Tiny Bypass that Relieves the Misery of Swollen Limbs
Lymphoedema — painful swelling in the limbs — is a common side-effect of treatment for breast cancer, but also blights the lives of thousands of men with conditions such as prostate cancer.
Stuart Elcock, 69, a retired civil servant from Buckinghamshire, underwent a new procedure for tackling it.
THE PATIENT
When doctors told me I might develop lymphoedema after surgery for a tumour on my thigh, it was the least of my worries: I just wanted to get rid of the cancer.
I’d been treated for testicular cancer years ago, but had more than three decades of good health after that.
Then, in 2011, I found a lump at the top of my right leg — it was a sarcoma, a rare type of cancer in the connective tissues.
The doctors said it might be due to the radiotherapy I had in the Seventies.
The surgeons managed to get the sarcoma out.
But over the next two months, my right leg swelled until it was about 50 per cent bigger.
I had lymphoedema, where the lymph system — a network of tiny vessels that drains tissue fluid back to the blood — doesn’t function properly.
It was caused when the surgeons removed some of the lymph nodes next to my cancer.
The nodes are like filters, and the surgeons took them out to check if the cancer had spread. But if they are damaged or removed, fluid can build up.
My leg grew very heavy and I lost the feeling from my groin down to my knee. The skin became hard and my knee and ankle swelled.
I struggled to walk short distances and had to stop driving.
And showering was difficult — I couldn’t wash my feet because my knee was swollen, so my wife, Morag, had to do it. She also had to put on my shoes and socks.
Other problems arose, too — the lymph system helps defend against infection, so you can get skin infections.
I needed antibiotics for two bouts of cellulitis, infection of the tissue below the skin.
I had numerous urinary infections, too.
My GP referred me to a lymphoedema clinic, where I was given a compression stocking, but after a few days of wearing it, the 8in surgery wound in my thigh opened slightly and lymph fluid started leaking.
Even with lighter compression, the wound opened and the fluid soaked on to my boxer shorts.
My GP referred me back to the Nuffield Orthopaedic Centre in Oxford, where I’d had my cancer surgery.
Dominic Furniss, a plastic surgeon, suggested I try a procedure he had recently learned in Japan, which would redirect the fluid away from the wound. I quickly agreed.
In April last year, I was put under general anaesthetic for six hours while the surgeons stitched some of my lymph vessels directly to my veins so the fluid could bypass damaged nodes.
Over the following weeks there was a gradual improvement in the swelling in my leg; although it’s only gone down a bit, the increase in mobility is tremendous.
The skin has softened and the feeling is back.
I can walk the half mile from home to the shops with no trouble, and can shower, drive and put shoes and socks on unaided.
The cellulitis, urinary infections and leakage are gone, and the wound has healed nicely.
THE SURGEON
Dominic Furniss is a plastic surgeon at Oxford University Hospitals Trust and Oxford University. He says:
More than 125,000 people in the UK are affected by lymphoedema.
It’s very common in women who’ve been treated for breast cancer — about 60 per cent of sufferers whose lymph glands are treated will develop it.
But you can get it after many other cancers, too, such as testicular, prostate and melanoma.
There are even reports of lymphoedema in the face after radiotherapy for head and neck cancer.
For someone like Stuart, who was leaking lymph fluid through his open wound, it can be very distressing.
Conventional treatment involves massage, compression and life-long skincare to prevent infections. But this doesn’t address the cause — the blockage to the outflow of lymph fluid.
With this new technique — supermicrosurgery — rather than trying to force the lymphatic fluid past the blockage, we direct the lymph vessels into the veins so the fluid bypasses the obstruction.
The lymphatic vessels and veins we work on are tiny — between 0.2mm and 0.8mm in diameter — so we use a microscope and super-fine instruments.
First, we make about four 1in incisions in the affected limb, and find the lymph vessels and veins just underneath the skin.
We then take some of the lymph vessels and stitch one end into a vein, using nylon stitches about a fifth of the thickness of a human hair.
Studies show the more vessels and veins you join, the more effective it is, so we do between six and ten, depending on time. The operation takes four to six hours.
As we only go up to 2cm deep into the tissue, the only real risk with the operation is a superficial wound infection.
It leaves scars, but they aren’t very noticeable, and there’s no great risk of damage to deep structures such as nerves and tendons.
The real joy about this operation is that it’s minimally invasive, and most patients can have it done under local anaesthetic.
When Stuart came to me, he was struggling with daily tasks and his wife said he wasn’t the man he used to be. But when I saw them again a few months ago, she said: ‘You’ve given me my husband back.’
He had normal shoes on and trousers — I’d only seen him in loose-fitting elasticated ones.
This technique won’t cure very bad lymphoedema, but we can reduce the complications, make the limb feel softer, and reduce the swelling.
And the benefits continue accruing for about four years after the operation.
We can now identify early stages of lymphoedema and even those patients who are at risk of getting it.
For example, if a woman with breast cancer is to have her lymph glands removed from her armpit, we can perform this surgery before the swelling manifests.
So many people survive cancer nowadays that we need to look at the complications of their treatment and improve their quality of life.
Techniques like this can help.
Diana Pilkington - MailOnline
