Decongestive Lymphatic Therapy Research Articles

SurLym trial: study protocol for a multicentre pragmatic randomised controlled trial on the added value of reconstructive lymphatic surgery to decongestive lymphatic therapy for the treatment of lymphoedema

IntroductionLymphoedema is a chronic condition caused by lymphatic insufficiency. It leads to swelling of the limb/midline region and an increased risk of infection. Lymphoedema is often associated with mental and...

Comparison of intermittent pneumatic compression pump as adjunct to decongestive lymphatic therapy against decongestive therapy alone for upper limb lymphedema after breast cancer surgery: A systematic review and meta-analysis

Background: Breast cancer is among the most prevalent malignancies in women worldwide, with substantial morbidity and mortality. Upper limb lymphedema (ULL) is a common complication after breast cancer surgery that affects patients' daily activities and quality of life. Decongestive lymphatic therapy (DLT) and intermittent pneumatic compression (IPC) therapy are two primary treatment methods for ULL. Objectives: This study aims to compare the efficacy of DLT with IPC versus DLT alone in the management of ULL following breast cancer surgery. Method: PubMed Central, SCOPUS, EMBASE, MEDLINE, Cochrane trial registry, Google Scholar, and Clinicaltrials.gov databases were comprehensively searched for randomized controlled trials (RCTs) comparing DLT with IPC and DLT alone in patients with breast cancer-related ULL. Risk of bias was evaluated using the RoB 2 tool. Pooled effect sizes were calculated using random-effects models. Results: A total of 1894 citations were identified by the systematic search. Of them, 9 RCTs were included in the analysis. The pooled SMD for percentage volume reduction was 0.63 (95%CI: -0.24 to 1.50; I2=90.9%), showing no significant difference between the DLT alone and DLT combined with IPC (p=0.15). Pain and heaviness scores were also comparable between the groups. However, there was a significant difference in external rotation joint mobility (SMD=0.62; 95%CI: 0.08-1.16; I2=23.8%), favouring DLT with IPC. Conclusions: Our findings suggest that DLT with IPC and DLT alone showed similar findings in managing ULL after breast cancer surgery, with DLT with IPC showing a greater impact on external rotation joint mobility. Healthcare providers should consider patient preferences and individual factors when selecting the most appropriate treatment modality for ULL management.

Conservative treatment versus lymphaticovenular anastomosis for early-stage lower extremity lymphedema

ObjectiveSeveral options for the treatment of lower extremity lymphedema (LEL) can be broadly classified into conservative treatment, such as compression garments and decongestive lymphatic therapy, and surgical treatment, such as lymphaticovenular anastomosis (LVA). The purpose of our study was to clarify the superiority of these treatments by comparing the outcomes of LVA with those of conservative treatment for early-stage LEL. MethodsWe performed a single-center, retrospective cohort study. The patients with LEL who presented to our department between January 2015 and December 2022 were identified and classified into two groups: conservative treatment and surgical treatment. The LEL indexes, calculated from the four lower extremity circumferences and the body mass index, were compared at the 6-, 12-, and 24-month follow-up between the two groups. ResultsOf the 101 patients with LEL, 53 with 72 affected limbs (conservative treatment, 39 patients and 53 affected limbs; surgical treatment, 15 patients and 19 affected limbs) were included in the present analysis. The therapeutic effect for reducing edema, as determined by comparing the corrected LEL index at 12 months (103.7 ± 12.7 vs 91.9 ± 10.7; P = .005) and 24 months (103.1 ± 12.9 vs 83.8 ± 7.2; P < .001), was significantly higher in the surgical treatment group than that in the conservative treatment group. The conservative treatment group showed little change in the corrected LEL index at ≤24 months of follow-up (+3.1%; P = .299). In contrast, the surgical treatment group showed a significant reduction in edema at 24 months according to the corrected LEL index (−16.2%; P = .019). ConclusionsIn early-stage LEL, conservative treatment centered on compression therapy alone only maintained edema (ie, edema did not worsen or improve). In contrast, LVA with compression therapy reduced edema.

