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Lymphoedema 461
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lymph-venous pressure gradient, which is essential for a correct approach to
microsurgical treatment of lymphoedemas. With this method, a lymphatic vessel
is isolated and cannulated at the lower third of the leg’s medial surface. Any
change in the flow-pressure rate can also be recorded during microsurgery,
in clino- and orthostatic positions, at rest and under dynamic conditions.
These studies have shown that a valuable lymphatic-venous pressure gradient is
essential to obtain medium- and long-term results by derivative microsurgery.
[Q2: B, C, E]
Manual lymphatic drainage has been shown to be a highly effective treatment in
the conservative management of lymphoedema [17–19]. This is followed by the
application of bandaging and eventually graded compression stockings. The use of
intermittent compression pneumatic devices is usually complementary to manual
lymphatic drainage and may contribute to further reduction of the lymphoedema.
Pharmacotherapy includes the use of antibiotics, particularly penicillin [20], antiinflammatory drugs and benzopyrones [21]. The positive effect of benzopyrones
was described by Casley-Smith et al. [21], but their role in the treatment of lymphoedema has yet to be clarified.
Thirty years ago, there were relatively few therapeutic solutions in the treatment
of lymphoedema. Only the most severe and advanced cases of elephantiasis were
treated surgically, mainly in order to reduce the volume of lymphoedematous limbs.
The most popular surgical methods were those proposed by Charles [22] (total
resection of skin-lipid layers), Thompson [23] (drainage with scarred subfascial
skin flap), and Servelle [24] (total surface lymphangectomy). Being highly destructive and invasive operations, they could not be recommended in less advanced or
initial stages or in childhood disease [25]. More recently, microsurgical lymphaticvenous and lymphnodal-venous anastomoses were introduced for the management
of lymphoedema resistant to conservative treatment [26, 27]. These techniques are
beneficial in not only secondary but also primary lymphoedemas [28], since early
intervention is possible even in young children with some minor modifications of
the technique, such as lymphatic-capsule-venous anastomosis [29].
Lymphostatic disease may be associated with venous impairment such as varices,
superficial thrombophlebitis, deep venous thrombosis and postphlebitic sequelae.
These conditions are a contraindication to traditional lymphatic-venous anastomosis.
Therefore, novel reconstructive lymphatic surgery techniques are used [30]. These
include segmental autotransplantation of lymphatic collectors [31] for the treatment
of monolateral lymphoedema or the personally described method of interposition
autologous venous grafting or lymphatic-venous-lymphatic plasty [32].
The use of free microvascular lymphatic or lymph nodal flaps [33, 34] is still in
clinical trials. However, it opens up interesting options in the treatment of lymphoedema that fails to respond to conservative therapy and that, for congenital
(aplasia or hypoplasia) or acquired (elephantiasis with diffuse obstructive lymphangitis) reasons, cannot benefit from the above-mentioned derivative or reconstructive microsurgical techniques.
Elastic stockings are worn for an average period of 1–5 years after microsurgery
according to the stage of the pathology at the time of operation. These stockings
aim to prevent the closure of anastomoses in the early postoperative period, following a rapid reduction of oedema and consequent decrease in lymphatic pressure
and flow as a result of the microsurgical drainage [35]. [Q3: A, B, D]
Through a properly planned follow-up at 1, 3, 6 and 12 months, and then annually for at least the first 5 years after surgery, lymphatic microsurgery results are
462 Vascular Surgery
Fig. 47a.7.
