Lymphödem

Zusammenfassung

Der Verzicht auf Kompression in der Therapie chronischer Extremitäten-Lymphödeme steigert das Risiko erysipelbedingter Komplikationen und führt zu einer hohen gesundheitsökonomischen Belastung. Nächtliche Kompressionsverfahren zeigen Vorteile und eine hohe Therapieadhärenz.
Aufgehoben wurde die Empfehlung, bei Erysipel auf Kompression zu verzichten. Im Gegenteil, Kompression ist explizit erwünscht.
Lymphödembetroffene Extremitäten zeigen im Vergleich zu nicht betroffenen Extremitäten eine starke Assoziation zu malignen Hauttumoren.
Mittels ICG-Lymphografie wurden 4 verschiedene anatomische Lymphbahnregionen am Bein differenziert, deren funktioneller Ausfall je nach betroffenem Bündel mit dem Schweregrad des Lymphödems korreliert.
Dem vaskularisierten Lymphknotentransfer wurde bezüglich Volumenreduktion, Funktionalität und Lebensqualität hinreichend Evidenz bescheinigt.
Je höher der BMI, umso höher das Risiko für Lymphödeme.
Metaanalysen belegen den Nutzen eines aktiven Lebensstils mit Bewegung und sportlichen Aktivitäten, in Einheit mit umfassender Patientenedukation. Tragbare apparative Kompressionssysteme sind eine vielversprechende Alternative zu bisherigen pneumatischen Kompressionsapparaten.
Das St.-George’s-Klassifikationssystem zeigt erstmals umfassend Zusammenhänge zwischen primären Lymphödemen und systemischen bzw. syndromalen Erkrankungen sowie vaskulären Malformationen. Als „Work-in-progress“-Algorithmus ist es eine wertvolle Hilfe zur Diagnosesicherung und um therapeutische Ansätze zu finden. Klassifikationen, die sich an der zeitlichen Manifestierung primärer Lymphödeme orientieren, wurden verlassen.

Abstract

The 5 most important pillars of conservative lymphoedema therapy are (1) compression, (2) manual lymphatic drainage (MLD), (3) exercise, (4) skin and wound care, and (5) self-management. Without compression therapy the risk of cellulitis is increased and causes an elevated health/economic burden. The use of nocturnal compression shows advantages and a high degree of treatment adherence. The previous recommendation that compression should not be used for cellulitis has been cancelled. On the contrary, compression therapy is explicitly desirable for inflammatory dermatoses. The fact that lymphedema extremities show a 3-fold higher association with malignant skin tumours compared to unaffected extremities deserves attention. Using ICG lymphography, 4 different functional regions of lymphatic leg bundles were differentiated. The severity of the lymphoedema correlated with the kind of affected bundles. Vascularized lymph node transfer, which is a reconstructive lymphatic surgery procedure, was found to show evidence in terms of volume reduction, improved functionality, and better quality of life. The higher the BMI, the higher the risk of developing lymphoedema. Meta-analyses confirm the benefits of an active lifestyle with exercise and sporting activities in conjunction with patient education. Apparative systems for decongestion (intermittent pneumatic compression) usually force patients to remain immobile during application. Portable apparative compression systems are a promising alternative but are not yet available in Germany. Primary lymphoedema is not a uniform entity. The St. George’s classification system shows the association of primary lymphoedema with systemic or syndromic diseases and vascular malformations as well. As a work-in-progress algorithm, it is a valuable aid in classifying primary lymphoedema, confirming the diagnosis and finding therapeutic approaches.

