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4.9 Pearls and Pitfalls
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Fig. 4.23 (a, b) The same patient as in
▶ Fig. 4.22. Magnetic resonance lymphan-
giography (a: coronal plane maximum
intensity projection, b: single axial plane)
demonstrating dilated ventromedial lymphatic vessels in the lower right leg and an
area of focal dermal backflow (white
arrowheads) as a sign of lymphedema
associated with the inguinal lymphatic
leakage.
leakage site, in inguinal lymph nodes, or in lymph vessels
and nodes above the suspected level of leakage
(▶ Fig. 4.22b–f). In cases with severe lymphedema the
patients can be asked to move their legs between image
acquisitions to propagate lymph flow.
Contrast-enhanced images should then be evaluated
concerning the presence and site of leakage, the location, course, and number of lymphatic vessels supplying
the leakage, the location and enhancement of adjacent
lymph nodes as well as signs of associated lymphoedema
(▶ Fig. 4.23).
Results of MRL in inguinal lymphatic leakage have so far
100
only been published in small case series.
In one report on
16 patients with iatrogenic/traumatic inguinal lymphatic
leakage, the leakage site/the leaking vessels could be identified in 15/16 cases. Interestingly these 15 patients also presented with lower extremity lymphedema of the respective
leg. These patients subsequently underwent successful surgical treatment. The patient without a detectable lymphatic
leakage or edema subsequently responded to continued
conservative treatment.
MRL is a clinically helpful imaging technique in the pretherapeutic workup of patients with therapy refractory
lymphatic leakage and can guide further treatment
strategy based on its high degree of spatial resolution
and local accuracy.
4.9 Pearls and Pitfalls
Tomke Cordts
Lymphedema patients require an extra amount of attention from the consulting physician and no fateful standard
of care treatment. A thorough and extensive examination
is as vital as a careful assessment of the individual personal
history. Moreover, selecting the appropriate patients for
the right surgery can be difficult. In the general population,
the term “lymphedema” is often used synonymously for all
kinds of diseases involving unilateral or bilateral swelling.
This includes adipose disorders, such as “lipedema,” which
occurs almost exclusively in women. Its prevalence is estimated to be as high as 10% in adult Caucasian women,
101
much higher than the 0.001% prevalence generally attributed to primary and the 0.1% attributed to secondary
lymphedema.
102
Therefore, as per our own experience,
finding actual presentations of lymphedema can be
quite challenging. During consultation, these few cas es
must be carefully filtered out of the la rge number of
other patient s.
Another common cause of er ror involves edema quantification. Using a nonstretch tape to measure extremity
circumference is considered a quick and easy method.
103
But as therapeutic decisions are often based on these
numbers (i.e., conservative treatment vs. surgical intervention), special care must be taken in obtaining them.
When patients are seen at follow-up examinations, variances of only a few centimeter s can mean a con siderable difference. Therefore, measurement should be as
standardized as possible in order to keep interpersonal
variances to a minimum. Finally, the available imaging
modalities of ICG lymphangiography, lymphoscintigraphic lymphangiography, and magnetic resonannace
lymphangiography have to be chosen with reference to
their advantages and disadvantages, summarized in
▶ Table 4.9.
Diagnostics and Stage-Dependent Preoperative Evaluation
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Table 4.9 Imaging modalities to evaluate lymphedema
Imaging Modality
Evaluation LSG ICG Lymphangiography MRL
Information about anatomy Poor resolution Excellent resolution of
superficial lymphatics
Excellent resolution of lymphatic
vessels, lymph nodes, venules,
and interstitial tissues
Information about function Excellent information
regarding lymphatic vessel
Shows only functional state of
superficial lymphatics
Rather poor to assess lymphatic
function
and lymph node function
Exposure to radiation Yes No No
Can be performed in
No Yes No
outpatient clinic and/or
operating room
Abbreviations: ICG, indocyanine green; LSG, lymphoscintigraphy; MRL, magnetic resonance lymphangiography.
References
[1] International Society of Lymphology. The diagnosis and treatment of
peripheral lymphedema: 2013 Consensus Document of the
International Society of Lymphology. Lymphology. 2013; 46(1):1–11
[2] Mattonet K, Wilting J, Jeltsch M. Die genetischen Ursachen des
primären Lymphödems: Erkrankungen Des Lymphgefäßsystems
2015;2013:in-press
[3] Radhakrishnan K, Rockson SG. The clinical spectrum of lymphatic
disease. Ann N Y Acad Sci. 2008; 1131:155–184
[4] Witte MH, Bernas MJ, Martin CP, Witte CL. Lymphangiogenesis and
lymphangiodysplasia: from molecular to clinical lymphology.
Microsc Res Tech. 2001; 55(2):122–145
[5] Evans AL, Bell R, Brice G, et al. Identification of eight novel VEGFR-3
mutations in families with primary congenital lymphoedema. J Med
Genet. 2003; 40(9):697–703
[6] Wilting J, Bartkowski R, Baumeister R, Földi E, Stöhr S, Strubel G, et al.
