Referral to National Highly Specialised Care (NHV) in lymphoedema surgery

After cancer treatment, such as breast cancer, malignant melanoma, genital cancer or trauma, lymphoedema can occur and microsurgical treatment of lymphoedema may be considered as a treatment.

The microsurgical treatments to relieve lymphoedema can be:

• Lymphaticovenous anastomosis (LVA) is a method where lymphatics are diverted into small venules (<1 mm) under the skin to transfer lymphatic fluid to the venous system. The operation is done under a microscope. Performed as day surgery under general anaesthesia.
• Lymph node transfer is a procedure whereby tissue containing one to three lymph nodes is transplanted into the lymphoedema affected part of the body. For patients who want and are suitable for breast reconstruction with DIEP, lymph nodes can be included in the tissue from the abdomen that will become the new breast. The lymph nodes are then placed in the axilla, arteries and veins are sewn together under a microscope to allow circulation in the tissue. No lymphatic pathways are sewn. Duration of care five to seven days.

How to refer

Referral sent to:  
Plastikkirurgmottagningen 
Akademiska sjukhuset 
751 85 Uppsala

Responsibility of the referring doctor:

• Provide a summarised medical history, including previous surgery, any co-morbidities and current medication.
• Ensure that the patient does not have active or recurrent cancer.
• Establish that the patient does not have serious co-morbidities that contraindicate surgery (e.g. severe heart, lung or kidney failure, severe untreated mental illness or ongoing infection).
• Attach relevant documentation from previous investigations, imaging and lymphoedema treatment.
• Indicate the current ongoing compression therapy (type of compression material, number of hours per day, compliance, etc.).
• Indicate if the patient has an iodine allergy or hyperthyroidism

Medical inclusion criteria for NHV assessment

Criterion and description

Verified diagnosis by lymphoscintigraphy

• Lymphatic scintigraphy (preferably with calculated transport index) should be attached. In special cases, alternative diagnostics may be considered, for example in ipsilateral lymphoedema after breast cancer.

Compression therapy for at least 6 months

• Treatment must be carried out in cooperation with a lymphatic therapist and evaluated as not sufficiently effective before surgery can be considered.

Ultrasound of venous circulation (leg oedema)

• For patients with leg oedema, venous insufficiency should be excluded by ultrasound. In case of pathology, vascular surgeon should be consulted for assessment/treatment before referral to NHV unit. Attach a statement.

Adjusted BMI ≤ 30

• Being overweight can have a negative impact on an operation. Higher BMI should be optimised before surgical assessment. Adjusted BMI is calculated based on height and weight. Note that specifically for the BMI for lymphoedema, the increase in volume is deducted, i.e. 1 litre of lymphoedema = 1 kg deducted from the weight in the equation.

Tobacco and nicotine free

• Nicotine can negatively affect an operation. The patient should be free of all nicotine use (including snus and ecigarettes) for at least 6 weeks before the planned surgery and must be informed of this before referral. The patient cannot be scheduled for surgery before nicotine withdrawal. The referral should include information on nicotine status and the condition to quit nicotine.

Documents and information to be attached to the referral

• Current medical report with medical history, status and summary of treatment.
• Medical records from lymphatic therapist and/or previous lymphoedema investigation.
• Compression plan and compliance.
• Imaging (lymphoscintigraphy, ultrasound, MRI, possibly photo documentation).
• Smoking and nicotine-free status and current weight/BMI.
• Indication of whether the patient has an iodine allergy or hyperthyroidism
• Confirmation that the patient authorises the sharing of their data between the referring unit and the NHV unit(s).

Documents in Swedish

Instruktion för lymfscintigrafi med transportindex (pdf) (Instructions for lymphoscintigraphy with transport index)

Lymfscintigrafi ben (pdf) (Lymphatic scintigraphy leg)  

Lymfscintigrafi arm (pdf) (Lymphatic scintigraphy arm)

Klinisk processkarta : lymfödem (pdf) (Clinical process map: lymphoedema)  

Contact us

Contact nurse microsurgery: Åsa Wiberg, telephone number 018-611 54 27.