Schlüsselwörter

Lymphödem - Kompressionstherapie - Lymphchirurgie

Keywords

lymphodema - compression therapy - cellulitis

Publication History

Article published online:
19 May 2025

• Literatur

• 1 Greene AK. Epidemiology and Morbidity of Lymphedema. In: Greene AK, Slavin SA, Brorson H. , Hrsg. Lymphedema: Presentation, Diagnosis, and Treatment. Cham: Springer International Publishing; 2015: 33-44
• 2 O’Donnell Jr TF, Allison GM, Iafrati MD. A systematic review of guidelines for lymphedema and the need for contemporary intersocietal guidelines for the management of lymphedema. J Vasc Surg Venous Lymphat Disord 2020; 8 (04) 676-684
• 3 Wilting J, Bartkowski R, Baumeister R. et al. S2k-Leitlinie Diagnostik und Therapie der Lymphödeme Registernummer AWMF-Registernummer 058-001. Stand: 2017. Accessed November 12, 2024 at: https://register.awmf.org/de/leitlinien/detail/058–001
• 4 Webb E, Bissett B, Neeman T. et al. Compression Therapy Is Cost-Saving in the Prevention of Lower Limb Recurrent Cellulitis in Patients with Chronic Edema. Lymphat Res Biol 2023; 21 (02) 160-168
• 5 Blom KY, Johansson KI, Nilsson-Wikmar LB. et al. Early intervention with compression garments prevents progression in mild breast cancer-related arm lymphedema: a randomized controlled trial. Acta Oncol 2022; 61 (07) 897-905
• 6 McNeely ML, Dolgoy ND, Rafn BS. et al. Nighttime compression supports improved self-management of breast cancer-related lymphedema: A multicenter randomized controlled trial. Cancer 2022; 128 (03) 587-596
• 7 Rabe E, Földi E, Gerlach H. et al. Medical compression therapy of the extremities with medical compression stockings (MCS), phlebological compression bandages (PCB), and medical adaptive compression systems (MAC): S2k guideline of the German Phlebology Society (DGP) in cooperation with the following professional associations: DDG, DGA, DGG, GDL, DGL, BVP. Hautarzt 2021; 72 (Suppl. 02) 37-50
• 8 Rabe E, Partsch H, Morrison N. et al. Risks and contraindications of medical compression treatment – A critical reappraisal. An international consensus statement. Phlebology 2020; 35 (07) 447-460
• 9 Nightingale R, Yadav K, Hamill L. et al. Misdiagnosis of Uncomplicated Cellulitis: a Systematic Review and Meta-analysis. J Gen Intern Med 2023; 38 (10) 2396-2404
• 10 Anand NC, Campbell EH, Baum CL. et al. Association of Lower Extremity Lymphedema and Nonmelanoma Skin Cancers. Mayo Clin Proc 2023; 98 (11) 1653-1659
• 11 Shinaoka A, Kamiyama K, Yamada K. et al. A new severity classification of lower limb secondary lymphedema based on lymphatic pathway defects in an indocyanine green fluorescent lymphography study. Sci Rep 2022; 12 (01) 309
• 12 Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen (IQWiG). Fortgeschrittenes Lymphödem: Lassen sich durch nicht medikamentöse Verfahren die Symptome lindern? HTA-Nummer: HT19–01, Version: 1.0, Stand: 2022, IQWiG-Berichte – Nr. 1337. Accessed November 12, 2024 at: https://www.iqwig.de/download/ht19–01_nicht-medikamentoese-verfahren-bei-lymphoedem_hta-bericht_v1–0.pdf
• 13 Grünherz L, Hulla H, Uyulmaz S. et al. Patient-reported outcomes following lymph reconstructive surgery in lower limb lymphedema: A systematic review of literature. J Vasc Surg Venous Lymphat Disord 2021; 9 (03) 811-819.e2
• 14 Ciudad P, Escandón JM, Manrique OJ. et al. Lessons Learnt from an 11-year Experience with Lymphatic Surgery and a Systematic Review of Reported Complications: Technical Considerations to Reduce Morbidity. Arch Plast Surg 2022; 49 (02) 227-239
• 15 Greene AK, Sudduth CL. Lower extremity lymphatic function predicted by body mass index: a lymphoscintigraphic study of obesity and lipedema. Int J Obes (Lond) 2021; 45 (02) 369 373
• 16 Shi B, Lin Z, Shi X. et al. Effects of a lymphedema prevention program based on the theory of knowledge-attitude-practice on postoperative breast cancer patients: A randomized clinical trial. Cancer Med 2023; 12 (14) 15468-15481
• 17 Hayes SC, Singh B, Reul-Hirche H. et al. The Effect of Exercise for the Prevention and Treatment of Cancer-Related Lymphedema: A Systematic Review with Meta-analysis. Med Sci Sports Exerc 2022; 54 (08) 1389-1399
• 18 Abe K, Tsuji T, Oka A. et al. Postural differences in the immediate effects of active exercise with compression therapy on lower limb lymphedema. Support Care Cancer 2021; 29 (11) 6535-6543
• 19 Rockson SG, Whitworth PW, Cooper A. et al. Safety and effectiveness of a novel nonpneumatic active compression device for treating breast cancer-related lymphedema: A multicenter randomized, crossover trial (NILE). J Vasc Surg Venous Lymphat Disord 2022; 10 (06) 1359-1366.e1
• 20 Gordon K, Varney R, Keeley V. et al. Update and audit of the St George’s classification algorithm of primary lymphatic anomalies: a clinical and molecular approach to diagnosis. J Med Genet 2020; 57: 653-659