P272 Manual lymph drainage does not substantially improve the effect of decongestive lymphatic therapy in people with breast cancer-related lymphoedema (EFforT-BCRL trial): a multicentre randomised trial

P272 Manual lymph drainage does not substantially improve the effect of decongestive lymphatic therapy in people with breast cancer-related lymphoedema (EFforT-BCRL trial): a multicentre randomised trial

The Effectiveness of Fluoroscopy-Guided Manual Lymph Drainage as Part of Decongestive Lymphatic Therapy on the Superficial Lymphatic Architecture in Patients with Breast Cancer-Related Lymphoedema: A Randomised Controlled Trial

The objective of this trial was to investigate the effectiveness of fluoroscopy-guided manual lymph drainage (MLD), as part of decongestive lymphatic therapy (DLT), on the superficial lymphatic architecture in patients with chronic mild to moderate breast cancer-related lymphoedema (BCRL). This trial was a multicentre, double-blind, randomised controlled trial involving 194 participants with BCRL. Participants were randomised into (1) DLT with fluoroscopy-guided MLD (intervention group), (2) DLT with traditional MLD (control group), or (3) DLT with placebo MLD (placebo group). Superficial lymphatic architecture was evaluated as a secondary outcome, visualised by ICG lymphofluoroscopy at the baseline (B0), post-intensive (P), and post-maintenance phases (P6). Variables were (1) number of efferent superficial lymphatic vessels leaving the dermal backflow region, (2) total dermal backflow score, and (3) number of superficial lymph nodes. The traditional MLD group showed a significant decrease in the number of efferent superficial lymphatic vessels at P (p = 0.026), and of the total dermal backflow score at P6 (p = 0.042). The fluoroscopy-guided MLD and placebo group showed significant decreases in the total dermal backflow score at P (p < 0.001 and p = 0.044, respectively) and at P6 (p < 0.001 and p = 0.007, respectively); the placebo MLD group showed a significant decrease in the total number of lymph nodes at P (p = 0.008). However, there were no significant between-group differences for the changes in these variables. In conclusion, based on lymphatic architecture outcomes, the added value of MLD, in addition to the other parts of DLT, could not be demonstrated in patients with chronic mild to moderate BCRL.

Power-assisted Liposuction for Lymphedema: A Cost-utility Analysis.

Extremity volumes from all patients who underwent debulking surgery of the upper extremity at two institutions between December 2017 and January 2020 with at least 12 months follow-up were included. Procedural costs were calculated using Medicare reimbursement data. Average utility scores were obtained for each health state using a visual analog scale, then converted to quality-adjusted life years. A decision tree was generated, and incremental cost-utility ratios were calculated. Sensitivity analyses were performed to evaluate our findings. Debulking surgery is associated with a higher clinical effectiveness (quality-adjusted life year) of 27.05 compared to conservative management (23.34), with a relative cost reduction of $74,487. Rollback analysis favored debulking surgery as the cost-effective option compared to conservative management. The resulting negative incremental cost-utility ratio of -20,115.07 favored debulking surgery and indicated a dominant strategy. Our study supports the use of debulking surgery for the treatment of chronic lymphedema of the upper extremity.

Manual lymphatic drainage with or without fluoroscopy guidance did not substantially improve the effect of decongestive lymphatic therapy in people with breast cancer-related lymphoedema (EFforT-BCRL trial): a multicentre randomised trial.

