Surgical rehabilitation guidelines

Integrating rehabilitation therapy into surgical programs

By Lori Radke

Infollow-up to the recent Contemporary Concepts in Lymphatic Surgery article by Dr. James Kennedy (Pathways, Winter 2020/21) this article will explore the lymphedema management process that occurs peri-operatively at the Rehabilitation Oncology clinic in Calgary, Alberta. In operation since 2009, this clinic provides outpatient rehabilitation, including lymphedema assessment and treatment, for cancer patients. The clinic is part of the Supportive Care: Psychosocial and Rehabilitation Oncology department of the Tom Baker Cancer Center, which is under the umbrella of Cancer Care Alberta. The clinic works in collaboration with Dr. Kennedy to ensure that a patient’s lymphedema has been optimally conservatively managed prior to undergoing surgery. Non-cancer lymphedema patients are treated similarly at the Calgary Ambulatory Lymphedema Service (CALS) clinic.

Different scenarios illustrate the referral pathways between the rehabilitation clinics (conservative therapy) and Dr. Kennedy’s clinic.

In Dr. Kennedy’s initial surgical consultation with a patient, he does not focus only on surgery. His assessment includes a thorough history and review of the conservative management that a patient has tried in the past and currently follows. If they have not seen a therapist for lymphedema management, then a referral to the Rehabilitation Oncology clinic or one of its provincial counterparts is the first step, before any surgical options are explored. Many referrals to the clinic have resulted in successful conservative management, eliminating the need for surgery.

advises the patient that surgery is not currently indicated as their lymphedema is already being well maintained with their present conservative measures to which they adhere. Patients are made aware that they can be referred again if their situation changes. They are often relieved to hear this and happy to continue with their maintenance plan.

The Rehabilitation Oncology clinic is a frequent referral source to Dr. Kennedy as patients often have questions regarding possible surgical options. We make it very clear to the patients that a resolution of their lymphedema or the elimination of the need for compression garments is not a realistic outcome of surgery. Lymphedema maintenance will still include compression garments, sometimes including night compression. A primary reason for a surgical referral is when the patient has frequent cellulitis infections.

“Surgical management

for

lymphedema

is

still in its infancy and comprehensively relies on a coordinated interplay with conservative therapy.”

-Dr. Kennedy

transfers, have demonstrated a reduction in cellulitis rates post-surgery.1-8 If the cellulitis episodes can be prevented, or at least reduced, then the outcome of conservative treatments is significantly improved. Tissue integrity and skin condition are enhanced, and limb volumes can usually be reduced over time, or at least maintained.

Another scenario is that Dr. Kennedy

All the procedures that Dr. Kennedy currently performs, including lymphovenous anastomosis (LVA), liposuction and lymph node

Lori Radke, PT, CLT is a physiotherapist who has worked in Alberta for more than 30 years since graduating from the University of Alberta in 1988. She has a passion for edema/lymphedema management and oncology. Radke has led the Rehabilitation Oncology program in Calgary since 2009. She is now the Clinical Practise Lead of the Cancer Care Alberta Rehab Teams.

“Defining appropriate patient selection remains challenging but should center around a few fundamental concepts. A compliant patient, with worsening limb function, minimal improvement using nonsurgical means for 12 months. Realistic expectations are paramount but often difficult to reconcile in the age of Internet medicine and exaggerated claims by a multitude of clinics and surgeons.”

Ideally, a patient is referred to the clinic for a pre-operative assessment as soon as the surgical consult occurs. If they are a current patient of one of the Rehabilitation Oncology

Holy Cross Centre in Calgary, Alberta.

CHART 1

Lymphedema surgical post-operative protocols

Dr. James Kennedy, Calgary, Alberta

All procedures

1 Referral sent to Rehabilitation Oncology clinic as soon as surgery is booked with Alberta Referral Directory form. The patient could go to Calgary, Red Deer, Lethbridge, or Edmonton depending where they are seen for their lymphedema treatments. Those with non-cancer lymphedema go to the Calgary Ambulatory Lymphedema Service (CALS).

2 Review of current lymphedema maintenance plan.

3 Limb volume assessment with Perometer or circumferential volumetric measurements.

4 Edema reduction for 1-2 weeks prior to surgery with compression bandaging (usually 2-4 appointments).

5 Plan for post-surgical compression day garments/ night compression.

Suction Assisted Lipectomy/ Liposuction

1 See 2-3 days post-op to begin compression bandaging again- remove surgical dressings. Wash limb with soap and water. No immersion in a bathtub or hot tub. Showering allowed. Antibiotics prescribed for 3-5 days (usually Keflex or Clindamycin)

2 Remove steri-strips at about 14 days, if still present.

3 Continue compression bandaging twice a week for 2-4 weeks, or until limb volumes stabilize according to two different sets of measurements.

4 Fit with new compression garments, custom or readymade. May need to re-bandage if any increase in volume occurs before new garments arrive.

5 Continue clinic protocol for lymphedema maintenance.

Post liposuction, day ten.

