It seems like a lifetime ago already – thank goodness I have my conference handbook to refer to because I wouldn’t remember one-tenth of the topics that were covered otherwise.
First up on Saturday morning there was a discussion on the relationship between clinical measures and underlying physiological changes – a couple of interesting points here – it has been demonstrated that tissue composition changes are evident in those with mild lymphoedema and that the impact of these changes depends on whether the affected arm is dominant or non-dominant. What that means is that generally, there is more fat present in the unaffected limb if the non-dominant arm is affected! Interesting.
Next was a presentation on segmental impedance thresholds for early detection and monitoring of upper limb lymphoedema. Early detection of LE is important for effective treatment outcomes so finding a way of measuring changes effectively is essential. Segmental measurements of the arm with Bioimpedence Spectropscopy was shown to be a reliable way of measuring early changes after measuring one hundred women without a history of breast cancer or lymphoedema.
There was a clinical practice review of the pitting test. The pitting test is widely used to assess oedema in healthcare, but there is no standardisation between clinicians – each person’s touch is significantly different. Three different therapists performed a pitting test assessment on six women with unilateral breast cancer related lymphoedema. The therapists were all reliable in determining whether the tissue was pitting or non-pitting but had less agreement on the tissue qualities. This study reinforces the need to develop a standardised pitting test protocol with guidelines for interpreting the test results.
Assessment of oedema in the breast skin following skin-sparing mastectomy and immediate reconstruction. As more women are choosing to undergo the above procedure it has been noticed that many experience oedema in the skin postoperatively but assessment of change has only been subjective so far. 53 patients were measured using the Delfin MoisturemeterD Compact to determine the percentage of fluid within the dermis. The conclusion was that the use of the Mosituremeter allows accurate documentation of localised and sub-clinical oedema in breast skin following mastectomy and reconstruction.
A patient self examination survey for staging the severity of lymphoedema. Fifty patients with either unilateral primary or secondary LE completed a number of questionnaires. One form was repeated one week after either by email or posted off. The patients were assessed with bioimpedance and staged by two therapists using the ISL staging system. The results of this study are currently being collated.
Current overview of surgical treatment of lymphoedema. Dr Suami spoke of the different types of surgical treatment available for LE: Liposuction, lymphovenous shunting, lymphatic grafts and vascularised lymph node transfers. Refinements in microsurgical techniques and improved imaging devices may lead to the establishment of standard surgical treatment of lymphoedema – wouldn’t that be amazing!!
Liposuction. The Macquarie University Cancer Institute is developing protocols for maximising outcomes for liposuction surgery for fatty lymphoedema limbs in Australia and NZ. There are very specific criteria for eligibility and bioimpedance and MR imaging were used to determine eligible candidates. Patients had pre-operative intensive treatment at Mt Wilga Hospital and there was a significant mean excess volume reduction pre-surgery. The conclusion of this prospective study demonstrates that in patients with large non-pitting limbs with L-Dex and MRI indicating deep fluid pocketing, a brief pre-operative CLT (that’s MLD, bandaging and physio) session can reduce the liposuction volume needed to achieve maximum outcomes.
Liposuction in the management of persistent arm swelling following conservative management of LE – a similar study to the one above (Alex Munnoch happily admitted that Mt Wilga’s results of pre-surgical CLT seemed much more effective than what they were achieving!). The conclusion of his study said that liposuction and continuous postoperative compression is an effective treatment for advanced arm lymphoedema.
Diet and its relationship to lymphoedema. This was a very interesting talk by Dr Kieron Rooney, with whom I had the pleasure of talking during the lunch break – he had been drinking numerous fizzy drinks daily and eating junk food and suddenly realised he was doing research on diet but yet wasn’t reading his own advice! He gave up sugar and lost a significant amount of weight which he has kept off easily simply by keeping off the refined sugar (yes, he does exercise too!). He is looking to see what fuels the capacity for change of lymphatic fluid into adipose tissue. It’s the advice we hear again and again, eat food in as close to its natural state as you can – avoid the processed food, stick with real food. Right on!
Liposuction for advanced LE – impact of liposuction on limb volumes. Surgical treatment results from Macquarie University Advanced LE Assessment Clinic. The conclusion of this study stated that liposuction is a safe and effective option for carefully selected patients with advanced lymphoedema.
Liposuction for leg LE. Alex Munnoch reviewed 7 years’ experience of performing liposuction for primary and secondary leg LE. The conclusion of the review stated that liposuction and continuous postoperative compression is an effective treatment for leg lymphoedema, although obtaining 100% reduction is much more challenging, particularly in primary LE patients.
Vascularised lymph node transfer for secondary LE. This was of particular interest to me because of my contact with Helen here in Sydney who has had the procedure. (Helen, you have a lovely lymphoscintigraph!) Lymph node transfer is emerging as a treatment for LE. Eight patients who had tried conservative therapy and experience progressive swelling, frequent infections or inabilitly to tolerate compression garments were offered LNT. All had MRIs, lymphoscintigrams, L-Dex readings and limb volume measurements pre and post operatively as well as ultrasound. The early results indicated no significant volume reduction with LNT but there were subjective improvements in skin infection frequency, softer arms as well as maintenance of oedema control without garment wearing.
Finally, there was a presentation by Dr Susan Gordon of James Cook University on the prevention and management of lymphatic filariasis related LE. Very interesting talk – way too much info to put into a few words.
And that brought us to the conclusion of the Conference. Oh wait. There was the closing ceremony, the one with the Islander dancers, the one where they got poor victims up on the stage to try the death-defying hip gyrations that were exhausting to watch, far less try to do. But well done to all who participated (I kept my head so far down it was almost in my lap!).