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Health, Beauty & Fashion

Draining swollen limbs

A new surgery to transfer lymph nodes helped Madam Tan Mei Fong when hers were destroyed during cancer surgery, resulting in her legs swelling with fluid.
The Straits Times - June 9, 2011
By: Ng Wan Ching
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Draining swollen limbs
For a woman who loved to look good, her swollen legs were a devastating blow to her self-image.

For nine months after cancer surgery destroyed her lymph nodes and made her legs balloon with fluid retention, Madam Tan Mei Fong (above) kept her limbs hidden under voluminous skirts and long dresses.

When the swelling increased so much that even her toes became stiff, painful and numb, Madam Tan, 40, a Singapore permanent resident living in Johor Bahru, decided she had to do something about it.

She came to Singapore for medical help, even though she knew it would be expensive, and became the first patient here to undergo a lymph node transfer operation, a year ago.

Since then, transfers have been done in at least four other patients at the National University Hospital (NUH) and KK Women's and Children's Hospital (KKH). The operations at KKH were done in collaboration with surgeons from Singapore General Hospital (SGH).

Doctors say this surgery is a good option for patients who suffer swelling that is difficult to control after their lymph nodes are removed or damaged during surgery, including that to remove cancer.

Outside of Singapore, it has been estimated that about 8 per cent of all gynaecological operations result in lymphoedema.

Surgeons usually try shunting (lymphaticovenular bypass) first - a joining of lymphatic channels to veins in order to help body fluids flow better.

Only those with recalcitrant swelling, which does not go away even with shunting, or those with chronic lymphoedema with fibrosis are offered this treatment, said Dr Jane Lim, senior consultant at NUH's division of plastic, reconstructive and aesthetic surgery.

Both shunting and transfer are done in some cases where the swelling is very advanced, such as in Madam Tan's case.


Madam Tan was diagnosed with uterine cancer in Singapore two years ago. She had wanted to have surgery here, but chose a Malaysian hospital instead for financial reasons.

After the surgery to remove the cancer, her legs started to swell, either because the lymph nodes in her lower abdomen had been removed or they had been scarred during surgery.

They became unable to channel fluid in the tissues there into the bloodstream, resulting in fluid retention.

The swelling would start every day, once she got out of bed, and become progressively worse throughout the day the longer she was standing and doing housework or walking around.

The fluid which pooled in her legs would drain only when she lay down and went to sleep.

The housewife and mother of three would wear pressure stockings to try and keep the swelling down.

But at the end of the day, the circumference of her legs would have grown by 30 to 40 per cent, with the swelling in her left leg being worse.

She said: 'My shoe size went from size 5 to size 8. It was horrible.'

She said her labia (the external fold of skin surrounding the vaginal opening) became as big as two eggs and felt very hard.

'I could not wear trousers for nine months. Nothing would fit,' she said in Mandarin.

Her legs became so big that she could 'wear only huge dresses'.

'I could feel the skin on them being stretched and the skin turned red and black,' she said.

Through a gynaecologist here, she was referred to Dr Lim.

Dr Lim said: 'It was in view of the severe swelling of both legs as well as her lower abdomen that we decided to do this lymph node transfer operation.'

She added: 'Lymph node transfer from one part of the body to another has been done in animals and has been found to have promising regeneration of lymphatic vessels after that.'

In recent years, vascularised lymph node transfers have been found to be beneficial in people with lymphoedema.

'It's a lymphatic reconstruction. After it's done, new vessels will grow to relieve the area,' Dr Lim said.

She thought the surgery would benefit Madam Tan.


A Japanese surgeon, whose speciality is lymphatic surgery and reconstruction, came to Singapore to help Dr Lim develop this area of surgery.

Dr Lim took two lymph nodes from Madam Tan's left armpit and transplanted them into the left side of her groin.

The tissue containing the two lymph nodes also contained an artery, a vein and a lymphatic channel (a tubular vessel that transports lymph).

'We joined them with blood vessels in the area of complaint to help with circulation,' said Dr Lim.

She also did three levels of shunting for Madam Tan in her upper thighs, around her knees and her calves.

As a result of the intervention, Madam Tan's swelling 'came down' very quickly.

Dr Lim has now done three such lymph node transfers, with Madam Tan being the first in May last year.

Later, two other patients who also had recalcitrant lower limb swelling because of cancer surgery had lymph nodes transferred from their necks. Both also underwent shunting at the same time.

'They both had a bit of double chin which they wanted to get rid of. As it contains lymph nodes, it was a two-in-one operation for them - reduction of double chin and lymph node transfer,' said Dr Lim.

SGH surgeons worked with KKH surgeons on two lymph node transfers for two patients with similar complaints after surgery for gynaecological cancers. One was done in February and the other last month.

Dr Evan Woo, associate consultant at KKH's department of plastic, aesthetic and reconstructive surgery, said: 'The first patient had a reduction in circumference of between 4cm and 9cm in the operated lower limb within the first month of surgery and it is being maintained.'

She needs less compression bandaging without the limb swelling again. The second patient's post-surgery measurements will be taken soon.

Associate Professor Tan Bien Keem, senior consultant at SGH's department of plastic, reconstruction and aesthetic surgery, said: 'Post-operatively, we have observed a gradual reduction in limb girth in patients and we are monitoring their progress.'

Men who get swelling after cancer surgery can also opt for this procedure.

As a class C patient, Madam Tan paid $3,100 for her surgery, which includes shunting and lymph node transfer.

Without subsidies, the surgery for both shunting and lymph node transfer at NUH will cost about $25,000. The cost is similar at the other two hospitals. Patients can use Medisave and MediShield.

Madam Tan is delighted with the results of the surgery.

'Now I feel beautiful again and I am back to wearing size 5 shoes,' she said, as she showed off her shapely calves.


Gall in the family