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    Overview

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    Description of the procedure

    Indications and current treatment

    Lymphoedema is the abnormal accumulation of subcutaneous fluid and fat in body tissues. It leads to chronic swelling that can cause disability, pain, and cosmetic issues. Any part of the body can be affected, but the condition is most common in the arms and legs. Lymphoedema can be complicated by recurrent infection (cellulitis), which further damages the lymphatic vessels and aggravates the condition. Primary lymphoedema results from a congenital inadequacy and gradual occlusion of lymphatics. Secondary lymphoedema results from damage to the lymphatic system or removal of lymph nodes by surgery, radiation, infection, or injury. In the UK, one of the most common types of chronic lymphoedema is secondary lymphoedema of the arm after breast cancer or its treatment.

    Current conservative treatments for lymphoedema include manual lymphatic drainage, which stimulates the movement of lymph away from the affected limb, and decongestive lymphatic therapy. Decongestive lymphatic therapy combines manual lymphatic drainage massage techniques with compressive bandaging, skin care and decongestive exercises. Once decongestive lymphatic therapy sessions are stopped, the person is fitted with a custom-made compression garment, which is worn every day for life. These techniques aim to reduce the pain and discomfort associated with lymphoedema. In severe cases, in people with lymphoedema that does not respond to conservative treatment, surgery can be used. Surgery includes liposuction to reduce the size of the limb, and procedures to restore lymphatic flow from the limb. These procedures include constructing an alternative lymph drainage pathway via lymphovenous anastomosis, or through lymph node transfer from a donor site.

    What the procedure involves

    Liposuction for chronic lymphoedema is usually done under general anaesthesia, but regional nerve blockade is also possible. A tourniquet is applied to the proximal limb. A few small incisions are made in the limb. Cannulas, connected to a vacuum pump, are inserted into the incisions and oedematous adipose tissue is removed by vacuum aspiration. Liposuction is done around and all the way along the limb up to the distal border of the tourniquet. The tourniquet is then removed, the proximal limb, unable to be controlled by tourniquet, is infused with tumescent solution, and the fluid and fat from this area are aspirated. Immediately after liposuction, a compression bandage is applied to the limb to control any bleeding and to prevent after surgery oedema. Antibiotics and prophylaxis against venous thromboembolism are typically prescribed before and after the operation. After the procedure, a custom-made compression garment must be worn for life to maintain the volume reduction. This garment is revised multiple times until the oedema volume has been reduced as much as possible and a steady state has been reached, but must still be worn at all times.

    Outcome measures

    Lymphoedema staging

    The International Society of Lymphology classifies lymphoedema into 4 stages:

    • Stage 0: latent or subclinical condition where swelling is not yet evident despite impaired lymph transport, subtle alterations in tissue fluid/composition, and changes in subjective symptoms. It can be transitory and may exist months or years before overt oedema occurs (Stages 1 to 3).

    • Stage 1: represents an early accumulation of fluid relatively high in protein content (for example, in comparison with 'venous' oedema) which subsides with limb elevation. Pitting may occur. An increase in various types of proliferating cells may also be seen.

    • Stage 2: involves more changes in solid structures, limb elevation alone rarely reduces tissue swelling, and pitting is manifest. Later in Stage II, the limb may not pit as excess subcutaneous fat and fibrosis develop.

    • Stage 3: encompasses lymphostatic elephantiasis where pitting can be absent and trophic skin changes such as acanthosis, alterations in skin character and thickness, further deposition of fat and fibrosis, and warty overgrowths have developed.