Lymphedema & Lymphedema Surgery
Lymphedema refers to swelling that generally occurs in one of your arms or legs. Although lymphedema tends to affect just one arm or leg, sometimes both arms or both legs may be swollen.
Lymphedema is caused by a blockage in your lymphatic system, an important part of your immune and circulatory systems. The blockage prevents lymph fluid from draining well, and as the fluid builds up, the swelling continues. Lymphedema is most commonly caused by the removal of or damage to your lymph nodes as a part of cancer treatment, but can occur for a variety of reasons including surgery, after injury, after infection, or because of congenital or spontaneous issues.
There’s no cure for lymphedema, but it can be controlled. Controlling lymphedema involves care of your affected limb.
Lymphedema symptoms include:
- Swelling of part of your arm or leg or your entire arm or leg, usually including your fingers or toes
- A feeling of heaviness or tightness in your arm or leg
- Restricted range of motion in your arm or leg
- Aching or discomfort in your arm or leg
- Recurring infections in your affected limb
- Hardening and thickening of the skin on your arm or leg
The swelling caused by lymphedema ranges from mild, hardly noticeable changes in the size of your arm or leg to extreme swelling that can make it impossible to use the affected limb. If your lymphedema is caused by cancer treatment, you may not notice any swelling until months or years after treatment.
Why does lymphedema occur?
In developed countries, such as the United States, the overwhelming majority is related to prior surgery, radiation, or some form of damage. In third world and less developed countries, parasites and other infections are responsible for most causes. The most commonly heard of situation in the USA is probably swelling of the arm after breast cancer surgery or radiation, but it can occur anywhere on the body.
What many people don’t know, however, is very often, there is a significant venous component to lymphedema. This is because the lymphatic and venous systems are closely intertwined, and the lymphatic system drains into the venous system as well. Unlike the arterial system – where average pressure is approximately 100mm of mercury and circulation is actively pumped by the heart – the venous and lymphatic systems rely on passive flow due to muscle contraction and gravity to move fluid, and very low pressure systems. Average venous and lymphatic pressures are anywhere from -5mmHg to 10mmHg, depending on the area measured. Because the lymphatic and venous systems are so low pressure, they require very little pressure to significantly impact their flow. A very small change in anatomy, a small scar, or any other pressure such as an injury can completely obstruct their flow, unlike arteries, which require a major obstruction because of the much higher pressure and active pump, the heart.
How does venous circulation affect lymphatic circulation? Any increase in venous pressure, by default, will cause a slowing of lymphatic circulation because the lymphatic system drains into the venous circulation, much the same way as a problem In your main drain to a house would affect any other drain.
In addition, venous circulatory system problems present with many of the same systems as lymphatic problems – swelling, fluid buildup, pain, and often redness of the affected area. This is why venous circulation should always be investigated, when a lymphatic circulation abnormality is suspected.
Correcting any venous circulatory issues, by the same logic, often leads to clinical improvement in many lymphatic problems due to the same logic. Although it may not solve the issue completely, it often offers a significant benefit, with a much lower risk profile as compared to lymphatic specific surgery, and does not remove the possibility of allowing lymphatic surgery in the future if needed.
What are some other causes of lymphedema?
While previous surgery or radiation is often the culprit for lymphedema, congenital causes also exist, and most often are due to anatomic compression of veins and lymphatics by an abnormal arrangement of internal anatomy, typically an artery compressing the veins. This type of lymphedema often has a strong venous component, and unlike post-surgical lymphedema, which is typically one sided, is typically bilateral or affects both sides of the body.
Lymphedema can also occur due to kinking of venous and lymphatic vessels, which often happens in situations where there are “hanging” tissue from certain parts of the body. This typically occurs in areas where there is hanging skin, or large pendulous breasts.
Lastly, it can occur due to external local compression of venous or lymphatic vessels by benign or malignant masses such as fibroids or tumors that occludes the flow in these vessels.