S2k Leitlinie Diagnostik und Therapie der Lymphödeme AWMF Reg.Nr. 058–001 2017. https://www.awmf.org/uploads/tx_szleitlinien/
058–001l_S2k_Diagnostik_und_Therapie_der_Lymphoedeme_2019–
07.pdf
[7] Karkkainen MJ, Ferrell RE, Lawrence EC, et al. Missense mutations
interfere with VEGFR-3 signalling in primary lymphoedema. Nat
Genet. 2000; 25(2):153–159
[8] Fang J, Dagenais SL, Erickson RP, et al. Mutations in FOXC2 (MFH-1), a
forkhead family transcription factor, are responsible for the
hereditary lymphedema-distichiasis syndrome. Am J Hum Genet.
2000; 67(6):1382–1388
[9] Finegold DN, Kimak MA, Lawrence EC, et al. Truncating mutations in
FOXC2 cause multiple lymphedema syndromes. Hum Mol Genet.
2001; 10(11):1185–1189
[10] Balboa-Beltran E, Fernández-Seara MJ, Pérez-Muñuzuri A, et al. A
novel stop mutation in the vascular endothelial growth factor-C gene
(VEGFC) results in Milroy-like disease. J Med Genet. 2014; 51(7):
475–478
[11] Ferrell RE, Baty CJ, Kimak MA, et al. GJC2 missense mutations cause
human lymphedema. Am J Hum Genet. 2010; 86(6):943–948
[12] Ostergaard P, Simpson MA, Connell FC, et al. Mutations in GATA2
cause primary lymphedema associated with a predisposition to acute
myeloid leukemia (Emberger syndrome). Nat Genet. 2011; 43(10):
929–931
[13] Irrthum A, Devriendt K, Chitayat D, et al. Mutations in the
transcription factor gene SOX18 underlie recessive and dominant
forms of hypotrichosis-lymphedema-telangiectasia. Am J Hum Genet.
2003; 72(6):1470–1478
[14] Har-El G, Borderon ML, Weiss MH. Choanal atresia and lymphedema.
Ann Otol Rhinol Laryngol. 1991; 100(8):661–664
[15] Alders M, Hogan BM, Gjini E, et al. Mutations in CCBE1 cause
generalized lymph vessel dysplasia in humans. Nat Genet. 2009; 41
(12):1272–1274
[16] Ostergaard P, Simpson MA, Mendola A, et al. Mutations in KIF11
cause autosomal-dominant microcephaly variably associated with
congenital lymphedema and chorioretinopathy. Am J Hum Genet.
2012; 90(2):356–362
[17] Quirion E. Recognizing and treating upper extremity lymphedema in
postmastectomy/lumpectomy patients: a guide for primary care
providers. J Am Acad Nurse Pract. 2010; 22(9):450–459
[18] Cormier JN, Askew RL, Mungovan KS, Xing Y, Ross MI, Armer JM.
Lymphedema beyond breast cancer: a systematic review and metaanalysis of cancer-related secondary lymphedema. Cancer. 2010; 116
(22):5138–5149
[19] de Vries M, Vonkeman WG, van Ginkel RJ, Hoekstra HJ. Morbidity
after inguinal sentinel lymph node biopsy and completion lymph
node dissection in patients with cutaneous melanoma. Eur J Surg
Oncol. 2006; 32(7):785–789
[20] Füller J, Guderian D, Köhler C, Schneider A, Wendt TG. Lymph edema
of the lower extremities after lymphadenectomy and radiotherapy
for cervical cancer.Strahlenther Onkol. 2008; 184(4):206–211
[21] Földi M, Földi E, Kubik S, eds. Lehrbuch der Lymphologie für
Mediziner, Masseure und Physiotherapeuten. 6. Munich: Urban und
Fischer; 2005
[22] Mehrara BJ, Greene AK. Lymphedema and obesity: is there a link?
Plast Reconstr Surg. 2014; 134(1):154e–160e
[23] Eberhardt RT, Raffetto JD. Chronic venous insufficiency. Circulation.
2014; 130(4):333–346
[24] International Society of Lymphology. The diagnosis and treatment of
peripheral lymphedema: 2013 Consensus Document of the
International Society of Lymphology. Lymphology. 2013; 46(1):1–11
[25] Grada AA, Phillips TJ. Lymphedema: diagnostic workup and
management. J Am Acad Dermatol. 2017; 77(6):995–1006
[26] Stemmer R. Ein klinisches Zeichen zur Früh- und Differential-
diagnose des Lymphödems [A clinical symptom for the early and
differential diagnosis of lymphedema]. Vasa. 1976; 5(3):261–262
[27] Gerber LH. A review of measures of lymphedema. Cancer. 1998; 83
(12) Suppl American:2803–2804
[28] Caban ME. Trends in the evaluation of lymphedema. Lymphology.
