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Lymphoedema is the accumulation of protein-rich interstitial fluid within subcutaneous tissue and skin as a result of dysfunction of the lymphatic system. It is an underestimated, widely neglected and debilitating chronic condition. This article presents an overview of lymphoedema and recent advances in its management.
Contexts in source publication
Context 1
... example, primary lymphoedema almost always affects children, with adult onset uncommon. In addition, clinical examination helps to assess severity ( Table 4). ...Citations
... ICG lymphangiography is gold standard for identifying functional lymphatic channels as well as grading lymphedema severity, making it the most appropriate diagnostic tool in modern lymphedema management, including planning lymphatic surgery. 60 Consequently, volume measurement of >10% of the affected limb was the most widely recommend parameter for diagnosing lymphedema. 61 Regardless of the underlying etiology, lymphedema management was recommended to focus on initial, intensive, and maintenance treatments, while individuals at risk of developing lymphedema were advised to undergo prospective surveillance. ...
Significance:
Lymphoedema is a common, distressing and debilitating condition with various aetiologies. Effective diagnosis, assessment and management rely on evidence-based clinical practice guidelines ("guidelines"). This study aims to describe and compare international guidelines on lymphoedema diagnosis, assessment and management. Recent Advances: The review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and registered on the International Prospective Register of Systematic Reviews (PROSPERO). Systematic searches of electronic literature databases and the web were completed in December 2020 for lymphoedema guidelines published in English since 2000. Quality was assessed using the AGREE-II reporting checklist. Synthesis took a narrative approach to compare guideline recommendations and associated levels of evidence.
Critical issues:
This systematic review of 1564 articles and 159 web pages yielded 14 guidelines. All guidelines were from high-income countries. Ten focused exclusively on lymphoedema, and four on cancer. Most (n=13) guidelines recommended an integrated medical, psychological assessment and physical examination, with a limb volume measurement of >10% in the affected limb compared, confirming a lymphoedema diagnosis. Recommended management involved Complex Decongestive Therapy (CDT) followed by self-management using skincare, self-lymphatic drainage massage, exercise and compression.
Future directions:
The underlying aetiology of lymphoedema appeared to make little difference to guideline recommendations regarding care. High-quality guidelines are available to guide lymphoedema care. However, their suitability for low resource settings is unclear.
... Procedures like debulking, liposuction and amputation are the other options requiring multi-disciplinary approach involving radiology, plastic reconstructive surgery, vascular surgery, surgical oncology, radiotherapist and of course a more experienced paramedical staff and intensive surgical care unit maintaining strict asepsis. 23,24 ...
Lymphoedema is a chronic, progressive debilitating disorder of lymphoreticular system, characterized by abnormal collection of excessive proteins, oedema, chronic inflammation and fibrosis.
Primary lymphoedema, associated with underlying, but inherent malfunction of lymphatic channels, unilateral or bilateral. It can be further subdivided in to congenital lymphoedema, lymphoedema praecox and lymphoedema tarda. Depends on the age of onset or manifestation. Another genetic disorder of lymphatic dysfunction is Milroy disease. It is an autosomal dominant condition due to VEGFR3 mutation characterised by lymphatic hypoplasia. Secondary lymphoedemas are more frequent than primary to dysfunction of lymphatics. Mostly localised, follwing recurrent infections, trauma, surgery, obesity and malignancy.
Inadequate drainage of lymphatics, leads to accumulation of lymph, interstitial fluid and proteins in skin and subcutaneous tissue. Elastic tissue disruption, fibroblast stimulation occurs and the resulting hypoxia causes chronic inflammation and fibrosis. Later adipocyte remodelling occurs and proinflammatory cytokines secreted.
Starts as pitting non tender pedal oedema, later skin thickening and fibrosis which results in non-pitting oedema. Squared off appearance and Kaposi Stemmer sign are characteristic features. May develop lymphorrhoea and secondary infections may supervene. Chronic venous insufficiency, lipoedema, myxedema.
Vicious cycle of infections and lymphedema.
Lymphoscintigraphy, lymphoflouroscopy- gold standard.
Depends on severity. Pneumatic compression garments, Low level light therapy (LLLT), Extracorporeal shock wave therapy (ESWT). Advanced stages may require surgical debulking, lymphatic reconstruction. But the results are mostly unsatisfactory, recurrences are inevitable. Combined multi-disciplinary approaches will be helpful and that should be continued throughout their life.
Lymphoedema effects approximately 200 000 people in UK. It is a chronic condition without a cure but there is much that can be done to ease and manage these complications. This article looks at the eight most common complications, providing advise on how to manage them, derived from the literature and the author's own experience. It also presents advise on how nurses can promote self-management of these complications, promoting patients' self-care.
Supermicrosurgery was popularised in 1997 and is defined as a technique of microvascular anastomosis for single nerve fascicles and vessels 0.3–0.8 mm in diameter. It requires the use of powerful microscopes, ultradelicate microsurgical instruments and specialist dyes. The development of supermicrosurgery has vastly improved the ability of microsurgeons to create true perforator flaps with minimal donor site morbidity for reconstructive surgery and improved the precision of additional microsurgical techniques. This review outlines the origins and history of supermicrosurgery, its current applications in reconstructive surgery (including fingertip reconstructions, true perforator flap surgery, nerve flaps and lymphoedema surgery), supermicrosurgery training and future directions for the field.
There has been a paradigm shift in the management of lymphedema with a better understanding of the functioning of lymphatics with the introduction of “lymphosome concept” and with the recent advances in super-microsurgical techniques. The most frequently used intraoperative imaging modality now is indo cyanine green lymphangiography. In endemic countries, any patient with lymphedema without prior history of trauma or, oncosurgical or radiotherapy interventions must undergo Alere filariasis test strip. Patients in early stages of disease can benefit from complex decongestive therapy and physiologic surgical procedures such as lymphovenous anastomosis or vascularized lymph node transfers. However, in advanced disease, excisions or debulking through radical reduction with preservation of perforators will be required. The localized adipose tissue deposits in lymphedema can be removed by liposuction. At present, there is still no cure for lymphedema, but emerging research in tissue engineering, lymphangiogenic growth factors, and immunomodulatory therapy may provide better management options for lymphedema in future.
