming soon. Please also share these posts with any local support groups, cancer groups, on twitter etc. We need to get the message out there!

If you would like to follow me on Twitter, please search for @OxfordOLP.

There is also a lot of information available on our website olp.surgery

[lisagp]

Is microsurgery ever an option for a patient with lymphedema distichiasis?

[LVASurgeon in reply to lisagp]

Hi lisagp,

The patient would need to be very carefully evaluated in clinic, including a scan of their venous system looking for reflux. If venous pressure is increased by venous valvular incompetence (common in lymphoedema distichiasis) , the likelihood of success is much less.

Hope this is clear!

If you would like to follow me on Twitter, please search for @OxfordOLP.

There is also a lot of information available on our website olp.surgery

[lisagp]

Thanks LVASurgeon. Alas, that is what I thought. There is venous insufficiency as well.

[Rebec]

Hi, I was wondering whether a surgeon like you, specialising in micro surgery, shouldn't operate on the lymph nodes while a breast surgeon deals with the cancer growth as in this way, many unaffected lymph nodes might be left in situ. Radiotherapy could, after the operation, destroy any cancerous cells which might have escaped from the nodes and this way, reduce by quite a lot the worry of developing lymphoedema afterwards. Am I talking rubbish or could this be something feasible?

[LVASurgeon]

Hi Rebec,

Sounds like a good idea, but there are 2 problems:

1. We can't see which lymph nodes are affected with cancer by looking at them. Clearly, the cancer surgeon (and radiotherapist and oncologist) want to give their patients the best chance of being cured.

2. Radiotherapy produces scarring (progressive for years after the treatment course) that in itself causes the blockage to lymphatic drainage leading to lymphoedema.

For me, the best approach is for patients to complete their cancer treatment in the usual way, then come for screening (with ICG Lymphography, as it is radiation free) around 3 months after their treatment is over. If this is all clear, they can continue to be screened 3 monthly for around 3 years (the peak onset of lymphoedema is in the first 3 years after cancer treatment). This will allow early signs of lymphoedema to be picked up (often before any symptoms), and intervention with LVA to be performed very early to prevent the need for other treatments and deterioration of the lymphoedema.

If you would like to follow me on Twitter, please search for @OxfordOLP.

There is also a lot of information available on our website olp.surgery

[pushkin]

LVA surgeon....good morning. I live in Ukraine where I have recently had the complete removal of my left breast as the lump was too close to the nipple. Soon I am supposed to undertake some radio therapy.... 20 days of 2mins very low level. I have been assured by my surgeon that there are no side effects as I was quite anti any form of radiation.( I have had lymphoedema for twenty five years caused by mismanagement ( make that non) of an accident at a hospital in New Zealand. ) My question to you is could the lymphoedema be further componded by this proposed radio therapy which my surgeon recommends me to have as an insurance policy? I have an extremely swollen and somewhat numb left arm mainly from the elbow to fingertips as a result of severely banging my ulnarve on a ahrd chait just as I was leaving hospital. I have been using Troxevasin gel on it but with limited success, Is there anything else better I could be doing? I am a very very active person and having to slow down is annoying the h---l out of me and I am feeling so frustrated as I enjoy a very full outdoors life. I am not spring chicken but neither am I ready for the knackers yard! I would very much appreciate some comments.

[LVASurgeon]

Dear Pushkin,

Sorry to hear about your troubles.

Whether the radiation therapy will worsen the lymphoedema depends on where is being irradiated. If it is just the breast, then it shouldn't make things worse. If it is the armpit (axilla) then it may well make things worse.

With regards to your painful arm / ulnar nerve, I think you are doing good things. Some patients with an irritated ulnar nerve find that sleeping with padding wrapped astound the elbow (eg a towel wrapped around it) cushions the nerve, and helps the arms to stay straight (which takes the tension off the nerve).

I hope that is helpful. Best of luck!