2002; 35(1):28–38
[29] Taylor R, Jayasinghe UW, Koelmeyer L, Ung O, Boyages J. Reliability
and validit y of arm volume measurements for assessment of
lymphedema. Phys Ther. 2006; 86(2):205–214
52
4.9 Pearls and Pitfalls
https://t.me/medicina_free
[30] Sander AP, Hajer NM, Hemenway K, Miller AC. Upper-extremity volume
measurements in women with lymphedema: a comparison of
measurements obtained via water displacement with geometrically
determined volume. Phys Ther. 2002; 82(12):1201–1212
[31] Stanton AW, Badger C, Sitzia J. Non-invasive assessment of the
lymphedematous limb. Lymphology. 2000; 33(3):122–135
[32] Perrin M, Guex JJ. Edema and leg volume: methods of assessment.
Angiology. 2000; 51(1):9–12
[33] Kaulesar Sukul DM, den Hoed PT, Johannes EJ, van Dolder R, Benda E.
Direct and indirect methods for the quantification of leg volume:
comparison between water displacement volumetry, the disk model
method and the frustum sign model method, using the correlation
coefficient and the limits of agreement. J Biomed Eng. 1993; 15(6):
477–480
[34] Megens AM, Harris SR, Kim-Sing C, McKenzie DC. Measurement of
upper extremity volume in women after axillary dissection for breast
cancer. Arch Phys Med Rehabil. 2001; 82(12):1639–1644
[35] Stranden E. A comparison between surface measurements and water
displacement volumetry for the quantification of leg edema. J Oslo
City Hosp. 1981; 31(12):153–155
[36] Bernas M. Assessment and risk reduction in lymphedema. Semin
Oncol Nurs. 2013; 29(1):12–19
[37] Hayashi A, YamamotoT, Yoshimatsu H, et al. Ultrasound visualization
of the lymphatic vessels in the lower leg. Microsurgery. 2016; 36(5):
397–401
[38] Visconti G, Yamamoto T, Hayashi N, Hayashi A. Ultrasound-assisted
lymphaticovenular anastomosis for the treatment of peripheral
lymphedema. Plast Reconstr Surg. 2017; 139(6):1380e–1381e
[39] Hayashi A, Giacalone G, Yamamoto T, et al. Ultra high-frequency
ultrasonographic imaging with 70 MHz scanner for visualization of the
lymphatic vessels. Plast Reconstr Surg Glob Open. 2019; 7(1):e2086
[40] Visconti G, Hayashi A, Tartaglione G, Yamamoto T, Bianchi A, Salgarello
M. Preoperative planning of lymphaticovenular anastomosis in patients
with iodine allergy: a multicentric experience. J Plast Reconstr Aesthet
Surg. 2020; 73(4):783–808
[41] Bianchi A, Visconti G, Hayashi A, Santoro A, Longo V, Salgarello M. Ultra-
high frequency ultrasound imaging of lymphatic channels correlates
with their histological features: a step forward in lymphatic surgery. J
Plast Reconstr Aesthet Surg. 2020; 73(9):1622–1629
[42] Hayashi A, Visconti G, Yamamoto T, et al. Intraoperative imaging of
lymphatic vessel using ultra high-frequency ultrasound. J Plast
Reconstr Aesthet Surg. 2018; 71(5):778–780
[43] Visconti G, Bianchi A, Hayashi A, Salgarello M. Ultra-high frequency
ultrasound preoperative planning of the rerouting method for
lymphaticovenular anastomosis in incisions devoid of vein.
Microsurgery. 2020; 40(6):717–718
[44] Visconti G, Salgarello M, Hayashi A. The recipient venule in
supermicrosurgical lymphaticovenular anastomosis: flow dynamic
classification and correlation with surgical outcomes. J Reconstr
Microsurg. 2018; 34(8):581–589
[45] Bianchi A, Salgarello M, Hayashi A, Yang JC, Visconti G. Recipient venule
selection and anastomosis configuration for lymphaticovenular
anastomosis in extremity lymphedema: algorithm based on 1,000
lymphaticovenular anastomosis. J Reconstr Microsurg. 2021. Epub
ahead of print.. DOI: 10.1055/s-0041-1735836
[46] Bourgeois P, Munck D, Becker C, Leduc O, Leduc A. Evaluation of a
three-phase lymphoscintigraphic investigation protocol of the lower
limbedemas. Eur J Lymphol. 1997; 21:22–28
[47] Bourgeois P. Radionuclide lymphoscintigraphies. In: Lee BB,
Rockson SG, Bergan J, eds. Lymphedema: A Concise Compendium
of Theo r y and Practice. Springer International Publishing AG;
2018:257–313
[48] Kleinhans E, Baumeister RGH, Hahn D, Siuda S, Büll U, Moser E.
Evaluation of transport kinetics in lymphoscintigraphy: follow-up
study in patients with transplanted lymphatic vessels. Eur J Nucl
Med. 1985; 10(7–8):349–352
[49] Fox IJ, Brooker LG, Heseltine DW, Essex HE, Wood EH. A
tricarbocyanine dye for continuous recording of dilution curves in
whole blood independent of variations in blood oxygen saturation.