When added to decongestive lymphatic therapy (DLT), what is the effect of fluoroscopy-guided manual lymphatic drainage (MLD) versus traditional MLD or placebo MLD for the treatment of breast cancer-related lymphoedema (BCRL)? Multicentre, three-arm, randomised controlled trial with concealed allocation, intention-to-treat analysis and blinding of assessors and participants. At five hospitals in Belgium, 194 participants with unilateral chronic BCRL were recruited. All participants received standard DLT (education, skin care, compression therapy and exercises). Participants were randomised to also receive fluoroscopy-guided MLD (n= 65), traditional MLD (n= 64) or placebo MLD (n= 65). Participants received 14 sessions of physiotherapy during the 3-week intensive phase and 17 sessions during the 6-month maintenance phase. Participants performed self-management on the other days. All outcomes were measured: at baseline; after the intensive phase; after 1, 3 and 6 months of maintenance phase; and after 6 months of follow-up. The primary outcomes were reduction in excess volume of the arm/hand and accumulation of excess volume at the shoulder/trunk, with the end of the intensive phase as the primary endpoint. Secondary outcomes included daily functioning, quality of life, erysipelas and satisfaction. Excess lymphoedema volume decreased after 3 weeks of intensive treatment in each group: 5.3 percentage points of percent excessive volume (representing a relative reduction of 23.3%) in the fluoroscopy-guided MLD group, 5.2% (relative reduction 20.9%) in the traditional MLD group and 5.4% (relative reduction 24.8%) in the placebo MLD group. The effect of fluoroscopy-guided MLD was very similar to traditional MLD (between-group difference 0.0 percentage points, 95% CI -2.0 to 2.1) and placebo MLD (-0.2 percentage points, 95% CI -2.1 to 1.8). Fluid accumulated at the shoulder/trunk in all groups. The average accumulation with fluoroscopy-guided MLD was negligibly less than with traditional MLD (-3.6 percentage points, 95% CI -6.4 to -0.8) and placebo MLD (-2.4 percentage points, 95% CI -5.2 to 0.4). The secondary outcomes also showed no clinically important between-group differences. In patients with chronic BCRL, MLD did not provide clinically important additional benefit when added to other components of DLT. NCT02609724.

Factors Predicting Limb Volume Reduction Using Compression Bandaging Within Decongestive Lymphatic Therapy in Lymphedema: A Multicountry Prospective Study.

Objectives: To identify predictive factors associated with limb volume reduction using different decongestive lymphatic therapy (DLT) systems in patients with lymphoedema, over a period of up to 28 days. Methods: A multicountry (Canada, France, Germany, the United Kingdom) prospective cohort study using (DLT): skin care, exercise, compression bandaging, and manual lymphatic drainage for up to 4 weeks. Reduction in limb volume comparing DLT with (1) standard multilayer bandaging with inelastic material, and with (2) multilayer bandaging with Coban2, together with the identification of factors associated with limb volume changes. Results: Out of 264 patients with upper or lower limb lymphedema, 133 used Coban2 and 131 used standard care. Following DLT, mean limb volume reduction was 941 mL using Coban2 compared with 814 mL using standard care. A difference of 127 mL was found (95% confidence interval -275 to 529 mL, p = 0.53). Of the 176 patients with leg swelling, 166 (94.3%) had a limb volume measurement after 28 days and were included in the risk factor analysis. Of these, 132 (79.5%) were female, with overall mean age of 60.1 years (standard deviation = 14.7), with secondary lymphedema in 102/163 (62.6%). Duration of lymphedema was >10 years in 75/161 (46.6%) and 99/166 (59.7%) were International Society of Lymphology late-stage II/III, indicating longstanding and/or a high frequency of patients with advanced stages of lymphedema. Ninety-one (54.8%) received Coban2 and 75 (45.2%) had standard care. Multivariable factors for a greater leg volume reduction were large initial leg volume (p < 0.001), DLT treatment duration of 4 weeks compared with 2 weeks (p = 0.01), and peripheral arterial disease (p = 0.015). Conclusion: Limb volume changes were found to be similar between groups. Lack of standardization of DLT makes interpretation of effectiveness problematic. There is an urgent need for randomized-controlled trials. Despite this, severe lymphedema with a large limb volume responded well to DLT in this study.

Quality of Life and Costs Within Decongestive Lymphatic Therapy in Patients with Leg Lymphedema: A Multicountry, Open-Label, Prospective Study.

