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UPDATE!
Micro-lymphatic Surgery for Lymphedema
By Denise Hardy, BSc., RN, Clinical Nurse Specialist - Kendal Lymphology Centre. Nurse Advisor to the Lymphoedema Support Network, Vodder-certified therapist, England, UK
“The ideal surgical
treatment of
lymphedema would
be to return the
swollen limb to its
normal size with
minimal scarring and
a near perfect
cosmetic result.”
Searching for a ‘cure’ for lymphedema is foremost
in the minds of many patients – preferable to the consuming daily management program inflicted upon them.
However, although present conservative treatment
options are not ideal – they are on the whole, deemed
preferable to the often unsightly limbs that many
health care practitioners have seen as a result of
surgical intervention. Figure 1 – illustrates a
‘Homan’s’ operation (a de-bulking procedure) that
failed to heal; the patient subsequently required
amputation.
Other such procedures, which can result
in extensive scarring, often help reduce a limb
initially, but cause further problems years later.
Liposuction for breast cancer related lymphedema is
a relatively new surgical procedure that has shown to
stabilize stubborn swelling (now being extended to
leg lymphedema patients); but availability in the
UK is very limited and long-term results are still
being evaluated.
So when one of my patients was referred to Professor
Baumeister in Germany for a ‘lymphatic transplant’,
I was intrigued (if not a little apprehensive) about
what this intervention would entail. Although I had
met one patient who had undergone such surgery and
assisted in providing postoperative garments, I had
not been personally involved prior to the surgery and
therefore had no real insight into such procedures.
Figure 1: Homan’s operation that failed to heal postoperatively
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Case Study
I first met AB when I set up my independent
lymphedema practice in 2004. She is a 57 year old
lady who suffers from left leg lymphoedema relating
to ilio-inguinal nodal stenosis (determined by
lymphscintigraphy). There were no obvious
contributing factors and although initial Combined
Decongestive Therapy (CDT) worked well (the leg
was reduced to just 8% larger) and was maintained at
this level for over a year, AB began to experience the
following problems:
1. Recurrent infections despite prophylactic
antibiotics. After each episode when antibiotics
(Clindamycin) were doubled, the leg became
larger and more difficult to reduce using
conservative methods.
2. Acute, intermittent, debilitating pain in the leg
which usually started with pins/needles or
numbness during exercise. Only rest and elevation
would relieve the pain which was thoroughly
investigated but no apparent cause found.
3. A purpuric rash – particularly evident on the inner
aspect of the lower thigh. Subsequent biopsy
showed no capillary haemorrhage and it was
finally diagnosed as ‘pigmented purpuric
dermatosis’.
4. Increased circumferential limb measurements –
particularly distally, but proximal measurements
(until recently, minimal) began to increase despite
AB being extremely compliant with all aspects of
her lymphoedema program (which included
regular sessions of MLD).
I suggested that AB seek Professor Mortimer’s
opinion and it was following his consultation and
subsequent investigations of her symptoms that a
referral was made to Professor Baumeister in
Munich. He has been performing micro-surgical
techniques for both cancer and non-cancer related
lymphoedema for many years with good success
rates. His pre-requisites for surgery are:
• The patient has to be 6 months post initial
surgery (e.g. post mastectomy)
• The patient must have had CDT for 6 months
with no significant improvement (or have an
excess volume of 50%)
• There should be no evidence of disease (cancer)
regression
• There must be patent lymphatics of the host
(normal) limb
• There must be general fitness for surgery
Following further intensive lymphscintigraphy studies
(to ascertain that there were patent lymphatics in the
host limb) and a lengthy consultation with the Prof., a
decision was made to proceed with micro-lymphatic
surgery.
AB kindly gave me her permission to accompany her
to observe the surgery first hand and it was a privilege
to therefore follow her through this pioneering surgical
intervention in this country, anyway!
The ideal surgical treatment of lymphedema would be
to return the swollen limb to its normal size with
minimal scarring and a near perfect cosmetic result. In
AB’s case–reducing the swelling was not the priority;
more it was to reduce / stop the pain and frequency of
infections that was making her life so miserable.
Reducing the swelling would be a bonus. Professor
Baumeister felt confident that these goals could be
achieved–though he warned that the surgery is not a
cure. He explained that the most that can be achieved is
to return the lymphoedema to stage 0, the latent stage
(where although there will be no signs and symptoms
of lymphedema, the transport capacity will remain
subnormal and that compression will be a probability
for life). Being familiar with compression garments,
AB had no reservations or second thoughts about going
ahead. She felt she had nothing to lose as her current
treatment regimen was not improving her condition at
all.
The Surgery
AB was admitted to the ‘Klinikum Grobhadern’ in
Munich, the day before surgery. The usual pre-surgical
observations / investigations were carried out,
including circumferential measurements of both legs
taken at 4 cm intervals.
