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 anastomoses (LVA) are a procedure in which lymphatic vessels are connected to small venules (<1 mm) beneath the skin to redirect lymphatic fluid into the venous system. The operation is performed under a microscope and is carried out as day surgery under general anaesthesia.
• Lymph node transfer is a procedure in which tissue containing one to three lymph nodes is transplanted to the part of the body affected by lymphoedema. For patients who wish to undergo and are suitable candidates for DIEP breast reconstruction, lymph nodes can be included in the tissue transferred from the abdomen to create the new breast. The lymph nodes are then placed in the axilla, and arteries and veins are connected under a microscope to establish circulation in the tissue. No lymphatic vessels are connected. Length of stay is five to seven days.

How to refer

Referrals should be sent to:
Plastikkirurgmottagningen 
Akademiska sjukhuset 
751 85 Uppsala

Responsibilities 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

Confirmed diagnosis by lymphoscintigraphy

• Lymphoscintigraphy (preferably including a calculated transport index) should be attached. In special cases, alternative diagnostic methods may be considered, for example in cases of ipsilateral lymphoedema following 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 assessment of venous circulation (leg lymphoedema)

• For patients with leg lymphoedema, venous insufficiency must be ruled out by ultrasound. If pathology is identified, a vascular surgeon should be consulted for assessment and treatment before the patient is referred to an NHV unit. Please attach the report.

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 status

• Nicotine can negatively affect an operation. The patient should be free of all nicotine use (including snus and e-cigarettes) for at least 6 weeks prior a planned surgery and must be informed of this before referral. The patient cannot be scheduled for surgery until they are nicotine-free. 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.
• Clinical notes from a lymphoedema therapist and/or previous lymphoedema assessment.
• Compression plan and compliance.
• Diagnostic 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

Microsurgery contact nurse: Åsa Wiberg, telephone number 018-611 54 27.