Lymphovenous Canada: Highlights from the 21st International Congress of Lymphology in Shanghai, China

The historic Jin Jiang Hotel was the setting for the 21st International Congress of Lymphology, held September 26 - 29, 2007 in Shanghai, China. It was the first time in its 40 year history the International Society of Lymphology has held a conference in China.

This years' bi-annual International Society of Lymphology (ISL) conference was organized by the Shanghai 9th People's Hospital and supported by the Shanghai Jiao Tong University Medical School. It was at the Jin Jiang Hotel that U.S. President Richard Nixon signed the Shanghai Communique with Zhou Enlai in 1972. This agreement re-established Sino-American relations and opened the country up to increased trade around the world.

Participants who attended the conference might not been as lofty as the 300 heads of state - such as President Nixon - who have stayed at the hotel, but their goals were. The 21st ISL conference provided many specialists and those with a special interest in lymphatic disorders in the Asian area to get together an exchange research and theories on treatment methods.

"Lymphologists, in comparison with other scientific fields, are small in numbers, but the lymphatic system plays an important role in many, many diseases," said Dr. Ningfei Liu, conference president, "But understanding in this area is increasing faster and faster. In the future many more people will get the benefit of this knowledge. The purpose of this conference is to bring lymphologists from around the world together to exchange their basic and clinical experiences and to promote the development of lymphology."

Dr. Liu works in the Department of Plastic and Reconstructive Surgery at the Shanghai 9th People's Hospital (one of the sponsors of the conference). Her department is made up of six surgeons and Phd students who treat patients with lymphedema with surgery and conservative therapy.

50 years ago China had a large number of patients with lymphedema caused by lymphatic filariasis (caused by a parasite), but were able to eradicate it through the treatment of patients and spraying for mosquito carriers. People with lymphedema still exist in China, however, like many industrialized countries in the world, most commonly as the result of cancer and cancer treatment. Cancer is currently China's number one killer.

"We need more medical students and doctors to have more knowledge about lymphedema"

"Because China has a big population and the incidence of malignant cancer has increased fast during the last two or three decades, secondary lymphedema is still remains a big problem." says Liu. "Often patients cannot get the right diagnosis and the right treatment so they go to every hospital and department - but very few medical people know what lymphedema is and how to treat it. So we need more medical students and doctors to have more knowledge about lymphedema."

China has recently moved towards a privatized health care system where patients pay for their services through health care insurance if their employer has coverage. Funding for patients receiving services in rural areas is not as comprehensive as it is in cities, however the government is working on improving this situation.

The close proximity of China to other countries in the area brought individuals such as Dr. Yener Demirtas, from Turkey, to attend the sessions. Dr. Demirtas, who bemoaned the absence of lymphatic therapists in the country, left the conference committed to establish a Turkish Society for Lymphology and a national treatment centre. Dr. Marwan Abu-Hijleh, Professor and Chair of the Department of Anatomy, with the Arabian Gulf University, College of Medicine and Medical Sciences in Bahrain (formerly from Canada) brought his research on the lymphatic implications of his research regarding superficial facia (the soft tissue component of the connective tissue) to the conference.

Others, such as Dr. Sufen Liao from Tiawan, demonstrated the work she has been part of through a poster display. In Dr. Liao's case this involved research the Changhua Christian Hospital undertook with 24 breast cancer patients between 2006 - 2007, integrating MLD (manual lymph drainage), rehabilitation and exercise with positive effects.

Dr. Christian Lohrmann with the University Hospital of Freiburg, Germany, is one of the younger generation of lymphologists now attending the ISL conferences. Dr. Lohrmann won the ISL Presidential Prize for his work in high resolution magnetic resonance lymphangiography and enhancements to imaging techniques.

Five other individuals received the 2007 Presidential Prize awards of $500 - $1,000. These included: Dr. Jurgen Becker, from the University of Gottingen in Germany, Sarah Daley and Michael Dellinger from the University of Arizona, Tucson USA, Vagelis Dimakakos, Aretaeion, Greece, and Alexander Kuznetsov, Novosibirsk, Russia. Dr. Sinnamohideen Jamal and Dr. Robert Cluzan received Lifetime Achievement Awards.

The conference covered a range of subjects, from advances in genetic research and lymphangiogenesis (tissue regeneration) to clinical and rehabilitation updates, immunity and pathophysical research, diagnostic imaging and clinical management, using conservative methods as well surgical approaches.

Dr. Marlys Witte, ISL Secretary-General, kicked off the conference on a cautious note, by pointing out that while there is greater knowledge about the genetic origins of lymphedema, we are still a long way from developing a treatment that would alter the genetic make-up of lymphedema. She suggested that we are more likely to find effective treatments from other areas of research in the near future. [Editor: In the 10 years since that first genetic treatment on Sept. 14, 1990, over 400 clinical trials have been undertaken worldwide. Results have been disappointing: since that time there have been a number of deaths associated with genetic treatments and few positive effects.]