Once AB was anaesthetized, dye was inserted into the
web spaces of the toes on both limbs so that the
lymphatics could be more easily visualized; but a
microscope with 40x magnification was also used to
assist with this extremely delicate procedure.
A small incision was made on the inner aspect of the
upper thigh on the swollen (left) leg and once the main
lymphatic channels had been identified, a plastic rod
was placed under the selected vessels to ensure easy relocation.
Figure 2: Shows how the harvested, healthy
lymphatics are transposed through the symphysis and
joined to the ascending lymphatic vessels in the
swollen leg.
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The vessels are generally thickened and grey–
rarely prominent or distended and when excised, the
lumen is filled with clear fluid.
Harvesting of healthy lymphatics then takes place in
the host (normal) leg (Figure 2). 2-3 (of the 6-17)
lymphatic collectors of the ventral-medial bundle in the
thigh are located and selected as grafts. These often (as
in this case) have 2 afferent branches, which give 3-5
sites for peripheral anastomosis. The grafts are
prepared from junctions at the groin and knee, up to 30
cm long.
Anastomosis of these healthy lymphatics then takes
place. The donor grafts stay connected with lymph
glands in the groin, but are cut at the knee and inserted
into a plastic tube. They are then pulled through the
subcutaneous symphysis and joined to the chosen
ascending lymphatic vessels in the swollen leg. Vessels
are then sutured end-to-end using absorbable suture
material not visible to the human eye!
Lymph movement within the vessel is visible almost
immediately.
The small (8 cm) wound on the swollen leg and the
longer (approx. 30 cm) is then sutured together
(Figure 3). Professor Baumeister then bandages both
legs using long stretch bandages).
This involves elevation and bed rest for 4 days, 2 weeks
in hospital with elastic (long stretch) compression
bandaging replaced daily, specific exercises with
physiotherapy and prophylactic antibiotics.
A Class 3 flat-knit custom-made compression panty was
fitted on discharge and recommended for at least 6
months.
Interestingly, Professor Baumeister has not found pre or
post op MLD to be of any benefit in the patients he has
treated.
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Figure 3: Scars well healed 2 months post op
Post Operative Care
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AB experienced very little pain or bruising apart from
tenderness around the symphysis pubis and her post
operative recovery was unremarkable (though the blue
dye remained in the legs for many weeks later). She was
more than ready for discharge 12 days later when the
hosiery was fitted. Her stay had been difficult only in
regard to the language barriers–though it is has to be
said that the staff knew far more English than we knew
German. The staff were friendly and caring and
endeavored to make her stay as pleasant as possible.
The lymphedema measurements were reduced on
discharge (predominantly due to the long stretch
bandaging) but subsequently regressed slightly upon
wearing the garment (usual post-bandaging rebound).
However, they soon stabilized and continued to
gradually reduce over the next few months.
Almost 1 year on, apart from one brief episode, AB has
not experienced any pain and has not had any further
attacks of cellulitis which were so troublesome prior to
surgery. Circumferential measurements have continued
to gradually reduce and at her last appointment, 11
months post op, the limb measured 18% larger as
opposed to 57% pre-surgery. The limb shape has
improved and is maintained by a Class 3 flat-knit,
thigh-high garment (which AB prefers over circular knit
garments).
The scars have faded, general skin color is vastly
improved, the subcutaneous tissues have softened and
the purpuric rash has started to recede. AB is delighted
and feels her quality of life has improved dramatically.
She is able to walk for long distances and exercise
without pain or regression in swelling and generally
feels so much better without the debilitating effects of
recurrent infections.
The surgery (including 12 nights stay in hospital) cost
around 9,500 Euro (approximately $12,500) and
although funding was sought from the Primary Care
Trust, this was subsequently refused.
Comment from Professor Weissleder
This is really an encouraging case. The disappearance
of pain and reduction in the incidence of cellulitis can
be considered as great results in addition to the volume
reduction. The method and its results are described in my book, Lymph edema Diagnosis and Therapy 3rd Edition 2008, in pages 464-472. Below is the abstract of Professor
Baumeister’s latest presentation, published in
LymphForsch.
Microsurgical lymph vessel transplantation a
traditional vascular surgical procedure increases
lymphatic transport capacity. Baumeister, R.G.H.,
LymphForsch 2008;12(1):12-13
Abstract:
Bypassing a disrupted vessel is conventional
procedure in vascular surgery that can also be applied to
disrupted lymph vessels with the help of an operating
microscope. Studies show that lymphatic transport can
reach nearly normal values after bypass. Because of the
tendency of tissue alterations to occur as a result of
lymphatic obstruction, the reconstructive procedure
should be performed early after a full course of
consistent conservative therapy has been carried out.§
Source: The February Therapy News, 2009. Dr. Vodder
School International.
Contact: Denise Hardy denise.hardy@kendal-lymphology.org
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