Clinical instrumental diagnostic staging of lymphoedema.
positive in more than 80 per cent of cases, with an even better outcome in patients
operated upon precociously (at stages II and III; see Fig. 47a.7). The incidence of
lymphangitic attacks decreases significantly after microsurgery. The reduction in
oedema volume obtained by microsurgery is seen immediately after operation
(within the first three postoperative days), and a further decrease in lymphoedema is also observed at medium- and long-term follow-up, particularly
between the first and fifth years after operation. From the fifth year onwards, the
clinical condition of the limb tends to remain stable with time, even more than 10
years after surgery. Lymphangioscintigraphy can document objectively that the
flow through the venous graft parallels the clinical improvement over the 10-year
period [36]. [Q4]
Turning to the prevention of secondary lymphoedema, early identification of
high-risk patients (such as those undergoing oncological lymphadenectomies, particularly in combination with radiotherapy) and early diagnostic lymphangioscintigraphy [37] has been suggested [38, 39]. In these cases, early microsurgery
is a reasonable option in order to fight, from their very onset, lymphoedemas that,
based on a reasonable statistical probability, are expected to show unrelenting
progression [40]. [Q5]
References
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lymphoedema: pathophysiological and therapeutic implications. Lymphology 1996;29S:190–8.
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2. Papendieck CM. Temas de Angiologia Pediatrica. Buenos Aires: Editorial Medica Panamericana,
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5. Tosatti E. Lymphatique profonds et lymphoedèmes chroniques des membres. Paris: Masson, 1974.
6. Mayall JC, Mayall ACDG. Standardization of methods of treatment of lymphoedema. Progress in
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7. Mariani G, Campisi C, Taddei G, Boccardo F. The current role of lymphoscintigraphy in the diagnostic
evaluation of patients with peripheral lymphoedema. Lymphology 1998;31S:316–19.
8. Witte C, McNeill G, Witte M, et al. Whole-body lymphangioscintigraphy: making the invisible easily
visible. Progress in Lymphology XII, Elsevier Science Publishers B.V. 1989;123.
9. Bourgeois P, Leduc O, Leduc A. Imaging techniques in the management and prevention of posttherapeutic upper limb oedemas. Cancer 1998;83 (12 Suppl American):2805–13.
10. Kinmonth JB. The lymphatics. Surgery, lymphography and diseases of the chyle and lymph systems.
London: Edward Arnold, 1982.
11. Bruna J. Indication for lymphography in the era of new imaging methods. Lymphology
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treatment. Int Angiol 1999;18:10–13.
13. Partsch H. Indirect lymphography in different kinds of leg oedema. In: Lymphology: advances in
Europe. Genoa: Ecig, 1989; 95–9.
14. Bollinger A, Jager K, Sgier F, Seglias J. Fluorescence microlymphography. Circulation 1981;64:195–200.
15. Olszewski W. Lymph and tissue pressures in patients with lymphoedema during massage and
walking with elastic support. Lymphology 1994;27S:512–16.
16. Campisi C, Olszewski W, Boccardo F. Il gradiente pressorio linfo-venoso in microchirurgia linfatica.
Minerva Angiologica, 1994;19.
17. Vodder E. La méthode Vodder – le drainage lymphatique manuel. Bagsvaer: Institute for
Lymphdrainage, 1969.
18. Földi M. The therapy of lymphoedema. EJLRP 1993–1994;14:43–9.
19. Leduc A. Le drainage lymphatique. Théorie et pratique. Paris: Masson, 1980.
20. Olszewski WL. Recurrent bacterial dermatolymphangioadenitis (DLA) is responsible for progression
of lymphoedema. Lymphology 1996;29S:331.
21. Casley-Smith JR, Casley-Smith Judith R. High-protein oedemas and the benzo-pyrones. Sydney:
Lippincott, 1986.
22. Charles RH. A system of treatment. In: Latham A and English TC, editors. London: Churchill, 1912.
23. Thompson N. The surgical treatment of chronic lymphoedema of the extremities. Surg Clin North
Am 1967;47:2.
24. Servelle M. Pathologie vasculaire. Paris: Masson, 1975.
25. O’Brien B. Microlymphatic-venous and resectional surgery in obstructive lymphoedemas. World J Surg
1979;3:3.
26. Degni M. New techniques of lymphatic-venous anastomosis for the treatment of lymphoedema.
Cardiovasc Riv Bras 1974;10:175.