Proc Staff Meet Mayo Clin. 1957; 32(18):478–484
[50] Flower RW. Injection technique for indocyanine green and sodium
fluorescein dye angiography of the eye. Invest Ophthalmol. 1973; 12
(12):881–895
[51] Kogure K, Choromokos E. Infrared absorption angiography. J Appl
Physiol. 1969; 26(1):154–157
[52] Hollins B, Noe B, Henderson JM. Fluorometric determination of
indocyanine green in plasma. Clin Chem. 1987; 33(6):765–768
[53] Yoneya S, Saito T, Komatsu Y, Koyama I, Takahashi K, Duvoll-Young J.
Binding properties of indocyanine green in human blood. Invest
Ophthalmol Vis Sci. 1998; 39(7):1286–1290
[54] Alander JT, Kaartinen I, Laakso A, et al. A review of indocyanine green
fluorescent imaging in surgery. Int J Biomed Imaging. 2012; 2012:
940585
[55] Hope-Ross M, Yannuzzi LA, Gragoudas ES, et al. Adverse reactions
due to indocyanine green. Ophthalmology. 1994; 101(3):529– 533
[56] Liang MI, Carson WE, III. Biphasic anaphylactic reaction to blue dye
during sentinel lymph node biopsy. World J Surg Oncol. 2008; 6:79
[57] Landsman ML, Kwant G, Mook GA, Zijlstra WG. Light-absorbing
properties, stability, and spectral stabilization of indocyanine green. J
Appl Physiol. 1976; 40(4):575–583
[58] Hirche C, Murawa D, Mohr Z, Kneif S, Hünerbein M. ICG
fluorescence-guided sentinel node biopsy for axillar y nodal staging
in breast cancer. Breast Cancer Res Treat. 2010; 121(2):373–378
[59] Hirche C, Mohr Z, Kneif S, et al. Ultrastaging of colon cancer by
sentinel node biopsy using fluorescence navigation with indocyanine
green. Int J Colorectal Dis. 2012; 27(3):319–324
[60] Executive C, Executive Committee. The diagnosis and treatment of
peripheral lymphedema: 2016 Consensus Docu ment of the
International Society of Lymphology. Lymphology. 2016; 49(4):
170–184
[61] Unno N, Inuzuka K, Suzuki M, et al. Preliminary experience with a
novel fluorescence lymphography using indocyanine green in
patients with secondary lymphedema. J Vasc Surg. 2007; 45(5):
1016–1021
[62] Ogata F, Narushima M, Mihara M, Azuma R, Morimoto Y, Koshima I.
Intraoperative lymphography using indocyanine green dye for nearinfrared fluorescence labeling in lymphedema. Ann Plast Surg. 2007;
59(2):180–184
[63] Yamamoto T, Matsuda N, Doi K, et al. The earliest finding of
indocyanine green lymphography in asymptomatic limbs of lower
extremity lymphedema patients secondary to cancer treatment: the
modified dermal backflow stage and concept of subclinical
lymphedema. Plast Reconstr Surg. 2011; 128(4):314e–321e
[64] Yamamoto T, Yamamoto N, Doi K, et al. Indocyanine green-enhanced
lymphography for upper extremity lymphedema: a novel severity
staging system using dermal backflow patterns. Plast Reconstr Surg.
2011; 128(4):941–947
[65] Chang DW, Suami H, Skoracki R. A prospective analysis of 100
consecutive lymphovenous bypass cases for treatment of extremity
lymphedema. Plast Reconstr Surg. 2013; 132(5):1305–1314
[66] Rosian K, Stanak M. Efficacy and safety assessment of lymphovenous
anastomosis in patients with primary and secondary lymphoedema:
a systematic review of prospective evidence. Microsurgery. 2019; 39
(8):763–772
[67] Cornelissen AJM, van Mulken TJM, Graupner C, et al. Near-infrared
fluorescence image-guidance in plastic surgery: a systematic review.
