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Lymphoedema

Sydney Vascular Surgeon - Dr Mayo Theivendran

What Is lymphoedema?

Lymphoedema is a medical condition that occurs when there is a blockage or damage to the lymphatic system, which is responsible for draining fluids from the tissues in your body. This results in a buildup of lymphatic fluid, causing swelling and discomfort in the affected area. Lymphoedema can occur in any part of the body but is most commonly seen in the arms and legs. It can be caused by a variety of factors, including surgery, radiation therapy, infection, and genetics.

Diagram showing disrupted flow of lymphatic fluid
Diagram showing normal leg vs mild oedema vs moderate to severe oedema

How does lymphoedema present?

Lymphoedema should be considered in patients who have swelling of a body part that has persisted for more than three months (or earlier if it is associated with surgical removal of lymph nodes). It may be associated with a feeling of heaviness and aching, and in the beginning, the swelling may fluctuate in severity from day to day.

What are the causes of lymphoedema?

There are two main types of lymphoedema:

Primary Lymphoedema

  • Congenital abnormalities or malformation of the lymphatic system (presenting under two years of age)
  • Late-onset due to underlying malformation (presenting over 2 years of age)
  • Syndromal conditions: lymphoedema-distichiasis, Klippel-Trenaunay syndrome and Prader-Willi syndrome, among others

Secondary Lymphoedema

  • Trauma and tissue damage: lymph node excision, radiotherapy, burns, varicose vein surgery, wounds
  • Malignant disease: lymph node lymphoma, pressure from large tumours
  • Venous disease: chronic venous insufficiency/ ulceration, post-thrombotic syndrome
  • Infection: cellulitis/ erysipelas, lymphadenitis, filariasis Inflammation: rheumatoid arthritis, dermatitis,
    psoriasis, sarcoidosis
  • Medications: calcium channel blockers, corticosteroids, NSAIDs, pregabalin, taxanes
  • Other: Obesity, lipoedema, dependency oedema, paralysis

Stages of lymphoedema

Stages of lymphoedema: Stage 0 & Stage 1
Stages of lymphoedema
Stages of lymphoedema: Stage 2 & Stage 3

Lymphoedema red flags

When diagnosing lymphoedema, other causes of swelling must be excluded when the following red flags are present

  • Sudden swelling
  • Pain as main complaint
  • Skin colour change
  • Lumps, sores & ulcers
  • History of unmonitored cancer
  • Paraesthesia (numbness & tingling)
  • Prominent veins in the swelling region

Investigations for lymphoedema

Lymphoscintigraphy

Lymphoscintigraphy

Lymphoscintigraphy is a nuclear medicine procedure used to demonstrate lymphatic morphology and function. It is particularly useful when the cause of swelling is unclear.

New Imaging Techniques

New Imaging Techniques

These can include indocyanine green fluoroscopy (ICG), which can be used to map the superficial lymphatics. This can be useful in difficult clinical cases.

Ultrasound

Ultrasound

Ultrasound, Doppler ultrasound, MRI & CT can be useful to exclude differential diagnoses and also to assess for local area tissue changes.

Treatment of lymphoedema

The best treatment will involve a multimodal regime.

Lymphoedema treatment Sydney - skin care

Skin care - Cleansing and moisturising provides a barrier and encourages lymphatic flow. Regular checks for fungal infections and cellulitis are also beneficial

Lymphoedema treatment Sydney - Exercise

Exercise - Encourages lymph flow and is important for weight management. Hydrostatic pressure using hydrotherapy is also recommended

Lymphoedema treatment Sydney - Compression

Compression - This is used initially in the form of bandaging to reduce swelling. Compression garments can then be used to maintain this reduction

Lymphoedema treatment Sydney - Manual lymphatic drainage

Manual lymphatic drainage - This is a specific decongestive massage technique to help move fluid away from congested areas

Lymphoedema treatment Sydney - patient education

Education - Engagement of patients in their self-management regimen is crucial

Compression

Contradictions for compression include:

  • Arterial Insufficiency / Peripheral Arterial Disease
  • Uncontrolled Heart Failure
  • Severe Peripheral Neuropathy (e.g. diabetes)
Newer compression treatments are constantly emerging, including:

  • Sequential Intermittent Pneumatic Compression
  • Negative Pressure
  • Lymph Taping

 

Before commencing lower leg compression, Dr Theivendran will conduct a vascular assessment to exclude any underlying arterial and venous insufficiency

The GP's role

The general practitioner (GP) plays an important role in managing the long-term care of patients with lymphoedema. The GPs role includes reinforcing:

  • Good skincare
  • Exercise
  • Antibiotic use
  • Massage
  • Travel precautions
GPs can help form a strong multidisciplinary team that may include a lymphoedema specialist, podiatrist, dietitian, and psychologist.

Photo demonstrating lymphoedema of the left hand

Before and after surgical treatment of lymphoedema of the right leg.

Finding a lymphoedema practitioner

Lymphoedema practitioners are healthcare professionals who specialise in lymphoedema management. They may include physiotherapists, occupational therapists, nurses, and remedial massage therapists who have completed lymphedema management training accredited by the Australian Lymphology Association (ALA). They can be found in larger public hospitals with lymphedema services and as private practitioners.

Surgical Intervention

New treatments are available for the surgical management of lymphedema. These can include:

1. Treating Venous Insufficiency

  • Venous stents: Opening veins for blood to flow through the blocked or narrowed vein
  • Venous ablation: To close off varicose veins which result in fluid build up

2. Treating Arterial Insufficiency

  • Angioplasty: Inserting a catheter with a balloon or stent into the artery to open a narrowed or blocked artery.
  • Bypass surgery: Creates a new pathway for blood to flow around blocked or narrowed arteries.

3. Liposuction

A surgical procedure that removes excess fat from the body. It can be used to reduce the amount of fatty tissue in areas affected by lymphoedema, which can help improve lymphatic flow and reduce swelling.

Liposuction process

  Questions

If you have any questions for Dr Theivendran or our team, please don't hesitate to contact our rooms on (02) 9066 6547

For appointments and enquiries:

Monday - Friday: 8:00am to 5:00pm
Fax: (02) 9182 7533

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