27. Campisi C. Rational approach in the management of lymphoedema. Lymphology 1991;24:48–53.
28. Campisi C. Lymphatic microsurgery: legend or reality? Phlebolymphology 1994;7:11–15.
29. Campisi C. Lymphatic microsurgery: a potent weapon in the war on lymphoedema. Lymphology
1995;28:110–12.
30. Campisi C, Boccardo F. Frontiers in lymphatic microsurgery. Microsurgery 1998;18:462–71.
31. Baumeister RGH. Clinical results of autogenous lymphatic grafts in the treatment of lymphoedemas.
In: Partsch H, editor. Progress in Lymphology XI, Elsevier Science Publishers BV, 1988, 419–420.
32. Campisi C. Use of autologous interposition vein graft in management of lymphoedema. Lymphology
1991;24:71–6.
33. Becker C, Hidden G, Godart S, Maurage H, Pecking A. Free lymphatic transplant. EJLRP 1991;2:75–7.
34. Trévidic P, Marzelle J, Cormier JM. Apport de la microchirurgie au traitement des lymphoedèmes.
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vasculaire, 1994;F.a. 43–225, 3.
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36. Campisi C, Boccardo F. Role of microsurgery in the management of lymphoedema. Int Angiol
1999;18:47–51.
37. Pecking AP, et al. Upper limb lymphedema’s frequency in patients treated by conservative therapy in
breast cancer. Lymphology 1996;29S:293–6.
464 Vascular Surgery
38. Campisi C, Boccardo F, Padula P, Tacchella M. Prevention of lymphoedema: utopia or possible
reality? Lymphology 1994, 27 (Suppl);676–82.
39. Pissas A. Prevention of secondary lymphoedema. Proceedings of the International Congress of
Phlebology, Corfu, Greece, 113, September 4–8, 1996.
40. Casley-Smith JR. Alterations of untreated lymphedema and its grades over time. Lymphology
1995;28:174–85.
47b. Management of Upper Extremity
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Lymphoedema with Liposuction
Håkan Brorson
A 53-year-old woman presented with an 8-year history of oedema of the right
arm. Twelve years ago she underwent treatment for right breast cancer. She had
mastectomy, removal of lymph glands, and postoperative irradiation. No
chemotherapy was given. The arm swelling started gradually without obvious
reason. Since the appearance of arm swelling she had experienced three bouts of
erysipelas that were treated with penicillin. Two years ago she was treated elsewhere with combined decongestive therapy (CDT) including manual lymphatic
drainage, bandaging and a set of compression garments. She had initially gained
some reduction of the excess volume, but no follow-up was done.
Now her main complain was pain and problems with clothing interfering with
her everyday activities. She stated that her arm was cosmetically unappealing and
that she did not want to see people in public. On examination she had a swollen
arm and limited limb movement.
Question 1
What would you do?
A. Perform the pitting test.
B. Perform an MRI.
C. Measure arm volumes.
D. Perform an indirect lymphoscintigraphy.
E. Start controlled compression therapy (CCT) or complete decongestive therapy
(CDT) with the help of a trained lymph therapist.
The pitting test showed pitting of 2 cm (Fig. 47b.1). Arm volume measurements
using the formula of the truncated cone showed an excess volume of 2700 ml. She
was referred to a lymph therapist for conservative treatment (CDT) to reduce the
excess volume. After 2 months the excess volume was reduced from 2700 ml to
465
466 Vascular Surgery
Fig. 47b.1.
The arm swelling is dominated by fluid, i.e. accumulation of lymph.
2100 ml. Further reduction was not possible in spite of a further 4 weeks’ treatment.
[Q1: A, C]
Marked arm lymphoedema after breast cancer treatment with deep pitting of several centimetres.
Question 2
What would be the next step in the management of this patient?
A. Perform the pitting test.
B. Perform an MRI.
C. Measure arm volumes.
D. Perform an indirect lymphoscintigraphy.
A new pitting test showed minimal pitting (4–5 mm) (Fig. 47b.2).
An MRI confirmed your suspicion of excess adipose tissue in the arm (Fig. 47b.3).
