LYMPHOEDEMA

Lymphoedema is the swelling of a limb because of the lymph nodes absence or dysfunction. Lymph nodes have immunologic activity and thus contribute to the prevention of infections. Lymphoedema can be iatrogenic or congenital, the onset can be insidious and the course is slowly progressive.

More often lymphoedema can occur several months or even years after an operation with axillary or inguinal lymph node resection and sometimes additional radiotherapy. Congenital lymphoedema is when some children are born with severe aplasia of lymph nodes.

The progression of the disease involves skin thickening with appearance of vesicles, color changes and more frequent infections. Recurrent subclinical infections lead to gradual organisation and fibrosis and eventually the progressive destruction of the lymphatic system. Lack of local hygiene leads to these secondary infections and eventually advanced elephantiasis.

Reconstruction technique of Lymph Node transfer

The idea of lymph node transplantation is to transport and fix living nodes in an area where they are lacking and eventual establishment of a new lymphatic system for normal circulation. In cases where there is extensive post irradiation fibrosis, the transfer of healthy tissue after the excision and liberation of all the scar tissue in the recipient area helps to make it soft.

There are three donor sites from where a free lymph node graft can be harvested, without causing donor site oedema:

  1. 1.A group of nodes in the proximity of the iliac crest (hip)
  2. 2.A group of nodes In the upper thorax (not the arm) just below the armpit
  3. 3.A group of nodes in the neck just above the clavicle

Clinical situations which can be treated with Lymph Node Transfer

1. Arm lymphoedema after breast cancer

After surgery for breast cancer where axillary lymph node clearance has been performed, patients may develop upper limb oedema. Preoperative preparation includes an isotopic lymphangiography and a MRI scan showing the site of lymph node obstruction or absence and the lymphatic pathways that can be developed.

The operation idea consists of the harvesting of a group of nodes from the hip and transplants it at the axilla, exactly where the original nodes had been removed. A hospital stay of two to three days is usual with lymphatic drainage commencing immediately postoperative.

Within two years after the operation the results are satisfactory

  • For moderate lymphoedema (stages 1 & 2): Normalisation of the limb can be seen in 40% of the patients and an improvement of more than 50% for the most of the remaining. Only 2% of the patients experience no improvement.
  • For huge lymphoedema (stage 3): There is an improvement in 98% of cases, with up to 30 cm loss in circumference. Sometimes, when lymphoedema transforms into lipoedema, a small liposuction can optimize the result.

2. Simultaneous reconstruction of breast with treatment of lymphoedema

Skin and fat can be harvested from the abdomen on the same vascular pedicle to reconstruct the breast in the same session as the node transplant. This allows simultaneous treatment of both problems with superior aesthetic results.

3. Arm palsy and pain after radiotherapy

Sometimes, lymphoedema is associated with neurological pain and complete or partial palsy. In those cases, the nerves are dissected from the fibrosis and a relatively large fatty flap is placed and fixed around the nerve to diminish subsequent fibrosis. More than 90% of patients experience pain relief.

4. Lower limb edema after malignancy

Lymphoedema can occur after extended radical hysterectomy for cancer, melanoma excision of the leg and lymph node clearance and after radical excision of lower pelvic malignancy (where lymph nodes are removed) in men. Preoperative preparation includes an isotopic lymphangiography and a MRI scan, showing the site of lymph node obstruction or absence and the lymphatic pathways that can be developed. The operation idea consists of the harvesting of a group of nodes from the upper thorax and transplants it at the hip, exactly where the original nodes had been removed. A hospital stay of two to three days is usual with lymphatic drainage commencing immediately postoperative.

Results show improvement in 90% of cases. Even in very long standing lymphoedema cases with extensive fibrosis, there is satisfactory improvement and a decrease in infection rates.

5. Congenital Lymphoedema

In congenital cases the inguinal nodes may exist but are not efficient because lack of channels. The nodes are transplanted in the inguinal or at the knee area if lymphoedema is presenting like a stock.

Postoperative physiotherapy is essential. Physiotherapy for lymphoedema must be done by specialized lymphologists. It is actually a lymphatic drainage and not a classic massage. Lymphatic drainage maneuvers are pushing the extracellular liquid to the lymphatic vessels in the subcutaneous tissue. The lymph nodes should be first emptied, to be filled with the drained liquid. After the lymph nodes transplantation, the new lymphatic vessels replace progressively the drainages.