Lymphovenous Anastomoses

1 Same protocol as above but compression delayed for 2 weeks post-op.

Lymph node transfers

1 Patient admitted to hospital for 3-5 days.

2 Drains typically removed on day 7 post surgery.

3 Compression wrapping started at 2 weeks; may be started sooner post groin lymph node transplant combined with free flap breast reconstruction.

Modified Charles Procedure (non-cancer related lymphedema)

1 Drains removed on day 7 post surgery

2 Wound care to incision line

3 Can start compression within 2-3 days.

If drain in place or patient has skin graft, start at 7 days.

clinics, they are referred back to that same clinic prior to surgery. Pre-op assessments include limb volume measurements, either with a Perometer 9,10 or circumferential measurements. All rehabilitation oncology clinics in Alberta currently have a Perometer used for upper limb measurements. Usually, lower limb lymphedema is measured using a tape measure and limb volume calculation formula, except in the Edmonton clinic, which uses a Perometer for both upper and lower limb volumes. The assessment also includes tissue palpation for quality of tissue and fibrosis, skin changes/wounds, appropriate joint ROM measurements, compression garment reassessment, and need/re-evaluation for night compression.

Patients are seen for active reduction phase treatment for 1-2 weeks prior to the surgery, or possibly 3-4 weeks if they have more edema. This is done primarily with compression therapy using multi-layer bandages applied by either a therapist or therapist assistant.11-13 Coban 2 short stretch bandages, are applied to the full limb and changed twice a week. If a patient does not tolerate Coban, then Comprilan multi-layer bandages are used and changed 3-4 times per week. Manual Lymph Drainage is included as indicated. Education, exercise prescription and skin care are a part of every visit to the clinic. Also any referrals for psychosocial support, including social work for financial assistance, would be made prior to surgery. The Alberta Aids to Daily Living (AADL) provides compression garments for lymphedema patients using a cost-share program. All patients can be authorized for either three ready-made garments or two custom-made garments per limb (per 12-month period) if they do not have private insurance coverage.

Post-surgical lymphedema treatments begin on day 2-3 post-op (Chart 1). There are multiple dressings applied to the limb in surgery and a layer of Coban holds the dressings in place. The dressings are removed at the clinic and the limb is washed and measured. Steri-strips cover the incision sites and remain in place for 10-14 days. Compression treatments continue until the limb volume stabilizes, usually 2-3 weeks, and then a fitting occurs with a certified AADL vendor for new compression garments. If a custom garment is necessary, the patient may continue bandaging at home, use an old

Photos: Tom Baker Centre (Consent obtained from all subjects.)

Images show post liposuction, day two.

garment or their night compression system, or be booked to come back for bandaging appointments prior to receiving their garments. We have not seen a significant change in limb volumes in this time period while waiting for the garments, which can be 10-14 days. We have also not seen any post-op infections out of approximately 20 surgeries.

The other benefit of the surgery is the use of the SPY, an intra-operative fluorescence imaging system, which visualizes and analyzes the lymphatic system in the affected limb. This information has informed clinicians and patients to better understand the lymphatic damage and drainage pattern in their limb. Occasionally we have found out that there are no functioning lymphatics, which helps to

understand the limitations of certain surgery techniques and guide conservative treatments.

“It is worth reiterating that despite improvements in surgical options, it has not supplanted non-surgical therapy. Instead, surgery has more recently become an additional modality in an integrated treatment strategy for lymphedema patients that still requires lifelong self-care and management.”

Lymphedema surgery in Calgary was initiated by Dr. Kennedy in 2015. Of the surgeries he has performed, lipectomy was by far the most frequent, which may reflect the later stage of lymphedema that is present when patients seek a surgical consult. Some patients may have multiple procedures; i.e. LVA followed by a liposuction, or repeated liposuction on a limb.

The first patient we saw at our clinic had an LVA on her right upper limb and subsequently suction-assisted lipectomy the following year. Our clinic became involved in her care after the second surgery, and included are some photos of the patient post-liposuction day 2 and then 1 week later. This patient reports a marked reduction in episodes of cellulitis since these procedures were done in 2016.

As with all active therapy patients, those who have undergone lymphedema surgery are reassessed at 3 months, 6 months, and 1 year. After that, they are seen once a year to review and assess their maintenance plan. If there is a change in limb size, symptoms or tissue changes, or if they have cellulitis, they are seen sooner. Patients may require active treatment to reduce these changes, or an update in their maintenance plan (compression day garments, night compression systems, exercise, skin care, self MLD, compression pump, or kinesiotape).14,15

All Cancer Care Alberta Rehabilitation Oncology clinics use the same referral form and process. The Alberta Referral Directory is AHS’s designated online system of information on how to refer to a variety of medical clinics and services. There is collaboration between Rehabilitation Oncology clinics in Calgary, Edmonton, Red Deer, Lethbridge and soon-tobe-open Grande Prairie to coordinate patient care. This provincial coordination enhances the “care closer to home approach” that is a priority for Cancer Care Alberta. LP

A full set of references can be found at www.lymphedemapathways.ca