Tweets from the BLS (2) – Other surgical options

[LVASurgeon]

@Oxford OLP

Oct 5

Munnoch: Liposuction only if patient is fully compliant with garments 24/7 ‪#lymphedema‬‬‬ ‪#BLS2014‬‬‬

Most of my patients want to get rid of their compression ‪#lymphedema‬‬‬ ‪#BLS2014‬‬‬

Ramsey: 60% patients undergoing lymph node transfer patients have decreased lymphatic function in donor limb ‪#lymphedema‬‬‬ ‪#BLS2014‬‬‬

I have discussed microsurgery for lymphoedema extensively on this forum over the last few weeks, so I think it is only fitting that my final post discussing developments from the ESL and BLS meetings covers other surgical options. Essentially, they fall into two categories: Liposuction and lymph node transfer.

Alex Munnoch from Dundee discussed his experience with Liposuction. The rationale here is that the presence of fluid drives the laying down of excess fat in the limb in the later stages of lymphoedema. The procedure therefore removes this excess fat, reducing the limb to normal or near-normal size.

Please note that this is very different to cosmetic liposuction, and certainly very different to “micro-liposuction” that some cosmetic surgeons might offer for lymphoedema. This procedure was pioneered by Hakan Brorson in Sweden, and any surgeon offering this operation should have been to Sweden to train with him.

This is major surgery done under General Anaesthetic, with a weeklong stay in hospital afterwards. Complications are relatively infrequent, but can be serious. Results are good, with arms or leg being reduced back to normal size. But (there had to be a but…….) the major drawback of this surgery is highlighted in my tweet - Liposuction only works in the long-term if the patient is fully compliant with garments 24/7. As soon as the patient stops wearing garments, the fluid re-accumulates, and the lymphoedema recurs. This is because the underlying problem that caused the lymphoedema hasn’t been addressed as it is with LVA. Most of my patients want to be rid of their garments more than anything, so most would not be suitable for liposuction.

Anne Dancey from Birmingham spoke about lymph node transfer for lymphoedema. Here, under General Anaesthetic, a lymph node is taken from an area unaffected by lymphoedema and placed into the area that is affected. It involves a 5-7 day stay in hospital after the procedure. There is then a process known as lymphangiogenesis (possibly), which improves lymphatic function. No-one really knows how this operation works. No-one has demonstrated lymphangiogenesis, or improved lymphatic drainage from the affected limb. There are some studies showing some effectiveness, but they are not high quality, and more work needs to be done.

There is also one further problem, highlighted by Kelvin Ramsey from London highlighted in my other tweet - 60% patients undergoing lymph node transfer patients have decreased lymphatic function in donor limb. This means that people who are already suffering with lymphoedema in one limb run the risk of developing lymphoedema in another limb that is currently normal. Again, most of my patients do not want to take this risk.

Given these considerations, it can be seen why LVA, a minimally invasive procedure performed under local anesthetic as a day case is the procedure I have adopted. The physiology of the procedure also makes sense to me (see my post on “How does microsurgery work?’).

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

[syrup01]

LVASurgeon

The lymph node transfer is a procedure carried out extensively in the Far East where the results are significantly better than the 60% figure you are quoting. Matt Griffiths at the Broomfield has performed this surgery on me, having travelled to the four corners seeking best practice. My donor site was my neck, which is apparently a much better donor site than another limb, plus as long as care is taken to avoid the sentinel lymph nodes, then the risks of reduced lymphatic function from the donor site is greatly reduced.

On another note - one big advantage to the liposuction is the opportunity it gives the surgeon to reshape the limbs.

[LVASurgeon in reply to syrup01]

Dear Syrup,

I agree that many surgeons are performing lymph node transfer, especially in the States and Far East. I am still to be convinced that there are benefits over and above LVA, and the risks are certainly higher.

Matt is a terrific surgeon, so I am sure you will get a good result.

Best of luck!

[shanty]

Thank you for taking the time to post. It is certainly interesting to have a health professional keep us informed of remedies and progress in the field. There are I am sure many contenders for LVA on this forum but the procedure remains inaccessible until it is approved by NICE and available to NHS patients.

[LVASurgeon in reply to shanty]

Dear Shanty,

I agree this is a big problem. We are working hard to show the benefits so that the NHS/NICE will take note. Patients demanding the surgery and "making a noise" politically will help too!

[lovesradio]

It is great to read about all the procedures that are being tested to inprove outcomes for us lymphies and give us hope for a future where newly diagnosed lymphies can be offered more than massage,compression garments and skin care regime. Not that these don't work, along with yoga and swimming I am now considered as a 'self management' lymphie but I know from this forum that others have not been as lucky as I have with my early diagnosis and fabulous physio in Fife, Scotland.