Background: Little is known of the impact in terms of health-related quality of life (HRQoL) and cost-effectiveness with decongestive therapy. Objectives: To examine changes in limb volume, quality of life (QoL), and treatment cost of methods of decongestive lymphatic therapy (DLT). Methods: Patients with chronic edema/lymphedema of the leg were invited to participate in a study of DLT in four countries (United Kingdom, France, Germany, and Canada). In each country two sites were selected. One site used their standard method of DLT in their service, including compression with multilayer bandaging with inelastic material. The other site used a system that included 3M™ Coban 2™ as the bandage treatment alongside other standard components of DLT. Patients were followed for either 2 or 4 weeks depending on the local protocols. At entry, at 2 weeks, and at 4 weeks, patients were assessed by using a health index (EQ-5D), a disease-specific HRQoL tool (LYMQOL) and resource usage was recorded over the treatment period. Results: Of the 165 patients with cost data, 90 were treated with Coban 2 and 75 with standard care compression bandaging. There was good evidence of an improvement in EQ-5D of 0.077 (p < 0.001) in all patients. LYMQOL showed significant improvements (p < 0.001) with lower scores. There were no major differences between the two arms of the study with respect to HRQoL. The number of treatment episodes was higher in those treated with standard care (8.15 vs. 6.37), but the overall treatment cost was higher with Coban 2 (£890.7) compared with standard care (£723.0). Conclusion: QoL improved in the standard care and Coban 2 group bandages, and there was no demonstrable difference between the care systems. Further work is required to examine the role of the individual parts of DLT that provide the greatest benefit to patients and the health systems that support them.

Physical therapies in the decongestive treatment of lymphedema: A randomized, non-inferiority controlled study

Objective: To assess whether the treatment with intermittent pneumatic compression plus multilayer bandages is not inferior to classical trimodal therapy with manual lymphatic drainage in the decongestive lymphedema treatment. Study Design: Randomized, non-inferiority, controlled study to compare the efficacy of three physical therapies’ regimens in the Decongestive Lymphatic Therapy. Participants: 194 lymphedema patients, stage II–III with excess volume > 10% were stratified within upper and lower limb and then randomized to one of the three treatment groups. Baseline characteristics were comparable between the groups. Intervention: all patients were prescribed 20 sessions of the following regimens: Group A (control group): manual lymphatic drainage + Intermittent Pneumatic Compression + Bandages; Group B: pneumatic lymphatic drainage + Intermittent Pneumatic Compression + Bandages; and Group C: only Intermittent Pneumatic Compression + Bandages. End-point: Percentage reduction in excess volume (PREV). Results: All patients improved after treatment. Global mean of PREV was 63.9%, without significant differences between the groups. The lower confidence interval of the mean difference in PREV between group B and group A, and between group C and group A were below 15%, thus meeting the non-inferiority criterion. Most frequent adverse events were discomfort and lymphangitis, without differences between groups. A greater baseline edema, an upper-limb lymphedema and a history of dermatolymphangitis were independent predictive factors of worse response in the multivariate analysis. Conclusions: Decongestive lymphatic therapy performed only with intermittent pneumatic compression plus bandages is not inferior to the traditional trimodal therapy with manual lymphatic drainage. This approach did not increase adverse events.

231 Breast Lymphedema After Breast Conservative Surgery; An Up-To-Date Systematic Review

Abstract Background While arm lymphedema following breast cancer treatment is a common complication; breast lymphedema following treatment is not uncommon. Several risk factors were found to contribute to breast lymphedema, Aim: We aimed to provide a systematic review to help avoiding or management of breast lymphoedema Method The search term 'breast lymphedema' was combined with 'breast conservative surgery' and was used to conduct literature research in PubMed and Medline. The term lymphedema was combined with breast, conservative and surgery to search Embase database. All papers published in English were included with no exclusion date limits Results A total of 2155 female patients were included in this review; age ranged from 26 to 90. Mean BMI was 28.4, most of the studies included patients who underwent conservative breast surgery. Incidence of breast lymphedema ranged from 24.8% to 90.4%. Several risk factors were linked to breast lymphedema after conservative breast surgery, such as body mass index (BMI), breast size, tumour size, tumour site, type of surgery and adjuvant therapy. Treatment options focused on decongestive lymphatic therapy, including Manual lymphatic drainage (MLD), self-massaging, compression bras or Kinesio taping. Conclusions Breast lymphedema is a relatively common complication, yet there is no clear consensus on the definition or treatment options.

