Tracking Outcomes Following Lymphedema Treatment




Key Points





  • Surgical success can be defined as the downgrading of the patient’s lymphedema with at least a 10% circumferential differentiation decrease, with improved symptoms, decrease in episodes of cellulitis, and improved quality of life.



  • Surgical failure can be defined as the inability to improve the symptoms and quality of life, including worsening them.



  • Surgical cure can be defined as a return to a normal limb circumference and the ability to wean off compressive therapy—in other words, not curing the lymphatic pathology, rather restoring a physiologically compensated limb and return to normal quality of life with surgery.



  • A new objective classification presented here aims at standardizing grading for streamlining management, selection of procedures, and improved communication about the disease.



  • Limb measurements require standardization.



  • Studies document that lymphedema surgery may improve quality of life.





Introduction


Modern lymphedema care is a growing field, currently defining itself, its breadth, its indications, and its promises. As with any emerging field, it also requires a better-defined framework for debate and effective communication. Due to recent rapid evolution, there still is a relative paucity of outcomes data from which to draw strong conclusions. More data and research is required to determine benchmarks for patient treatment outcomes, a key aspect in the progress of care. The goal of this chapter is to help navigate published data, but also to attempt to fill the required gaps to treat lymphedema patients based on expert opinions for best practice. This chapter outlines a step-by-step approach for postoperative care and management. Lastly, experience with quality of life measures is presented for the various types of lymphedema surgeries. By accruing knowledge of patient-related, subjective outcomes, the field of lymphatic surgery can gauge itself with the ultimate measure of patient satisfaction, and in turn reflect on and pave the way for refinement and innovation in technique.




Definitions and Assessing Outcomes


Relatively few ailments can be truly cured in medicine. Instead, we would like to propose definitions for surgical success, surgical failure, and surgical cure in lymphatic microsurgery procedures. Several staging systems exist, with the International Society of Lymphology (ISL) staging being the most accepted by the medical community so far. However, it is difficult to use the ISL staging for surgical patients, and apply it to track outcomes. Therefore, we propose a grading system, as shown in Table 23.1 , for preoperative and postoperative assessment based on objective observations including circumferential differentiation, lymphoscintigraphy, episodes of cellulitis in the last year, and quality of life. This grading system provides easy communication between surgeon and patient, and between healthcare professionals. Surgical success can be defined as the downgrading of the patient’s lymphedema with at least 10% circumferential differentiation decrease, with improved symptoms, decrease in episodes of cellulitis, and improved quality of life. Surgical failure can be defined as the inability to improve the symptoms and quality of life, including worsening them. Surgical cure can be defined as a return to normal limb circumference and ability to wean off compressive therapy—in other words, not curing the lymphatic pathology, rather restoring a physiologically compensated limb and return to normal quality of life with surgery. Figure 23.1 shows representative grading examples, also depicting the clinical improvement that can be seen with downgrading.



Table 23.1

Cheng’s Grading System of Lymphedema and Available Options for Management














































Grade CD Lymphoscintigraphy Episode of Cellulitis in the Last Year ICG Pattern Options for Management
0 < 9% Partial obstruction 0–1 Linear CDT
I 10–19% Partial obstruction < 2 Linear, splash CDT, LVA, liposuction
II 20–29% Total obstruction 2–4 Linear, splash, stardust VLN transfer, LVA
III 30–39% Total obstruction 4–6 Splash, stardust, diffuse VLN transfer with liposuction or partial excision
IV > 40% Total obstruction > 6 Stardust, diffuse Excision surgery with VLN transfer

CD, circumferential differentiation; ICG, indocyanine green; LVA, lymphovenous anastomosis; VLN, vascularized lymph node; CDT, complete decongestive treatment





Figure 23.1


Examples of lymphedema grade 1, 2, 3, and 4 according to Cheng’s grading system for left upper (A–D) and lower limb lymphedema (E–H) . Grade 0 has a near-normal limb appearance with abnormal lymphoscintigraphy findings, and is therefore not illustrated.




Postoperative Considerations


Schedule of Visits


Postoperative clinic visits are conducted weekly for the first month, then monthly for a year, and every three months afterwards unless guided by symptoms otherwise. Visits occur at the same time or in parallel to physiotherapy appointments, depending on facilities and patient preference. Goals of the early visits are to identify and manage early postoperative complications, ensure timely coordination with other specialists, and maintain good rapport and encouragement among this challenging group of patients. As some studies have found, patient compliance is the most important factor in lymphedema treatment. It is also important to be vigilant and look for early signs of complications, such as hematoma, dehiscence, wound infection, and flap compromise or decrease in function from early compressive therapy. Figure 23.2 depicts skin changes that can be seen postoperatively. Later visits mostly aim at maintenance of the surgical result, assessment of need for revisionary surgery, and adjunctive liposuction, as needed.




Figure 23.2


Preoperative photographs (A,B) of the bilateral lymphedematous feet documenting fungal infection and dermatitis. Photographs at two months after vascularized submental lymph node flap transfer to the ankle (C,D) show subsided fungal infection and improved dermatitis.