Arm volumes were calculated using the formula of the truncated cone and
showed an excess volume of 2045 ml (Fig. 47b.4). The patient now wanted further
reduction of the excess volume. [Q2: A, B, D]
Question 3
What would you do next?
A. Start conservative therapy again with the help of a trained lymph therapist.
B. Perform lymphatic-venous anastomoses.
C. Perform lymphatic-venous-lymphatic plasties (interposition autologous venous
grafting).
D. Perform transplantation of lymph vessels using vessels from the thigh.
E. Refer the patient for liposuction.
Lymphoedema 467
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Fig. 47b.2.
hard pressure by the index finger for one minute. A slight reddening is seen at the two spots where pressure has
been exerted. The “oedema” is completely dominated by adipose tissue. The term “oedema” is at this stage
improper as the swelling is dominated by hypertrophied adipose tissue and not lymph. At this stage the aspirate
contains no or minimal amount of lymph (Fig. 47b.6).
Pronounced arm lymphoedema after breast cancer treatment. There is almost no pitting is spite of
a
b
Fig. 47b.3. a
in the elbow region. Note the honeycomb pattern. bThe healthy left side in the same patient for comparison.
MRI (elbow region) showing a right-sided, secondary arm lymphoedema after breast cancer treatment
468 Vascular Surgery
Fig. 47b.4.
53-year-old woman with a preoperative oedema volume of 2050 ml in the right arm for 8 years.
Fig. 47b.5.
Peroperative pictures from the beginning a, during b, c, and at the end dof surgery.
Lymphoedema 469
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The patient was operated on with liposuction under bloodless conditions using a
tourniquet (Fig. 47b.5).
After 2 hours the aspirate removed during bloodlessness measured 2100 ml. A
standard compression garment was fitted on the arm before the tourniquet was
released. The size of the garment was determined from preoperative measurements
on the healthy arm. In order to reduce bleeding, tumescent technique was used on
the most proximal part of the upped arm that was covered by the tourniquet.
Tumescent technique includes infiltration with a saline-adrenaline solution (1 mg
adrenaline/1000 ml saline) followed by liposuction. The next day the aspirate had
sedimented and showed 92 per cent adipose tissue and 8 per cent fluid (lymph/
interstitial fluid) (Fig. 47b.6).
Following surgery, controlled compression therapy (CCT) was instituted: Two
days after surgery measurements were taken for custom-made compression garments, that is, sleeve and glove, two of each. The patient was discharged after
5 days, and was seen after 2 weeks. During the first 2 weeks the patient alternated
two standard sets of sleeve-and-glove garments, i.e. two sleeves and two gloves. At
the 2-week visit plethysmographic measurement of both arms showed an excess
volume of 185 ml (91 per cent reduction). She was fitted with the custom-made compression sleeves and gloves ordered on measurements taken 2 days postoperatively.
Fig. 47b.6.
This picture shows a typical aspirate of 2000 ml with an adipose fraction of 90 per cent and a fluid fraction of
10 per cent.
The aspirate achieved under bloodless conditions usually contains 90–100 per cent adipose tissue.
470 Vascular Surgery
Fig. 47b.7.
During the consecutive follow-up the patient was seen at 4 weeks, 3 months,
6 months and 1 year. At the 3-month visit complete reduction was achieved and has
lasted ever since. Then, as complete reduction had been achieved, she was seen once
a year (see detailed information later in the text regarding CCT). At the last control,
10 years after surgery, an excess volume of –340 ml was registered; thus the treated
arm was somewhat smaller than the normal one (Fig. 47b.7).
Clinical result 10 years after liposuction.
Question 4
How often, after the first year, is the patient checked when complete reduction has
been achieved?
A. Every month.
B. Every 3 months.
C. Twice a year.
D. Once a year.
E. Not necessary.
Question 5
At least how many compression garments (sleeve-and-glove) a year should this
patient be provided with?
A. One garment.
B. Two garments.
C. Three garments.
D. Four garments.
E. Garments are not needed.
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