Surgical management of lymphoedema

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Lymphoedema is broadly described as swelling caused by the abnormal build-up of lymph fluid in any part of the body. It’s mostly caused by surgical removal of, or damage to your lymph nodes as part of cancer treatment.

Damaged lymph nodes and vessels are unable to drain lymphatic fluid sufficiently from the tissue which results in lymph fluid collection, swelling (particularly of the limbs), chronic pain, inflammation, and a feeling of heaviness in the affected areas.

With cancer treatments, the targeted areas of treatment are most often the axilla (armpit) relating to breast cancer and groin relating to bladder or prostate cancer. These targeted areas of treatment most commonly result in swelling of the arms and legs respectively.

CONSERVATIVE MANAGEMENT

It’s best to always consider conservative management before surgical management. Conservative management involves non-surgical approaches aimed at reducing swelling, improving lymphatic flow, and managing symptoms. It’s often the first-line of treatment and is sufficient for many patients, particularly in the early stages of the condition. Common strategies include:

• Compression therapy assists with improving lymphatic drainage and reducing swelling through the daily wear of compression garments (sleeves and stockings), bandaging with multi-layer compression wraps, and pneumatic compression devices (intermittent compression pumps).
• Manual lymphatic drainage (MLD) is a gentle, specialised massage technique that encourages lymphatic fluid to move toward areas with functioning lymph nodes. It’s performed by certified lymphoedema therapists (physiotherapists, occupational therapists, and nurses). Self-massage techniques can also be prescribed by your therapist.
• Exercise and weight management promotes lymphatic flow through muscle activity including low-impact exercises (walking, swimming, or yoga) as well as specific exercises tailored by your therapist for lymphoedema management.
• Skin care prevents infections, such as cellulitis, which can worsen lymphoedema.
• Medication is rarely used, but diuretics or anti-inflammatory medications may be prescribed in specific cases to manage symptoms.

Conservative management often requires a combination of these strategies and is usually overseen by a healthcare team specialising in lymphoedema care.

SURGICAL OPTIONS

If conservative management doesn’t adequately reduce or control your lymphoedema symptoms, surgical options mostly performed by a plastic and reconstructive surgeon may be considered. These include:

• Liposuction is the removal of excess fat caused by lymphoedema. When lymphatic fluid leaks into the surrounding tissues, it can lead to inflammation and stimulate the growth of fat stem cells, which is then removed. Lymphoedema liposuction is only a debulking procedure and doesn’t modify your body’s physiological lymph drainage mechanism. Therefore, a lymph node transfer should be performed a couple of months following the liposuction procedure to prevent re-occurring symptoms.
• Lymphaticovenular anastomosis (LVA) is achievable using advanced microsurgical techniques in a minimally-invasive surgical procedure that connects functional lymphatic vessels to veins in the affected area, allowing lymph fluid to be redirected into the venous bloodstream. This helps bypass the blocked lymphatic network, providing a drainage pathway. The diversion of lymph to the bloodstream is a natural process, as there are inherent connections between the lymphatic system and bloodstream in certain anatomical regions. The purpose of LVA is to address the fluid element of lymphoedema and can be performed at any stage of severity.
• Vascularised lymph node transfer (VLNT) involves transplanting functional lymph nodes from a healthy donor site to an area of the body with a damaged or underperforming lymphatic system. It’s particularly suitable when functional lymphatic vessels for LVA are unavailable. The transfer improves lymphoedema by introducing functional nodes to the affected limb, establishing a new lymph drainage pathway. Common donor sites for lymph nodes include the groin, axilla, and neck. Thorough imaging is essential for identifying the optimal donor lymph nodes. This inpatient procedure typically requires a recovery period of a few days before you can return to normal activities.

While there is no full recovery for lymphoedema, these treatment options will contribute to decreased swelling and discomfort. It’s advised that you talk to your healthcare team about the best treatment options for you.