Limb Measurements


There is no global consensus on how to best measure and define the limb volume changes in lymphedema or how to assess progress or regress with treatment. Limb measurement is important postoperatively to track surgical results and outcomes, and to ease communication between surgeon and patient, and between healthcare professionals, as mentioned. The circumferential differentiation obtained from these measurements is a key objective parameter in the grading system introduced in this chapter. Modern lymphedema care requires such limb measurement standardization for diagnosis and grading. Several modalities exist and are discussed and compared in the literature, including circumferential tape measurement, water displacement, skin tonometry, perometry, bioelectrical impedance, and computed tomography (CT). Further investigation to find an easier and universal measurement may help global communication among lymphedema specialists.


Water Displacement


Limb volume can be determined by using Archimedes’ principle of water displacement. The limb is placed in a container housing a volume of water than can be displaced outside the container and measured. Water displacement is considered by some to be the gold standard in the laboratory, but not necessarily in the clinical setting, as this method of volume measurement is not amenable to patients with open wounds, is cumbersome, and reveals no information about the localization of the edema in the limb. Furthermore, it may be difficult to perform in severe, higher-grade lower limb lymphedema.


Circumferential Tape Measurement


Tape measurements are easily performed at every postoperative visit. In our institution, measurements for limb lymphedema are taken at 10 cm above and below the elbow joint for upper limb, and at 15 cm above and below the knee and 10 cm above the ankle for the lower limb. If limb volumes are desired, they can be approximated by calculation of the volume of a frustum, CT, or magnetic resonance imaging. Serial measurements are used to track improvement in limb size, and also to see when patients reach a plateau in circumferential reduction.


As shown in Figure 23.3A–D , circumferential differentiation (CD) is defined as the circumference of the lesion limb minus the healthy limb, divided by that of the healthy limb. Circumferential reduction rate (RR) is defined as the preoperative difference between the circumferences of the lesion and healthy limbs minus the postoperative difference, divided by the preoperative difference. As an example, in a study of vascularized lymph node transfer for upper limb lymphedema, at a mean follow-up of 39 months, the mean improvement of circumferential differentiation was 7% and the reduction rate was 40% in postmastectomy upper limb lymphedema.






Figure 23.3


Circumferential differentiation (CD) and reduction rate (RR) for upper (A,B) and lower limb (C,D) lymphedema. Such measurement is practical in many settings, reproducible, and facilitates communication between healthcare professionals. It is easy to track limb size changes preoperatively and postoperatively. AA, above ankle; AE, above elbow; AK, above knee; BE, below elbow; BK, below knee.


There are several advantages to this measurement modality:



  • 1.

    Circumferential tape measurement can be performed readily in many settings.


  • 2.

    It is a test that does not have to be performed or administered by a doctor.


  • 3.

    It is low cost, accessible, and easily reproducible.


  • 4.

    It does not require special equipment.


  • 5.

    It does not expose the patient to radiation.



This modality is easy to compare the improvement of lymphatic microsurgery ( Figure 23.4 ). A comparative study between different modalities for limb volume measurement concluded that compared to water displacement volumetry, circumferential measurement has better reliability, and that this technique should be considered as the method for lymphedema measurement in clinical practice.




Figure 23.4


The progress of circumferential differentiation in different levels of the lower limb post vascularized submental lymph node flap transfer to ankle at a follow-up of 12 months.


Skin Tonometry


A tonometer measures tissue tension, which is representative of tissue resistance to compression. As lymphedema worsens with fibrotic change, the tissue becomes firmer. Postoperatively, tonometry can be used to assess the improvement in tissue tension as lymphedema improves, especially in cases where frank fibrotic change has not set in. Skin tonometry only assesses the skin tension of the superficial compartment, which may not accurately represent any deep-compartment pathology.


Perometry


Perometry is an optoelectronic volumetry device that uses infrared light to measure cross-sectional areas of a limb. The limb is placed in the perometer’s frame, which scans the limb longitudinally, and a computer then integrates this information to obtain a volume. Standard deviations of 8.9 mL, or about 0.5% of arm volume, have been reported. Perometers, although not readily available, are validated measuring tools.


Bioelectrical Impedance


Bioelectrical impedance determines the amount of extracellular fluid in a limb via resistance to an electrical current. The current is passed through the limb via standardized electrodes, and resistance is determined at various points. With increasing fluid content, resistance lowers. The measurement is rapid and can be readily used in community settings and it is reliable. Advantages of its postoperative use are ease of measurement in the clinic, and ability to place electrodes away from wounds. However, values can take time to normalize as postoperative changes such as edema resolve, and the results of surgery become evident.


Duplex Ultrasound


Duplex ultrasound is used not only preoperatively for the assessment of venous competence, but also in the postoperative setting if there is any sign of venous incompetence or varicose veins becoming engorged with lymphedema improved. In our institution, duplex ultrasound examination is also performed at six months postoperatively to count the number of lymph nodes transferred and document pedicle patency and vessel diameters.


Computed Tomography (CT)


Computed tomography scans have an important role preoperatively and postoperatively for several reasons. This imaging modality, exemplified in Figure 23.5 , can show the current state of lymphedema and its improvement, areas of poor lymphatic drainage, and allow exact volume measurement. In our institution, CT scans are performed preoperatively and at six months postoperatively. They also represent valuable comparative data with preoperative scans.


Apr 10, 2019 | Posted by in General Surgery | Comments Off on Tracking Outcomes Following Lymphedema Treatment
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