P28 Breast Lymphedema after breast conservative surgery; an up-to-date systematic review

BackgroundWhile arm lymphedema following breast cancer treatment is a common complication; breast lymphedema following treatment is not uncommon. Several risk factors were found to contribute to breast lymphedema, including axillary surgery, high BMI, increased bra cup size, adjuvant chemotherapy, locoregional and radiotherapy boost and upper outer quadrant tumours.AimWe aimed to provide an up to date systematic review to help avoiding or managing breast lymphoedema after Breast conservative surgery for breast cancer.MethodsThe search term 'breast lymphedema' was combined with 'breast conservative surgery' and was used to conduct a literature research in PubMed and Medline. The term lymphedema was combined with breast, conservative and surgery to search Embase database. All papers published in English were included with no exclusion date limitsResultsA total of 2155 female patients were included in this review; age ranged from 26 to 90. Mean body mass index was 28.4, most of the studies included patients who underwent conservative breast surgery.Incidence of breast lymphedema ranged from 24.8% to 90.4%. Several risk factors were linked to breast lymphedema after conservative breast surgery, such as body mass index (BMI), breast size, tumour size, tumour site, type of surgery and adjuvant therapy.Treatment options focused on decongestive lymphatic therapy, including Manual lymphatic drainage (MLD), self-massaging, compression bras or Kinesio taping.ConclusionBreast lymphedema is a relatively common complication, yet there is no clear consensus on the definition or treatment options.

Responsiveness of the Lymphedema Functioning, Disability, and Health Questionnaire for Upper Limb Lymphedema in Patients with Breast Cancer-Related Lymphedema.

Background: The Lymphedema Functioning, Disability, and Health questionnaire for Upper Limb Lymphedema (Lymph-ICF-UL) is a health-related quality-of-life questionnaire for patients with breast cancer-related lymphedema. Previous testing of this questionnaire showed very good psychometric properties; however, responsiveness has not yet been established. The aim of this study was to determine its internal and external responsiveness. Methods and Results: Ninety-five patients treated with decongestive lymphatic therapy in a longitudinal trial were recruited. Patients completed the Lymph-ICF-UL twice within a time interval of 7 weeks ("intensive group" receiving intensive treatment; n = 73) or 3 months ("stable group" receiving maintenance treatment; n = 22), and once the Global Perceived Effect (GPE) questionnaire at the second time point. The significance of change in scores and standardized response mean (SRM) were determined for the total and domain scores. Correlations between Lymph-ICF-UL and GPE were ascertained. In addition, the minimal clinical important difference (MCID) was determined. The Lymph-ICF-UL total score changed significantly in the intensive group (p < 0.001) and nonsignificantly for those in the stable group (p = 0.25). The SRM represented moderate responsiveness (0.65). Patients who reported a clinical improvement ( = responders) after intensive treatment showed a significant decrease in total score (p < 0.001), this was also the case for nonresponders (p < 0.001). Lymph-ICF-UL total and domain scores showed nonsignificant weak correlations with the GPE (p > 0.05). There was a significant difference in mean total score changes between responders and nonresponders (p < 0.001). MCID for the total score was 9%. Conclusion: The Lymph-ICF-UL is responsive to change after decongestive lymphatic therapy. No correlations were found between Lymph-ICF-UL change scores and GPE. Future studies should be conducted in a clinical setting, with more variability between participants and their treatment responses.

Managing Lymphedema in Fracture Care: Current Concepts and Treatment Principles.

Lymphatic flow plays a notable role in the regulation of bone formation and remodeling. Chronic accumulation of the lymph fluid within tissues may lead to issues with proper bone healing after fractures, emphasizing the importance of proper management of lymphedema after trauma. Many associated risk factors place patients at risk for lymphedema, including previous surgery with nodal dissection, radiation therapy, infection, malignancy, family history of congenital lymphedema, and trauma. The benchmark imaging technique for the diagnosis of lymphedema is lymphoscintigraphy. Other modalities include duplex ultrasonography, CT, and MRI. First-line conservative treatment of lymphedema is compression. Complete decongestive therapy or complex physical therapy, also known as decongestive lymphatic therapy (DLT), has shown positive results in reducing lymphedema. Surgical interventions aim to either reconstruct and restore function of the lymphatic system or debulk and reduce tissues and fluids. Understanding the significance of lymphedema on bone healing and techniques available to recognize it are important factors in preventing delay in diagnosis and ensuring proper management of lymphedema after trauma.

What are the economic burden and costs associated with the treatment of breast cancer-related lymphoedema? A systematic review.

