Questions for Oxford Lymphoedema Practice

Questions for Oxford Lymphoedema Practice – June 2019

The following questions were posted from the Official Lymphie Strong Inspiration Group for Lymphedema. For more information on surgical options, visit http://olp.surgery/ to request a consultation. Note: This site has a disclaimer. The answers presented below are for informational purposes only.  


1. Thank you for being with Lymphie Strong.  Question: I recently scheduled a lymph transfer surgery…while under the surgeon presented images of my arm that showed no live/active lymph in my arm from the dye test. The image of my arm was a solid grey mass of nothing. The transfer was not completed because there was no viable lymph to work with. Does this mean my arm will never ever have active lymph again? Once they are dead are they always dead? Thanks!

 

Unfortunately, this means that your arm will not have lymph flow again. The lymphatic channels have degenerated to such an extent that they have stopped working. The mainstay of treatment moving forward will be compression therapy to limit the amount of fluid that accumulates. Liposuction can be used to reduce the size of the arm to close to normal, as compression will need to be worn anyway.

 

 

2. What are the risks of the surgery to impact flow in a negative way or cause lymphedema elsewhere? 

 

I am assuming this question means for lymph node transfer surgery. We are very careful to take lymph nodes only from areas of the body that don’t suffer from lymphoedema – inside the abdomen (omental flap); or the right side of the neck (supraclavicular flap). This minimizes as much as possible the risk of getting lymphoedema somewhere else. Some surgeons take lymph nodes from the armpit (axilla) or groin (inguinal) regions. Each of these has a small chance (probably around 1-2%) of causing lymphoedema in the arm or leg respectively. We prefer not to take this risk.

 

3. Question: My insurance has approved me for lymphovenous anastamosis (LVA), but has denied coverage for suction assisted protein lipectomy (SAPL), saying that they consider it “experimental” for lymphedema. Can you discuss the differences between those procedures, provide some guidance on when SAPL is appropriate, and perhaps give some advice for how to make the case for SAPL to an insurance company? Thanks in advance!

 

It is very unlikely you would be suitable for both LVA surgery and liposuction, they are different operations used in different stages of lymphoedema. Neither are experimental, having been in use for over 20 years worldwide. Convince your insurance company by referring them to the works of the pioneer HakanBrorson. Go to https://www.ncbi.nlm.nih.gov/pubmed/?term=Brorson+h+AND+lymph*

We are refreshing our website, and hope to put some of these papers online soon.

 

LVA – this is used in early stage disease to deal with the fluid element of lymphoedema. Functioning lymphatic channels are joined to functioning veins in the arm or leg, bypassing the blockage in the system. If the patient has had lymphoedema for a long while, the lymphatics degenerate and lose their ability to pump fluid, so this technique is no longer useful. ICG lymphography should be used to test whether the lymphatics are still functioning and are therefore suitable for LVA surgery.Successful LVA surgery improves lymphatic function, and therefore the dependency on compression goes down, and some patients don’t need any compression or massage at all afterwards.

 

Liposuction – the fluid that accumulates in lymphoedema also contains proteins and growth factors that cause the fat in the arm or leg to get bigger. When the lymphatics have degenerated at this late stage, the patient is often left with a larger limb that doesn’t go down with rest and elevation, and is “non-pitting” – this is fat accumulation. The only way to deal with this late stage fat accumulation is by liposuction. The liposuction does not reconstruct the lymphatics, so compression needs to be worn 24/7 afterwards.

 

 

4. I have primary lymphoedema in my foot. How do I know if I am a candidate for the surgery?

 

We have seen many patients with primary lymphoedema, and only around 5% are suitable for reconstructive microsurgery. The pattern you describe, where there is localized lymphoedema of the foot, is never suitable for reconstructive microsurgery, as there are no functioning lymphatics beyond the area that is problematic that can be used to bypass the affected area. The patients with primary lymphoedema who do benefit have a problem higher up, for example in the thigh, meaning the lymphatics in the calf can be used to bypass the problem area.

 

5. I am a secondary LE patient which affects my right leg toe to hip. Do you see more successful surgeries/results with LVA alone or LVA plus node transfer. If there are better results when node transfer is included-what are the risks of developing LE in a different area of the body as a result of the node transfer?

 

 

The decision as to whether to add LNT to LVA is a very personal one, and we would create a bespoke treatment plan with each patient depending on their goals, expectations, and ICG scan results. Usually, our patients opt for the lower risk LVA surgery alone, and if they don’t see a satisfactory result by 1 year, then opt for LNT surgery. If we offer LNT surgery as the primary procedure, we always add in LVAs at the same time, as we have multiple surgeons performing the operation anyway, so the addition of some LVAs doesn’t lengthen the procedure or increase the risks.

