The continuous monitoring of signs of lymphoedema allowed Mr Lim to receive prompt diagnosis and treatment.
In 2020, Mr Lim’s life took an unexpected turn when a sacral skin tumour was identified on his back, and he was diagnosed with skin cancer. Following surgery and radiotherapy treatments to completely remove the cancer, he then faced a new challenge that would impact his daily life — lymphoedema.
Lymphoedema, a condition characterised by swelling in the limbs, is typically caused by abnormalities in the lymphatic system. The lymphatic system is a key part of the body’s immune system, formed by a network of tissues and organs that help rid the body of toxins, waste and other unwanted materials. When the lymphatic system is impaired or damaged, the limbs swell due to an accumulation of protein-rich lymphatic fluid that causes a blockage and prevents the flow of lymph fluid. As a result, the affected area becomes swollen, heavy and prone to infections. “After my cancer treatment, I noticed my leg would swell significantly, especially after standing for long periods,” said Mr Lim. “After about eight hours, my entire leg would become bulky, swollen and extremely heavy.”
As the surgery and radiotherapy Mr Lim underwent affected his lymphatic system and increased his risk of developing lymphoedema, the multi-disciplinary Lymphoedema Service care team at CGH kept him under close watch. The first to sound the alarm was his physiotherapist, Alicia Tan, Senior Physiotherapist, Department of Rehabilitative Services, CGH. She had been working with him on compression bandaging to manage the swelling in his right leg. However, the swelling persisted.
Clin Asst Prof Jeremy Sun uses an infrared camera to track real-time imaging flows of ICG dye that maps the patient’s lymphatic system during the ICGL test at CGH.
To identify if lymphoedema was the cause, Clinical Assistant Professor Jeremy Sun, Consultant, Department of Surgery and Director, Lymphoedema Service, CGH, arranged for Mr Lim to undergo an Indocyanine Green Lymphography (ICGL) test. The ICGL test utilises real-time lymphography imaging for screening and diagnosis of lymphoedema, and is part of a formal screening programme offered at CGH. Introduced in September 2023, the screening programme focuses on early diagnosis and intervention, complemented by continuous monitoring and personalised care for patients to better manage the condition.
The ICGL test confirmed that Mr Lim had secondary lymphoedema — lymphoedema that develops in individuals later in life. Unlike primary lymphoedema — which is hereditary and the result of a congenital abnormality or defect in the development of the lymphatic system — patients commonly develop secondary lymphoedema as a result of trauma-related injuries or cancer treatment that affect the lymphatic vessels or lymph nodes. These include those with cancer who have undergone lymphatic clearance (the removal of lymph nodes and surrounding vessels) and/or radiotherapy, or patients who have met with motor accidents.
Clin Asst Prof Sun, who is also Director of CGH’s Plastic, Reconstructive and Aesthetic Surgery Service, emphasises the need for early diagnosis and treatment. “People living with lymphoedema may face lifelong challenges and poorer quality of life as they require long-term treatment to manage the condition,” he says. “Patients who are in the early stages of the disease respond much better to treatment with conservative therapy or day surgery. In fact, about 50% of patients who are treated at early stages of lymphoedema are more likely to be weaned off compression altogether.”
As lymphoedema is a lifelong condition, patients who are identified to be at high risk — and are screened and diagnosed early — have a better chance of going compression-free without surgical treatment. When patients are referred for therapy after being diagnosed with end-stage lymphoedema, infection frequencies are higher, often resulting in hospital readmissions.
End- or late-stage lymphoedema is known as elephantiasis. The condition is characterised by massive swelling and skin changes that resemble the thick, rough skin of an elephant. Elephantiasis severely impairs function and quality of life, and management of the condition becomes challenging due to the irreversible nature of the tissue changes. Hence, early diagnosis of lymphoedema is imperative to avoid further disease progression.
Beyond diagnosis, prospective ICGL is carried out at six-month intervals across the care journey of patients, to continually monitor patients who are at high risk of or who have been diagnosed with lymphoedema. This close surveillance allows for timely adjustments to patients’ care plans, avoiding complications before they arise. The proactive care approach enhances long-term patient outcomes and minimises the need for invasive surgeries.
Nurse Clinician Ong Ling provides pre- and post-operative care, medical advice and counselling for lymphoedema patients.