To provide an overview of costs associated with the treatment of breast cancer-related lymphoedema (BCRL) and its possible sequelae, borne by patients or by society. According to the PRISMA guideline, a systematic literature search was carried out in four electronic databases: PubMed, Web of Science, Cochrane Clinical Trials and EMBASE. Searches were performed on October 1, 2018. Eligibility criteria: (1) expenses of adults (age > 18 years), (2) concerning patients with BCRL, (3) overview of (in)direct costs associated with BCRL, (4) expenses in which at least one type of conservative treatment modality for lymphoedema is included and/or costs for hospital admissions due to infections. Reviews and meta-analyses were excluded. After assessing the risk of bias and level of evidence, quantitative data on (in)direct costs for BCRL treatment during a well-mentioned timeframe were extracted. Eight studies were included. Three studies reported on patient-borne costs related to BCRL. Mean direct costs per year borne by patients ranged between USD$2306 and USD$2574. Indirect costs borne by patients ranged between USD$3325 and USD$5545 per year. Five studies estimated society-borne costs related to BCRL from claims data, billing prices and providers' services during 12 to 24 months of follow-up. Mean direct treatment costs after 1 year of decongestive lymphatic therapy (DLT) ranged between €799 (= USD$1126.60) and USD$3165. This systematic review revealed that BCRL imposes a substantial economic burden on patients and society. However, more standardized high-quality health economic analyses among this field are required. Recent economic analyses related to BCRL treatment in Europe, Asia, Africa and South America are lacking. Worldwide, further scrutiny of the economic impact of DLT for BCRL in clinical settings is needed. The review makes part of a double-blind, multi-center, randomized controlled trial (EFforT-BCRL trial), which is registered in clinicaltrials.gov (NCT02609724). CME reference S58689, EudraCT Number 2015-004822-33.

Klippel-Trenaunay syndrome: case report and literature review

Klippel-Trenaunay syndrome (KTS) is a rare congenital disease, characterized by a triad of clinical features: (1) capillary malformations, manifesting as a “port wine stain”, (2) vascular anomalies, mostly varicose veins and (3) bone and/or soft tissue hypertrophy, usually of one lower extremity. The symptoms are frequently accompanied by lymphatic abnormalities that in some cases may lead to lymphedema. KTS is mostly benign in the course. Nevertheless, patients with KTS are at higher risk of developing deep vein thrombosis (DVT), pulmonary thromboembolism, recurrent episodes of thrombophlebitis, dermatolymphangitis or internal bleeding. Management in KTS should be individualized, minimally invasive and involve multidisciplinary care of the patient. We report a case of a man with fully symptomatic KTS, after incident pulmonary thromboembolism in the past and with severe phlebolymphedema, effectively treated with decongestive lymphatic therapy (DLT). We also provide a review of the literature on the clinical aspects of this complex syndrome.

Decongestive lymphatic therapy in postfilarial lymphedema: A prospective study

Context: In a filariasis endemic country like India, the need for an effective and consistent treatment for filarial lymphedema has long been recognized. In this study, we set out to evaluate decongestive lymphatic therapy (DLT) for postfilarial lymphedema. Aims: The aims of this study are to determine the efficacy of DLT in the management of postfilarial lymphedema of extremities. Settings and Design: This is one prospective study from April 1, 2010, to March 30, 2011 included twenty patients with the diagnosis of lymphedema of the extremities. After the Institutional Review Board approval, consent was taken. Subjects and Methods: Patients with unilateral postfilarial lymphedema were included in the study. Exclusion Criteria: (1) Other forms of lymphedema, (2) Clinical evidence of local infection, (3) Severe cardiac disease, (4) Uncontrolled hypertension, (5) Malignancy. The clinical profile of the patient was recorded and was noted. Limb circumferences were measured at axial intervals of 10 cm for the entire limb length. Each segment's volume was calculated with the truncated cone formula H × (C2 + Cc + c2)/12 Π, H = height, C = circumference at the top of the cone, c = circumference at the base of the cone. Total limb volume was acquired by adding the segments. Patients were subjected to daily DLT which included manual lymphatic drainage, low-stretch compression bandaging, and skin care and exercises and volume reduction measured. The patients were followed up for 1 year. Statistical Analysis Used: Spearman's rank correlation coefficient, one sample t-test, Mann–Whitney U-test. Results: The mean reduction in the volume of the affected limb was 63.12% with standard deviation of 11.38 and P