Eur J Plast Surg. 2018; 41(3):269–278
[68] Yamamoto T, Narushima M, Yoshimatsu H, et al. Indocyanine green
velocity: lymph transportation capacity deterioration with
progression of lymphedema. Ann Plast Surg. 2013; 71(5):591–594
[69] Yamamoto T, Narushima M, Yoshimatsu H, et al. Dynamic
indocyanine green (ICG) lymphography for breast cancer-related arm
lymphedema. Ann Plast Surg. 2014; 73(6):706–709
[70] Olszewski WL. Contractility patterns of normal and pathologically
changed human lymphatics. Ann N Y Acad Sci. 2002; 979:52–63,
discussion 76–79
Diagnostics and Stage-Dependent Preoperative Evaluation
https://t.me/medicina_free
[71] Yamamoto T, Iida T, Matsuda N, et al. Indocyanine green (ICG)-
enhanced lymphography for evaluation of facial lymphoedema. J
Plast Reconstr Aesthet Surg. 2011; 64(11):1541–1544
[72] Yamamoto T, Yamamoto N, Yoshimatsu H, Hayami S, Naru shima M,
Koshima I. Indocyanine green ly mphography for evaluation of
genital lymphedema in secondary lower extremity lymphedema
patients. J Vasc Surg Venous Lymphat Disord. 2013; 1(4):400 –
405.e1
[73] Mihara M, Hara H, Kikuchi K, et al. Scarless lymphatic venous
anastomosis for latent and early-stage lymphoedema using indocyanine
green lymphography and non-invasive instruments for visualising
subcutaneous vein. J Plast Reconstr Aesthet Surg. 2012; 65(11):1551–
1558
[74] Yang JC, Wu SC, Chiang MH, Lin WC, Hsieh CH. Intraoperative
identification a nd definition of “functional” lymphatic collecting
vessels for supermicrosurgical lymphatico-venous anastomos is in
treating lymphedema patients. J Surg Oncol. 2018; 117(5):994–
1000
[75] Chen WF, Zhao H, Yamamoto T, Hara H, Ding J. Indocyanine green
lymphographic evidence of surgical efficacy following microsurgical
and supermicrosurgical lymphedema reconstructions. J Reconstr
Microsurg. 2016; 32(9):688–698
[76] Shih HB, Shakir A, Nguyen DH. Use of indocyanine green-SPY
angiography for tracking lymphatic recovery after lymphaticovenous
anastomosis. Ann Plast Surg. 2016; 76 Suppl 3:S232–S237
[77] Mihara M, Seki Y, Hara H, et al. Predictive lymphatic mapping: a
method for mapping lymphatic channels in patients with advanced
unilateral lymphedema using indocyanine green lymphography. Ann
Plast Surg. 2014; 72(6):706–710
[78] Gentileschi S, Servillo M, Albanese R, De Bonis F, Tartaglione G,
Salgarello M. Lymphatic mapping of the upper limb with
lymphedema before lymphatic supermicrosurgery by mirroring of
the healthy limb. Microsurgery. 2017; 37(8):881–889
[79] Basta MN, Gao LL, Wu LC. Operative treatment of peripheral
lymphedema: a systematic meta-analysis of the efficacy and safety of
lymphovenous microsurgery and tissue transplantation. Plast
Reconstr Surg. 2014; 133(4):905–913
[80] Azuma S, Yamamoto T, Koshima I. Donor-site lymphatic function after
microvascular lymph node transfer should be followed using
indocyanine green lymphography. Plast Reconstr Surg. 2013; 131(3):
443e–444e
[81] Vignes S, Blanchard M, Yannoutsos A, Arrault M. Complications of
autologous lymph-node transplantation for limb lymphoedema. Eur J
Vasc Endovasc Surg. 2013; 45(5):516–520
[82] Pons G, Masia J, Loschi P, Nardulli ML, Duch J. A case of donor-site
lymphoedema after lymph node-superficial circumflex iliac artery
perforator flap transfer. J Plast Reconstr Aesthet Surg. 2014; 67(1):
119–123
[83] Ciudad P, Manrique OJ, Date S, et al. A head-to-head comparison
among donor site morbidit y after vascularized lymph node transfer:
pearls and pitfalls of a 6-year single center experience. J Surg Oncol.
2017; 115(1):37–42
[84] Demiri E, Dionyssiou D, Tsimponis A, et al. Donor-site lymphedema
following lymph node transfer for breast cancer-related
lymphedema: a systematic review of the literature. Lymphat Res Biol.
2018; 16(1):2–8
[85] Scaglioni MF, Arvanitakis M, Chen YC, Giovanoli P, Chia-Shen Yang J,
Chang EI. Comprehensive review of vascularized lymph node transfers
for lymphedema: outcomes and complications. Microsurgery. 2018; 38
(2):222–229
[86] Klimberg VS. A new concept toward the prevention of lymphedema:
axillary reverse mapping. J Surg Oncol. 2008; 97(7):563–564
[87] Ochoa D, Korourian S, Boneti C, Adkins L, Badgwell B, Klimberg VS.
Axillary reverse mapping: five-year experience. Surgery. 2014; 156
(5):1261–1268
[88] Dayan JH, Dayan E, Smith ML. Reverse lymphatic mapping: a new
technique for maximizing safety in vascularized lymph node transfer.
Plast Reconstr Surg. 2015; 135(1):277–285
[89] Halvorson EG, Orgill DP. Discussion: reverse lymphatic mapping: a
new technique for maximizing safety in vascularized lymph node
transfer. Plast Reconstr Surg. 2015; 135(1):286–288
[90] Aliotta RE, Schwarz GS. Reverse lymphatic mapping without
radioisotope in the surgical treatment of lymphedema. J Plast
Reconstr Aesthet Surg. 2018; 71(5):766
[91] Arrivé L, Derhy S, El Mouhadi S, Monnier-Cholley L, Menu Y, Becker
C. Noncontrast magnetic resonance lymphography. J Reconstr
Microsurg. 2016; 32(1):80–86
[92] Lohrmann C, Foeldi E, Langer M. Indirect magnetic resonance
lymphangiography in patients with lymphedema preliminary results
in humans. Eur J Radiol. 2006; 59(3):401–406
[93] Mitsumori LM, McDonald ES, Wilson GJ, Neligan PC, Minoshima S,
Maki JH. MR lymphangiography: how I do it. J Magn Reson Imaging.