 

 

6. Question:  I have secondary lymphedema in my left arm, hand and truncal area.  I had a lymph node transfer 2years ago that has helped my arm/hand tremendously.  However, my trunk area is difficult to manage and feels like it is getting worse.  I was told that LVA will not work in this area.  Are there any other options to help truncal lymphedema?  Thank you!

 

Often truncal oedema is secondary to radiotherapy, andperforming supermicrosurgery in an area previously treated with radiotherapy is very difficult. LVA in the trunk area in general is indeed difficult, and the results are often unpredictable. However, it has been done, and has sometimes showed positive results. ICG lymphography of the trunk would be a vital investigation before embarking on surgery in order to define the lymphatic channels that can be targeted.

 

 

7. What are the criteria for people with stage 1 in lymphedema in thigh?

 

Patients with Stage 1 lymphoedema in the thigh are usually ideal candidates for LVA or LNT surgery. The earlier the better, before the lymphatics undergo their inevitable degeneration. ICG lymphography would confirm that the lymphatics are functioning well, and are therefore suitable for reconstructive microsurgery. 

 

8. Do you think technology will ever evolve enough to be able to develop artificial lymph nodes much like we’ve been able to develop artificial hearts? (My dream!!)

 

My dream too! I fear that I will be long gone from this World before this becomes a reality!

 

 

9. I would also like to know if there are any options for secondary truncal lymphedema.

 

See above.

 

 

10. My question is are there any indicators that would make surgery not a good option such as weight, sedentary employment,  age, frequent infections?  Thank you for arranging this event!

 

It is a pleasure! 

 

Frequent infections: All of the modern surgical treatments for lymphoedema (LVA, LNT, and liposuction) have been shown in scientific articles to reduce the risk of getting infections, by something like 80-90%. So frequent infections is actually a really good reason to have surgery.

 

Age and sedentary employment are not contraindications at all. 

Weight is a relative contraindication. We certainly see better effects on people of normal weight. If a patient is overweight or obese, then their risks from having a long operation under general anaesthetic (like LNT or liposuction) are higher than someone of normal weight.

 

 

11. Would this surgery work for someone whose ICG showed a diffuse pattern from long-term swelling in the feet? I have primary lymphedema that is mostly in my feet. How soon can results be noticed? Does super microsurgery yield significantly better results than microsurgery?

 

As I mentioned above, microsurgery is not helpful in cases where there is just diffusion in the feet – there are no functioning lymphatics to work with to reconstruct. 

 

Microsurgery describes surgery that requires a microscope (rather than the naked eye) to be performed, typically joining together vessels (arteries and veins) that are 1-4mm in diameter. LNT uses these techniques. Supermicrosurgery describes microsurgery on smaller vessels, typically 0.2-0.8mm in diameter. Lymphatics are this size, hence LVA surgery is often described as supermicrosurgery. This requires special training and experience, as well as special equipment and sutures. 

 

12. Thanks, Veronica! I follow them on FB too. My question would be about super microsurgery LVA. Do you prefer multiple site LVA up and down the limb or a single site, proximally, doing several LVAs in one larger incision? Which have you had better success with?


We do as much as we can on all patients. We always operate with two surgeons (sometimes 3) and use multiple incisions, including one high up where we put multiple lymphatics into a slightly larger vein. We certainly think that you must use several incisions, as sometimes we see brilliant functioning lymphatics further down the limb (say in the ankle and knee) but higher up the lymphatics have degenerated and aren’t transporting much fluid at all (say in the groin). In those patients, if we had just used a single groin incision, they wouldn’t have had a good result. 

 

Similarly, sometimes we will concentrate our surgical efforts on one part of the arm or leg. For example, if someone has only hand swelling, why treat above the elbow? Bespoke care based on patient needs and goals, and ICG scan results is what is required to get the best result for every patient.

 

“Don’t put all of your eggs in one basket”

13. Is this option only for severe cases or mild cases too?

 

LVA is best performed as early as possible in the disease, before the lymphatics start to degenerate. If you have mild lymphoedema, you are the ideal candidate, and there is a possibility it could be so successful that you wouldn’t need to wear compression at all again – we have several patients who consider themselves cured. LNT is similar, but tends to be reserved for slightly later stage disease, as it is a bigger operation with more risks involved.

 

Liposuction is used in the end stage of disease. It increases the reliance on compression, but is very reliable at equalizing the size of the arms or legs. Because it doesn’t reconstruct the lymphatics, the reliance on compression increases after the operation. 

 

The choice between reconstruction and liposuction is a very personal one, and we offer a bespoke treatment package based on the stage of disease, patient goal and expectations, and importantly ICG lymphography scan results.