Good things come in small packages

28 October 2017

After living for years with a swollen right arm due to lymphoedema – a condition caused by the damage or removal of lymph nodes – Joyce Kuntz Hetrick found solace in the healing hands of Dr Wei Chen and an innovative surgical technique that relieved many of her symptoms. Hetrick underwent a mastectomy following a breast cancer diagnosis in 2007 and noticed, posttreatment, that her right arm was becoming edematic. Despite visiting numerous doctors and physical therapists, the infections in Hetrick’s arm only worsened. She began to use massage and compression sleeves to try and minimise her discomfort.

Eventually, a referral to Chen in August 2015 offered Hetrick the chance of a resolution. She attended one of his patient seminars, and the next month underwent surgery. Chen connected 11 tiny lymphatic vessels, each about 0.3mm wide, to equally small veins in order to bypass the blockages. This ‘octopus’ surgical technique worked, and, after a few months, Hetrick’s arm had almost returned to its normal size. She considers the procedure a major success.

Lymphoedema: a hidden scourge

According to the Lymphoedema Support Network in the UK, it is estimated that at least 240,000 people in the UK may be affected by this condition. Gentle massage, known as manual lymphatic drainage (MLD) and deep breathing can help to move the lymph more effectively, but often this provides only minor relief in severe cases, and surgical solutions must ultimately be considered.

There is also a high risk of the affected area becoming infected, with cellulitis, a condition caused by bacteria on the skin getting inside the body, leading to a spreading infection of the skin and subcutaneous fat. It usually causes redness, swelling and heat, and often makes the area tender to touch. It can also cause systemic upset with fevers, sweating, shivers, muscular aches and pains, headache, nausea and vomiting. As the lymphoedema worsens, nerves in the limbs may become compromised, affecting functionality. The skin also weakens, meaning that some injuries, despite being minor, are unable to heal.

It is essential that lymphoedema is correctly diagnosed and appropriately assessed, but, unfortunately, there is still a severe lack of medical knowledge and expertise in this area, and some patients are still being told that nothing can be done to help them. This makes the research of Chen all the more important.

The main difficulty when tackling lymphoedema is working with the ultra-fine network of the lymphatic system.

Lymphaticovenular anastomosis surgery (LVA) is a supermicrosurgery in which lymphatic vessels are connected to veins. The procedure allows for lymphatic fluid to bypass the lymph nodes and be dispersed through the venous system. Super-microsurgery, the technique of anastomosing vessels under 0.8mm, is an increasingly important technique in reconstructive surgery, and requires a more technically refined skill set compared with standard microsurgery. Some vessels, especially in the lymph-node transfer procedure, are short, creating an even greater challenge. Super-microsurgery demands rigorous eye-microscopehand coordination, dexterous handling of delicate tissues and fine motor skills. LVA is increasingly performed for the treatment of lymphoedema due to its efficacy and minimal invasiveness.

Fixing the unfixable

Lymphoedema initially presents as edema in the affected anatomic region (commonly arms or legs) but, over time, it causes skin and soft tissue changes including hyperkeratosis, fat deposition and subcutaneous fibrosis. When lymphoedema occurs, the affected body part is unable to adequately and effectively drain lymphatic fluid, leading to abnormal accumulation of protein-rich fluid in the tissues. Left untreated, irreversible tissue changes occur that can lead to severe functional compromise, and even deformity.

There are treatments available that aim to ease the effects of the disease and prevent further degeneration. Non-surgical therapies are possible, but where they cannot improve a patient’s condition, surgery must be considered.

Now, thanks to Chen’s work, he has provided patients with a new source of hope. At the University of Iowa’s centre for lymphoedema research and reconstruction, Chen has been pioneering several breakthrough procedures and multiple regional firsts, including the revolutionary ‘octopus’ technique, which aims to circumvent the stumbling blocks associated with traditional techniques, allowing surgeons to increase the number of lymphatic drainage pathways than would otherwise be accomplished with the standard super-microsurgery technique.

“We were the first in the Midwest to perform an autologous lymph node transplant and to perform LVA, and we were the first in the country to carry out an autologous lymphatic vessel transplant,” says Chen. Through his research, Chen’s team have been able to increase the effectiveness of existing reconstructive procedures. Not only has this research helped to broaden the patient population that can be treated with these procedures, but Chen has also been helping to train other surgeons who are interested in helping lymphoedema patients.

Originally developed in 2000 by Dr Isao Koshima at the University of Tokyo, super-microsurgical lymphaticovenular anastomosis has now become an established technique, at least in the hands of experienced microsurgeons, due to the various technical refinements and clinical applications made over the past two decades. A series of experiments on raw chicken thighs worked well as a super-microsurgery training model for other surgeons and surgical trainees, as well as a tool to help them hone their steadiness when working on such a tiny canvas.

A life-altering technique

“Our ‘octopus’ technique is an example of a technical advancement that has resolved the limitations of the standard procedures,” Chen explains. “We have designed it to be applicable in situations where the patient’s lymphatic vessels are severely compromised by the disease, when there are significant number or size mismatches between the lymph vessels and the veins.”

Industry responses to Chen’s research have been highly favourable, and patients from around the world have begun to feel the benefits. Teaching others how to use his new technique is integral to Chen’s research, and he runs regular education sessions at the University of Iowa to do just that.

“Our patients come from across the country and from overseas,” says Chen. “We routinely accommodate surgeons from domestic or foreign institutions who want to come and learn these procedures first hand from us.”

Microsurgery meets major problems

However, Chen’s teaching regime faces two main hurdles. Firstly, despite the best efforts of international micro and supermicrosurgeons, he feels that the majority of physicians and patients are unaware that treatments for lymphoedema are even available, and that they fail to grasp that the earlier a treatment is administered, the better the patient’s prognosis will be. Secondly, the immense amount of training required and the poor reimbursement available for these procedures may be discouraging surgeons from helping the lymphoedema patient population.

With Chen’s new surgical solutions having provided a significant medical breakthrough, how does he aim to ensure his research will have a big enough impact to change the face of a lymphoedema diagnosis, and improve wound care in general?

“We need improved collaboration between wound care specialists and plastic reconstructive surgeons,” states Chen. “Generally, wound care specialists care for wounds that need non-operative management, while plastic reconstructive surgeons obviously deal with wounds that require reparative surgery. Based on my observations and research, there needs to be a better dialogue between these two specialities in order to provide optimal and complete wound care to patients.”

What’s next for Chen and his research team? Currently conducting multiple new projects, his work is far from done.

“We’re working on technical improvements of existing techniques, developing new procedures, improving diagnostic and patient-tracking modalities,” Chen explains. “We want to develop a more streamlined, efficient care of patients using a multidisciplinary approach.”

While the research continues, so does Chen’s campaigning through education and patient seminars to raise awareness of lymphoedema and its potential treatments to patients and surgeons who need reassurance that a life-changing solution is possible.

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