2015; 42(6):1465–1477
[94] Twine CP, Lane IF, Williams IM. Management of lymphatic fistulas
after arterial reconstruction in the groin. Ann Vasc Surg. 2013; 27(8):
1207–1215
[95] Pieper CC. [Thoracic lymphatic pathologies with chylous leakages—
imaging and interventional treatment]. Röfo Fortschr Geb Röntgenstr
Nuklearmed. 2018; 190(8):674–679
[96] Pieper CC, Hur S, Sommer CM, et al. Back to the future: lipiodol in
lymphography—from diagnostics to theranostics. Invest Radiol. 2019;
54(9):600–615
[97] Gruber-Rouh T, Naguib NNN, Lehnert T, et al. Direct lymphangiography
as treatment option of lymphatic leakage: indications, outcomes and
role in patient’s management. Eur J Radiol. 2014; 83(12):2167–2171
[98] Arrivé L, Derhy S, Dahan B, et al. Primary lower limb lymphoedema:
classification with non-contrast MR lymphography. Eur Radiol. 2018;
28(1):291–300
[99] Pieper CC, Schild HH. Interstitial transpedal MR-lymphangiography
of central lymphatics using a standard MR contrast agent: feasibility
and initial results in patients with chylous effusions. Röfo Fortschr
Geb Röntgenstr Nuklearmed. 2018; 190(10):938–945
[100] Lu Q, Bui D, Liu NF, Xu JR, Zhao XH, Zhang XF. Magnetic resonance
lymphography at 3T: a promising noninvasive approach to
characterise inguinal lymphatic vessel leakage. Eur J Vasc Endovasc
Surg. 2012; 43(1):106–111
[101] Wollina U. Lipedema—an update. Dermatol Ther (Heidelb). 2019; 32
(2):e12805
[102] Grada AA, Phillips TJ. Lymphedema: pathophysiology and clinical
manifestations. J Am Acad Dermatol. 2017; 77(6):1009–1020
[103] Caban ME. Trends in the evaluation of lymphedema. Lymphology.
2002; 35(1):28–38
54
Section III
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Modern Management of Chronic
Lymphedema
Edited by Yves Harder
5 Establishment of an
Interprofessional and
Multidisciplinary Lymphedema
Network 57
III
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5 Establishment of an Interprofessional and Multidisciplinary
https://t.me/medicina_free
Lymphedema Network
Holger Engel
Summary
The adequate t reatment of lymphedema depends on a
multimodal approach that includes all available options, such as conservative therapy, specific lymphatic
surgery, and, eventually in the future, specific antiinflammatory drugs and regenerative medicine (see
Chapter 19). The basis for lymphedema treatment is still
considered to be conservative therapy, i.e., integrative,
multiprofessional conservative treatment, whereas lymphatic surgery predominantly aims at reconstructing
lymph flow (e.g., lymphovenous anastomosis and/or
autologous lymph node transfer) and reducing extra fat
deposit (e.g., suction-assisted l ipectomy). To coordinate
this spectrum of treatment modalities, a single physician or patient manager is barely sufficient. A patient
should, therefore, be treated i n an interprofessional
and multidisciplinar y national lymphedema net work to
ensure the provision of structured and evidence-based
therapy.
Keywords: conservative treatment, interprofessional
collaboration, lymphoablative surgery, multidisciplinary
lymphedema network, multimodal treatment,
reconstructive surgery, surgical treatment
5.1 Presentation of the Concept
Health care systems around the world can differ from one
another. They vary in terms of their financial coverage of
patient therapy, compensation of health care providers,
and availability of therapeutic modalit ies, e.g., lymphatic
therapists, medical supply stores, chiropodists, general
practitioners, microsurgeons, etc. The establishment of a
functioning lymphedema network should be regional or
ideally “national” (national lymphedema network [NLN])
and should take into consideration each health care
system’s peculiarities (▶ Fig. 5.1).
5.2 Goals
An NLN should have both a clear framework and purpose
that define its level of ambition.
create awareness of lymphedema among the medical
community, the patients, and the general public by disseminating information, providing education, organizi ng
conferences, and constituting patient advocacy group
(patient support group) professionals. Prediction and
prevention of lymphedema are the most critical issues
to be addressed initially.
1
First, an NLN should
Fig. 5.1 Composition of a national lymphedema network. EBM, evidence-based medicine; LE, lymphedema; PSG, patient support group
(patient advocacy); QoL, quality of life.
Establishment of an Interprofessional and Multidisciplinary Lymphedema Network
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Second, an NLN should provide points of contact for
patients and relatives, involved health care providers
such as physicians, medical supply stores, and hospitals,
as well as for insurance companies to increase the quality
of diagnosis and therapy. Centralizing these services on
an evidence-based practice is crucial to ensure predictable patient outcomes. Therefore, recording performance
data regarding each activity is essential.
