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Obesity-induced lymphedema

Weight loss not surgery better for lower-extremity lymphedema

(Credit: Bobjgalindo)
Morbidly obese patients with significant MLL overgrowths should undergo counseling for weight loss, then bariatric surgery and if that fails before undergoing an operation to remove the MLL overgrowths

Morbidly obese individuals are prone to overgrowths in their lower extremities that can lead to infections and other health-threatening complications. Little was previously known about the underlying causes of this condition, and conventional treatment has involved surgical removal of these overgrowths. However, a study published online in the Journal of the American College of Surgeons has identified the underlying cause for these overgrowths, and the researchers recommend that weight loss, not a surgical procedure, be the preferred initial treatment for these patients.

In the paper, ‘Massive Localized Lymphedema: A Case-Control Study’, the research team led by Dr Arin K Greene, a plastic surgeon at Boston Children's Hospital, Harvard Medical School, developed a probability scale that can help physicians identify patients at greatest risk of this condition, known as massive localised lymphedema (MLL). This study is the first to identify the cause of MLL as obesity-induced lymphedema (OIL), and it builds upon previous work Greene and colleagues have published in which they identified OIL as a disease resulting from obesity.

Once an individual's BMI exceeds 50, the lymphatic system in the legs becomes damaged and patients develop lower extremity swelling, known as obesity-induced lymphedema. Over time, massive overgrowths can occur in these patients; the higher the BMI, the greater the risk.

Arin K Greene (Credit: Boston Children's Hospital)

"The major clinical takeaway for physicians is that if they have a patient with massive localised lymphedema, the individual has an underlying disease called obesity-induced lymphedema and the initial treatment should be weight loss," said Greene. "Surgeons should consider removing one of these massive growths only after the patient has lost significant weight, because the risk of recurrence is lower and the operation is much safer."

The Boston Children's-Harvard study involved 82 obese patients who underwent lymphoscintigraphy, a nuclear medicine test for evaluating lymph drainage, to evaluate lower extremity lymphatic function between 2009 and 2016. Seventeen were diagnosed with MLL, and all of them had underlying OIL. Their median BMI was 66 (ranging from 62 to 78) with a median age of 61 years (median age of controls who did not have MLL was 55 years). Patients with a BMI greater than 56 had a 213 greater odds of developing MLL than patients with lower BMI. Greene explained out that lymphoscintigraphy "is very accurate in determining if the lymphatic vessels in the lower extremities are functioning properly."

"An important finding of the study is that we can now counsel patients with OIL who have not yet developed MLL about the likelihood that they will develop MLL if they do not lose weight," he added.

The study researchers developed a probability scale that identifies a patient's risk for developing MLL: a 4 percent chance at BMI40; 15 percent at 50; 40 percent at 60; 75 percent at 70; and 92 percent at 80.

The key is that morbidly obese patients with significant MLL overgrowths should undergo counseling for weight loss, non-surgical at first, then bariatric surgery if that fails before undergoing an operation to remove the MLL overgrowths.

"In our centre, individuals with obesity-induced lymphedema, with or without MLL, are referred to a bariatric surgical center to treat the underlying cause of their lymphatic function, which is their weight," said Greene. "Not only will weight reduction prevent the occurrence of MLL, but it will significantly shrink the area of overgrowth and facilitate its resection."

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