Protocol of a randomised controlled trial regarding the effectiveness of fluoroscopy-guided manual lymph drainage for the treatment of breast cancer-related lymphoedema (EFforT-BCRL trial)

ObjectivesLymphoedema is a dreadful complication following breast cancer therapy. According to the International Society of Lymphology, the consensus treatment for breast cancer-related lymphoedema (BCRL) is the decongestive lymphatic therapy. This is a two-phase treatment and combines different treatment modalities including skin care, manual lymphatic drainage (MLD), compression therapy and exercise. However, the additional effect of MLD is debated since pooled data only demonstrated a limited non-significant additional value. A possible explanation is that in previous studies MLD has been applied blind, without knowledge of patient-specific lymphatic routes of transport. In addition, the MLD hand manoeuvres used by the therapists in previous studies, possibly did not optimally stimulate lymphatic transport. Recently, near-infrared fluorescence imaging has been introduced to visualise the superficial lymphatic network which allows MLD at the most needed location. The aim of the present study is to determine the effectiveness of the fluoroscopy-guided MLD, additional to the other parts of the decongestive lymphatic therapy and compared to the traditional or a placebo MLD, in the treatment of BCRL. Study designA three-arm double-blinded randomised controlled trial will be conducted in different university hospitals in Belgium. Based on a sample size calculation, 201 participants with chronic BCRL stage 1 or 2 of the arm or hand, with at least 5% difference between both sides (corrected for hand dominance) need to be recruited. All participants receive the standard treatment: skin care, compression therapy and exercises. The intervention group additionally receives fluoroscopy-guided MLD. One control group additionally receives the traditional ‘blind’ MLD and a second control group receives a placebo MLD. All subjects receive 3 weeks of daily intensive treatments and 6 months of maintenance treatment. Follow-up period is 6 months. The primary outcomes are the reduction in lymphoedema volume of the arm/hand and the change in stagnation of lymph fluid at level of the shoulder/trunk.

The decongestive lymphatic therapy in the massive primary lower limb lymphedema treatment

The decongestive lymphatic therapy is recommended by the International Society of Lymphology, the International Union of Phlebology and the International Lymphoedema Framework as the conservative treatment of choice in the lymphedema patients. This method enables effective treatment even in patients with difficult and complicated lymphedema. We present a case of a young man with a massive, primary right lower limb lymphedema, effectively treated with the DLT.

Do surgical interventions for limb lymphoedema reduce cellulitis attack frequency?

Recurrent cellulitis is a frequent and challenging complication of lymphoedema. British Lymphology Society cellulitis guidelines state that decongestive lymphatic therapy reduces the frequency of cellulitis attacks, but do not mention the effect of surgical interventions. This systematic review aims to assess whether surgical interventions for lymphoedema reduce the frequency of attacks of cellulitis. Embase, Medline, and the Cochrane database were searched for relevant articles from database inception to January 2016. Four hundred and thirty-six abstracts were retrieved. Studies were included which contained quantitative data on cellulitis incidence before and after a surgical intervention. Two independent reviewers applied selection criteria, selecting 27 papers for full text review. Two were unavailable in the UK from any source. A variety of surgical techniques were utilized in the 25 papers included: lymphaticovenous anastomosis, superficial-to-deep lymphaticolymphatic anastomosis, lymph node transfer, Charles procedure, muscle flap transfer, Homan's procedure, and subcutaneous tissue excision below skin flaps. Five studies combined techniques. One study compared the intervention to a control group (physical therapy). Cellulitis incidence was decreased following surgical intervention in 24/25 studies included. Eight had quantifiable reductions in cellulitis over a set follow-up period; in the other 16 preoperative incidence was not precisely defined. Surgery appears effective at reducing cellulitis incidence in lymphoedema. However, high quality evidence from randomized controlled trials is lacking. Future research should concentrate on comparison with control groups, for example compression alone versus compression with surgical intervention, in patients with lymphoedema and greater than two attacks of cellulitis per year.