Ideally, the best treatment plans arise from a multi-system evaluation, and a full understanding of how they relate to each other in order to select the most effective treatment, which is what we are able to provide at NYC Surgical.
Aside from the reasons stated, why is it a good idea to get venous problems corrected prior to any other surgery on an affected limb?
Aside from swelling, venous circulatory problems affect oxygen delivery to the affected area, and in doing so, make poor healing and infection a more likely scenario. In a simplistic fashion, a venous narrowing could be looked at very similarly to having a tourniquet tied around the area, and affects the circulation in much the same way. Venous blood, which is oxygen poor, mixes with arterial blood, which is oxygen rich, and the overall result is similar to mixing fresh water with dirty water…….the overall quality of oxygen is not as bad as pure venous blood, but clearly worse than if there was no venous blood trapped. When oxygen concentration is not as high as normal, healing is impaired, as is clearance of infection. This is because your body needs a rich supply of oxygen for cellular maintenance, especially when an injury has been inflicted, as it is in surgery of any type.
When to see a doctor about lymphedema
Make an appointment with your doctor if you notice any persistent swelling in your arm or leg.
Lymphedema in your arm or leg can lead to serious complications, such as:
- Infections. Lymphedema makes your affected arm or leg particularly vulnerable to infections. Possible infections include cellulitis — a serious bacterial infection of the skin — and lymphangitis — an infection of the lymph vessels. Any small injury to your arm or leg can be an entry point for an infection.
- Lymphangiosarcoma. This rare form of soft tissue cancer can result from the most-severe cases of untreated lymphedema. Possible signs of lymphangiosarcoma include blue-red or purple marks on the skin.
Your doctor may try to rule out other causes of swelling when diagnosing lymphedema. Swelling can have many causes, including a blood clot or an infection that doesn’t involve your lymph nodes.
If you’re at risk of lymphedema — for instance, if you’ve recently had cancer surgery involving your lymph nodes — your surgeon may diagnose lymphedema based on your signs and symptoms.
Typical testing involved starts with vascular and soft tissue ultrasound imaging, which is painless and non-invasive, but if the cause is not clear, other testing may include MRI, CT scanning, and lymph scanning.
Lymphedema treatment options
Treatment options for lymphedema start with non-surgical options such as compression garments, therapeutic massage and physical therapy. If disease remains unmanageable with these options, surgical options include a variety of techniques from lymph fluid rerouting by microsurgery and lymph node tranposition to therapeutic liposuction to remove some of the bulky tissue involved. Because our offices offer the most cutting edge diagnostic imaging as well as the full spectrum of surgical options, we can tailor the plan to each patients needs.
What are the risks of treatment?
The risks of any endovenous treatment is largely the same as any other endovascular surgery. While it is for the most part a very low risk procedure, things like blood vessel damage, and blood clots can form, although this is a rare occurrence. Most often, especially in the lower limbs, correction of narrowing of veins requires implantation of a small device called a stent, which is permanent. Although this is quite a safe procedure, it is of critical importance that your surgeon clearly illustrates the need for treatment, and discusses all options thoroughly with you prior to treatment. In the right hands, stenting has an extremely high success and satisfaction rate.
Risks of lymphatic specific surgery have additional complications as they often involve an incision unlike endovascular surgery, which is done though an IV. Most additional complications are incision related, such as infection, wound problems, and scarring. As lymphatic specific surgery is typically done where the problem exists, and scarring is one of the causes of lymphedema, there is a small but present risk that it makes the problem worse.
What are the risks of non treatment?
In general, risk of non treatment is very low, and largely related to the problems that are currently present in the patient. Typically, lymphedema is a progressive disease that worsens with time, although at a very slow rate. In severe, longstanding cases, scarring occurs due to the chronic inflammation that renders the problem partially irreversible at some point, but this typically takes time to develop, and your decision to seek treatment should be a well thought out one, and only made when you have a full understanding and feel comfortable proceeding. It does not need to be an urgent decision. Medical management (non surgical) mostly consists of compression devices of numerous types and options.