Third, the NLN should also support research groups,
raise funds, and provide scholarships.
most effectively accomplished in cooperation with national and international societies of lymphology and lymphatic
surgery.
2
These aims can be
5.3 Organizational Structure and
Involved Personnel
An absolute prerequisite to achieving the aforementioned
aims begins with the finding of dedicated people who
share the same vision and passion for delivering the best
specific and individualized care to the patient. If only a
few people begin networking, other people will soon join
in support. Unfortunately, due to an under-compensation
of treatment involving lymphedema, this work is not
attractive enough to potential caregivers, eventually leading to an undersupply in most areas. However, this does
not mean that individuals and organizations lack interest
in this field. For example, medical supply stores and companies earn money by selling compression garments, so
they have a financial interest in joining lymphedema networks. It is, therefore, essential to be familiar with every
party’s interest when establishing such a network. Finding the “right” people requires the involvement of physicians and nonmedical health care providers as well as
persons with the expertise in bylaws, juridical issues,
marketing, and event organization, among other things.
Members of an NLN should meet regularly.
For each meeting, different topics should be included
in a given agenda. It is advisable to discuss organizationrelated issues separately from those involving specific
patient issues and medical education. In particular, an
accredited continuing medical education (CME) program
attracts other physicians and experts in the field to participate in such a meeting.
Structuring an NLN as a nonprofit organization that
operates independently best fits the purpose and allows
for tax advantages in many countries. The organization
should have a committee as well as an advisory board of
experts. The resumes, certificates, and proof of training
held by the experts must meet high standards in the field
of lymphedema treatment. It is advisable if these standards are precise and partially case-load guided (e.g., a
lymphatic therapist with practical experience of 5 years
of weekly practice of 10 treatments; a plastic surgeon
with practical experience of 5 years, 250 free tissue
transfers, and 50 LVAs). Different types of potential
membership could allow an NLN to grow and to ensure
its financial sustainability. These memberships could be
differentiated between experts and laypersons in the
field and active and passive members bo th with and
without the right to vote. The standards should also
implement a transparent declaration for the executive
committee, stating that they have no conflict of interes t.
5.4 Funding
Membership fees and donations should be the basis of
the financing of such an organization. The establishment
of national conferences in which sponsoring fees are
charged for industry exhibition offers another source of
income. As the popularity of an NLN increases, it could
become possible for the organization to provide specific
and foremost certified educational activities to physicians, lymphatic therapists, nurses, and eventually patients, including online webinars, live chats, etc. Later on,
and after having achieved a standard of patient care using
evidence-based practices, there will also be the possibility of obtaining support directly from the health care
system or the government.
5.5 Marketing
The establishment of an NLN has been shown to lead to a
significant improvement in patient care.
crucial that such an organization disseminates information and becomes well known, not only to fulfill its own
goals but also to establish a solid financial foundation
from which to act. Lymphedema networks should utilize
all the marketing tools today available, including branding, corporate identity and design, search engine optimization (SEO), flyers, posters, business cards, Facebook,
TikTok, and Instagram. Online performance marketers
could create funnels that subsequently create leads, new
members, and followers. Additionally, nonmember health
care providers could be certified by NLNs, thus demonstrating their high-quality standards. However, the certification process costs money but provides prestige to the
health care provider.
2,3,4
However, it is
5.6 Expert Group/Lymphedema
Board and Patient Advocacy
In the medical curriculum of most universities, there is
still a lack of information with regard to lymphology. In
Europe, to date there is no board-certified specialist in
lymphology, which complicates the selection of an ideal
specialist.
Therefore, patients should be seen and reviewed by a
group of specialists, namely, a “lymphedema board.” These
board members should include a general practitioner, an
internist, a plastic surgeon, and a vascular surgeon who all
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5.9 Pearls and Pitfalls
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have profound knowledge and practical experience in the
field of lymphology. Plastic surgeons should be trained in
the field of supermicrosurgery and microvascular tissue
transfer. Further and ideally, these boards need to include
lymphatic therapists trained in complete decongestive
therapy (CDT: also known as complete decongestive therapy), health care providers working with compression garments (e.g., medical supply stores), chiropodists trained in
infection prevention, psychologists, wound experts, and
other skincare-related providers. Finally, a patient advocacy should be included as well.
5.7 Evidence-Based Medical Care
The expert advisory board has to establish the evidencebased standard for each diagnosis and treatment modality, which should be eventually published and updated
on a regular base in guidelines. Every involved health care
provider needs to adhere to the NLN to guarantee the
implementation of the standards, recommendations, and
guidelines.
To monitor the quality of patient care, a registry for
data acquisition and a system for data assessment is
crucial. Basically, a personalized diagnostic and treatment plan should be defined for every patient, including the monitoring during follow-up, and eventually
objectively registered in specific data bases. Although
most probably institution-specific, data should be electronically available to all health care professionals of the
network. Therefore, informed consent of the patients
which decla res their agreement to share sensitive data
is necessary.