“Throughout the patient’s journey, the multi-disciplinary care team conducts collaborative consultations to review and refine care plans together with the patient,” says Ong Ling, Nurse Clinician, Department of Specialty Nursing, CGH. “Specialist nurses help to identify at-risk patients, facilitate referrals for screening and diagnosis, and provide end-to-end, perioperative care for these lymphoedema patients, including wound management and medical advice.” She adds that the team also carries out quality-of-life assessments, ensuring that the patient’s quality of life is not compromised throughout their recovery journey.
Mr Lim underwent a lymphatic venous anastomosis (LVA) surgery in December 2022, and a second LVA surgery in 2023 to enhance his care outcomes, and restore good lymphatic flow in his limbs, chest and back.
LVA, a bypass surgery, is one surgical option offered to CGH patients who do not improve after three to six months of therapist-led combined decongestive therapy, a combination of compression bandaging, manual lymphatic drainage and exercise. An alternative surgery is a lymph node transfer, where lymph nodes from other unaffected parts of the body are transplanted.
In LVA, healthy lymphatic vessels are connected directly to nearby veins in the affected limb, thus ‘bypassing’ the damaged lymphatic vessels. By establishing these alternative routes, the surgery creates new pathways for lymphatic fluid to drain, thus reducing swelling and providing relief from the discomfort caused by lymphoedema.
Mr Lim’s second LVA was performed as a day surgery, and with the post-operative care of CGH nurses, he was discharged the same day and back at work the next day.
A newer surgical option introduced by CGH in September 2023 is the Lymph Interpositional Flap Transfer (LIFT), a specialised surgical lymphatic reconstruction. The surgery is targeted at individuals with acute lymphatic disruptions and/or sizeable wounds from trauma or cancer surgery, as well as those with moderate to severe lymphoedema who have not responded to conventional treatments.
During surgery, a portion of body tissue with healthy lymphatic vessels is mapped out with ICGL, harvested from the unaffected site, and transplanted to the affected limb to bridge the lymphatic gap and restore flow after the tissue transplant has healed.
How Lymph Interpositional Flap Transfer (LIFT) surgery works
From left to right: A soft tissue flap (blue triangle) with lymph vessels (green arrowheads) is harvested from the groin region and transplanted to the open wound in the leg to bridge the gap and re-establish lymphatic flow.
Clin Asst Prof Sun, who has performed LIFT procedures at CGH, says, “By introducing healthy lymph vessels and tissues, our LIFT surgery seeks to restore disrupted lymphatic flow, provide long-term relief, and prevent further disease progression or recurrence.”
Still, the success of any treatment hinges on patients’ compliance to rehabilitative therapies.
“In a post-operative patient, their compliance to compression therapy is very important because with maximised compression, the fluid gets removed through the lymph. If there is no compliance to compression therapy, the lymph size will not reduce and could cause the operation to fail. For the surgically-created bypass to remain patent and open, pressure is needed for fluids to pass through,” explains Ms Tan.
The CGH care team thus engages the patient as an active partner in their treatment plan, empowering them to set realistic and meaningful goals for the management of their condition.
Ms Tan elaborates, “Our goal is to help patients balance the impact of treatment in managing the condition with their daily lives, considering factors like work or school commitments, social support and personal goals. By working collaboratively with the patient, we can create a care plan that is meaningful and realistic, which helps to promote higher levels of compliance, and leads to improved patient outcomes.”
Senior Physiotherapist Alicia Tan performs compression bandaging on a patient’s arm and hand to promote lymph flow and alleviate swelling as part of lymphoedema treatment.
Following Mr Lim’s discharge, the CGH care team followed up with him closely on a prescribed compression therapy plan that would suit his lifestyle while enabling him to manage his condition. He also modified his diet to help with weight loss and reduce pressure on his limbs.
With compliance to the prescribed therapy plan, Mr Lim’s condition has improved and he now uses the compression stockings intermittently to manage his lymphoedema.
“I’ve accepted the fact that I’m a cancer survivor and I have lymphoedema, possibly for the rest of my life,” he shares. “But I’m adapting to my ‘new normal’ and I’m grateful to the CGH care team for identifying and treating my post-cancer lymphoedema so that I can still work and live my life to the fullest.”
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