On a more positive note, Elsina Brouwer, organizer of the Dutch Lymphology Network spoke about work which has taken place in the Netherlands to establish the NLNet (Nederlands Lymphfoedeem Netwerk) which provides a platform for patients with lipedema and lymphedema. She stressed the important role of self-management courses in reducing expensive post-surgical treatments for breast cancer patients with lymphedema.

Karin Johansson from the Lymphedema Unit at the Lund University Hospital in Sweden reported positive effects for breast cancer patients who exercised by walking using walking sticks/poles.

On-line international survey data collected by the National Lymphedema Network in San Francisco, USA of 570 survey respondents found that persons with secondary types of lymphedema (such as breast-cancer related lymphedema) were twice as likely to follow a daily self-care program than those born with primary lymphedema. 72% had pain associated with lymphedema. The internet was cited as the greatest source of information by those surveyed, followed by doctors. TV ranked last as a reliable source of information.

Jane Armer, Professor at the University of Missouri-Columbia School of Nursing spoke about her on-going study on lymphedema occurrence following breast cancer treatment. Armer believes the rate of lymphedema is 20-40% overall. Dr. Helen Mackie with the Mt. Wilga Lymphoedema Clinic in Australia reported a drop in post cancer lymphedema in the patients they see, with a rise in lower limb lymphedema (both primary and secondary) and lymphedema caused by morbid obesity.

Dr. Neil Piller and Amanda Mosley from the Flinders University School of Medicine called for more evidence-based research into conservative treatments for lymphedema, after their systemic review of journal articles (on common conservative therapies for secondary arm or leg lymphedema subsequent to cancer treatment) found few evidence based studies confirming the effectiveness of treatments, despite a range of positive outcomes identified.

The absence of peer-reviewed studies in scientific and medical journals on the long-term effectiveness of surgical interventions on lymphedema has continued to hinder the credibility of other treatments in this area.

A number of clinics have opened throughout the world modelled after Dr. Hakan Brorson's use of liposuction on persons with lymphedema (Lund University, Sweden). Dr. Brorson has published on the results of his work in which he reports promising results in this area. He performs liposuction on patients with both upper and lower limb lymphedema. Only patients with non-pitting lymphedema, however, who have not responded to conservative treatments are operated on. Prior to surgery patients must show that they can wear compression garments on their effected limb 24 hours a day. After surgery patients resume wearing their compression garments day and night.

Dr. Alex Munnoch is head of a liposuction treatment centre at the Ninewells Hospital (a national health service hospital) in Dundee, Scotland, modelled after Dr. Brorson's method of treatment. His centre has been open for 30 months and has assessed over 20 patients for treatment. To date eight patients have undergone surgery. Four patients were referred for pressure garments and massage therapy and seven patients have been declined any surgerical intervention. The National Institute for Clinical Excellence in Scotland introduced guidelines for new surgical procedures in 2005. Liposuction for lymphedema was considered to be a new procedure, resulting in lengthy delays in the provision of treatment at this facility while appropriate authorization was obtained. The service continues to be evaluated.

"Most surgeons in the UK have been reluctant to provide surgery as part of the management of lymphedema. They are very wary of the technique and the results. Why is there a reluctance to do surgery on patients with lymphedema?"asks Munnoch. "I think in the past surgery has been poorly performed, and there has been very poor reporting of evidence of the techniques in mainstream medical journals to support it. We plan to eventually publish the results from the work. Our work supports the published results of Brorson."

Dr. Brorson and Dr. Munnoch are plastic surgeons who operate in a regulated environment within their country's health care system. In many parts of the world, including the U.S. and Canada, individuals with no training in surgery are conducting cosmetic surgery including liposuction, with questionable results.

The death of a 32-year-old mother (without lymphedema) who received liposuction on Sept. 20, 2007, has resulted in an investigation of 36 doctors in the province of Ontario (Canada) by the College of Physicians and Surgeons. Many of these doctors were performing high-risk cosmetic procedures (such as liposuction) in private clinics without proper qualifications. A set of new rules, where the title "surgeon" is limited only to physicians certified as surgical specialists by recognized medical bodies, is being proposed by the College. The College is hoping its proposals will become law in the next year.

To purchase copies of the proceedings of the 21st International Congress of Lymphology Sept. 26-29, 2007 or for further information, please contact:

Dr. Ningfei Liu
Dept. of Plastic and Reconstructive Surgery
Shanghai 9th People's Hospital
Medical School of Shanghai Jiaotong University
639 Zhi Zao Ju Rd, Shanghai 200011, China
Tel: +86-21-63138341, Ext 5125; Ext 5604
Fax: +86-21-53078125
E-mail: liun2002@yahoo.com