The monitored outcome parameters can be qualitatively assessed using measurements related to circumference, volume (water displacement vs. perom eter
[see www.pero-system.de]), tissue quality (tonometry,
bioimpedance), and functionalit y of the lymphatic system (lymphoscintigraphy, ICG lymphangiography, CT or
MRL, and ultrasound) (see Chapter 4). The number of
infectious events including cellulitis and erysipelas
should also be recorded. Fu rther, it is essential to monitor the patient’s quality of life before and after treatment, which c an be accomplished using a wi de array of
available quality of life questionnaires (e.g., LYMQOL,
Lymph-ICF, SF36 a.o.).
Since indication for surgery is diverse, for example, for
LVA (see Chapter 8), autologous lymph vessel transfer
(see Chapter 9), autologous lymph node transfer (see
Chapter 10 and 11), nod-venal shunt (see Chapter 12),
suction-assisted lipectomy, lymphoablative surger y
(see Chapter 13), and lympho-ablative procedures (see
Chapter 14), as well as secondar y procedures (see
Chapter 15), it is essential to document each interven-
tion accurately.
5,6
7,8
5.8 Future of Lymphedema
Networks and Data-Driven Medicine
Currently, data acquisition in the health care sector is
continuously and progressively shifting from handwritten
paper-based to electronic paper-free form registry databases. Accordingly, the volume of “virtual” medical data
increases at a rate of 50% per year. These data are linked
with each other to demonstrate correlations and causalities
9,10
that have not been previously visible.
Additionally, in
the future artificial intelligence (AI) could be implemented
for retrospective analyses used to detect lymphedema.
For example, deep learning systems could be employed to
implement new algorithms that predict lymphedema
treatment outcomes. In the future, lymphedema networking will also change dramatically, resulting in a new “partner AI” that will further improve the care of lymphedema
patients.
12,13
5.9 Pearls and Pitfalls
●
When creating an NLM, the crucial element is to find
the right fellow companions who share the same vision
and passion.
●
An NLN should exemplify professionalism similar to
any other successful company.
●
An NLN needs time to grow such an organization.
●
Possible short-term accomplishments are generally
overestimated.
●
Standards of treatment quality should not be lowered.
●
The network should ideally unite the experts in the
field, guarantee specialist independence irrespective of
personal interests and political issues.
References
[1] Friett K. Lymphoedema Support Network update. Br J Community
Nurs. 2019; 24 Sup4:S38
[2] Underwood E, Woods M, Riches K, Keeley V, Wallace A, Freeman J.
Lymphedema research prioritization partnership: a collaborative
approach to setting research priorities for lymphedema
management. Lymphat Res Biol. 2019; 17(3):356–361
[3] Omidi Z, Kheirkhah M, Abolghasemi J, Haghighat S. Effect of
lymphedema self-management group-based education compared
with social network-based education on quality of life and fear of
cancer recurrence in women with breast cancer: a randomized
controlled clinical trial. Qual Life Res. 2020; 29(7):1789–1800
[4] Thomas MJ, Morgan K. The development of Lymphoedema Network
Wales to improve care. Br J Nurs. 2017; 26(13):740–750
[5] O’Donnell TF, Jr, Allison GM, Iafrati MD. A systematic review of
guidelines for lymphedema and the need for contemporary
intersocietal guidelines for the management of lymphedema. J Vasc
Surg Venous Lymphat Disord. 2020; 8(4):676–684
[6] O’Donnell TF, Jr, Allison GM, Melikian R, Iafrati MD. A systematic
review of the quality of clinical practice guidelines for lymphedema,
as assessed using the Appraisal of Guidelines for Research and
Evaluation II instrument. J Vasc Surg Venous Lymphat Disord. 2020; 8
(4):685–692
11
Establishment of an Interprofessional and Multidisciplinary Lymphedema Network
https://t.me/medicina_free
[7] Borman P, Yaman A, Denizli M, Karahan S. The reliability and validity
of Lymphedema Quality of Life Questionnaire-Leg in Turkish patients
with lower limb lymphedema. Lymphat Res Biol. 2020; 18(1):42–48
[8] Wedin M, Fredrikson M, Ahlner E, et al. Validation of the
Lymphoedema Quality of Life Questionnaire (LYMQOL) in Swedish
cancer patients. Acta Oncol. 2020; 59(3):365–371
[9] Roski J, Bo-Linn GW, Andrews TA. Creating value in health care
through big data: opportunities and policy implications. Health Aff
(Millwood). 2014; 33(7):1115–1122
[10] Vayena E, Dzenowagis J, Brownstein JS, Sheikh A. Policy implications
of big data in the health sector. Bull World Health Organ. 2018; 96
(1):66–68
[11] Fu MR, Wang Y, Li C, et al. Machine learning for detection of
lymphedema among breast cancer survivors. mHealth. 2018; 4:17
[12] Briganti G, Le Moine O. Artificial intelligence in medicine: today and
tomorrow. Front Med (Lausanne). 2020; 7:27
[13] Vougas K, Almpanis S, Gorgoulis V. Deep learning: shaping the
medicine of tomorrow. Mol Cell Oncol. 2020; 7(3):1723462
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