Leg Volume in Patients with Lipoedema following Bariatric Surgery

INTRODUCTION

Lipoedema is characterized as subcutaneous lipohypertrophy in association with soft-tissue pain affecting female patients. Recently, the disease has undergone a paradigm shift departing from historic reiterations of defining lipoedema in terms of classic edema paired with the notion of weight loss-resistant leg volume towards an evidence-based, patient-centered approach. Although lipoedema is strongly associated with obesity, the effect of bariatric surgery on thigh volume and weight loss has not been explored.

MATERIAL AND METHODS

In a retrospective cohort study, thigh volume and weight loss of 31 patients with lipoedema were analyzed before and 10-18 and ≥19 months after sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB). Fourteen patients, with distal leg lymphoedema (i.e., with healthy thighs), who had undergone bariatric surgery served as controls. Statistical analysis was performed using a linear mixed-effects model adjusted for patient age and initial BMI.

RESULTS

Adjusted initial thigh volume in patients with lipoedema was 23,785.4 mL (95% confidence interval [CI] 22,316.6-25,254.1). Thigh volumes decreased significantly in lipoedema and control patients (baseline vs. 1st follow-up, p < 0.0001 and p = 0.0001; baseline vs. 2nd follow-up, p < 0.0001 and p = 0.0013). Adjusted thigh volume reduction amounted to 33.4 and 37.0% in the lipoedema and control groups at the 1st follow-up, and 30.4 and 34.7% at the 2nd follow-up, respectively (lipoedema vs. control p > 0.999 for both). SG and RYGB led to an equal reduction in leg volume (operation type × time, p = 0.83). Volume reduction was equally effective in obese and superobese patients (weight category × time, p = 0.43).

CONCLUSION

SG and RYGB lead to a significant thigh volume reduction in patients with lipoedema.

Lipoedema and Pain: What is the role of the psyche? – Results of a pilot study with 150 patients with Lipoedema

Introduction The present exploratory study is the first so far to investigate the psychological stress in the period before the development of pain symptoms typical for lipoedema.

Methods 150 patients diagnosed with lipoedema syndrome were questioned in semi-structured interviews about psychological stress and were diagnosed with psychological disorders according to ICD-10 criteria. The development of the symptoms typical for lipoedema was recorded in a second interview. Both interviews were blended together in collaboration with the patients, this means Lipoedema-associated pain and psychological stress were related to time.

Result Exactly 80 % of the patients diagnosed with lipedema show a high level of psychological distress immediately before the onset of lipedema-associated symptoms! In this study, mental distress was defined as the presence of a manifest mental disorder (ICD 10 F diagnosis) such as Depression, eating disorder or post-traumatic stress disorder and/or serious psychological distress such as burnout syndrome or chronic stress.

Summary These results contradict a widespread statement that all psychological problems of patients with the diagnosis lipoedema syndrome are caused solely by lipoedema, that lipoedema even causes the patient’s mental disorder.

Moreover, depression and posttraumatic stress disorders are significantly related to the maximum pain intensity estimated by patients in everyday life. This demonstrates that it is imperative to rethink lipoedema therapy and to implement a psychosocial pillar in an overall therapy concept.

Lipoedema – myths and facts, Part 5

The four previous articles in this series addressed the myths and facts surrounding lipoedema. We have shown that there is no scientific evidence at all for the key statements made about lipoedema – which are published time and time again. The main result of this “misunderstanding” of lipoedema is a therapeutic concept that misses the mark. The patient’s real problems are overlooked.

The national and especially the international response to the series, which can be read in both German and English, has been immense and has exceeded all our expectations. The numerous reactions to our articles make it clear that in other countries, too, the fallacies regarding lipoedema have led to an increasing discrepancy between the experience of healthcare workers and the perspective of patients and self-help groups, based on misinformation mostly generated by the medical profession.

Parts 1 to 4 in this series of articles on the myths surrounding lipoedema have made it clear that we have to radically change the view of lipoedema that has been held for decades. Changing our perspective means getting away from the idea of “oedema in lipoedema” – and hence away from the dogma that decongestion is absolutely necessary – and towards the actual problems faced by our patients with lipoedema. Such a paradigm shift in a disease that has been described in the same way for decades cannot be left to individuals but must be put on a much broader footing. For this reason, the lead author of this series of articles invited renowned lipoedema experts from various European countries to discussions on the subject. Experts from seven different countries took part in the two European Lipoedema Forums, with the goal of establishing a consensus. The consensus reflects the experts’ shared view on the disease, having scrutinized the available literature, and having taken into account the many years of clinical practice with this particular patient group. Appropriate to the clinical complexity of lipoedema, participants from different specialties provided an interdisciplinary approach. Nearly all of the participants in the European Lipoedema Forum had already published work on lipoedema, had been involved in drawing up their national lipoedema guidelines, or were on the executive board of their respective specialty society.

In this fifth and final part of our series on lipoedema, we will summarise the relevant findings of this consensus, emphasising the treatment of lipoedema as we now recommend it. As the next step, the actual consensus paper “European Best Practice of Lipoedema” will be issued as an international publication.

Instead of looking at the treatment of oedema, the consensus paper will focus on treatment of the soft tissue pain, as well as the psychological vulnerability of patients with lipoedema. The relationship between pain perception and the patient’s mental health is recognised and dealt with specifically. The consensus also addresses the problem of self-acceptance, and this plays a prominent role in the new therapeutic concept. The treatment of obesity provides a further pillar of treatment. Obesity is recognised as being the most common comorbid condition by far and an important trigger of lipoedema. Bariatric surgery should therefore also be considered for patients with lipoedema who are morbidly obese. The expert group upgraded the importance of compression therapy and appropriate physical activity, as the demonstrated anti-inflammatory effects directly improve the patients’ symptoms. Patients will be provided with tools for personalised self-management in order to sustain sucessful treatment. Should conservative therapy fail to improve the symptoms, liposuction may be considered in strictly defined circumstances.

The change in the view of lipoedema that we describe here brings the patients’ actual symptoms to the forefront. This approach allows us to focus on more comprehensive treatment that is not only more effective but also more sustainable than focusing on the removal of non-existent oedema.

Replik auf Leserbrief der Kollegen der Hanseklinik in Lübeck

Das Erfreuliche an Leserbriefen ist die Möglichkeit der Replik, in der im Artikel offensichtlich unzureichend präzise Dargestelltes präzisiert werden kann. Dass die wissenschaftliche Auseinandersetzung um das Lipödem bei den Lesern der Phlebologie auf großes Interesse stößt, zeigt auch die Rankingliste der „meistgelesenen“ Artikel dieser Zeitschrift, in der sowohl unsere Artikel über die Mythen des Lipödems als auch die Leserbriefe zu diesen Artikeln unter den Top Ten platziert sind 1. Insofern danken wir den Autoren aus Lübeck für die Gelegenheit, ihre erwähnten Kritikpunkte aufzugreifen. Bemerkenswert erscheint uns in diesem Zusammenhang, dass zu unserer Artikelserie bislang nur Leserbriefe von die Liposuktion durchführenden Kollegen die Redaktion erreicht haben – nicht eine kritische Rückmeldung erhielten wir bisher von konservativen Behandlern.

Lipödem – Mythen und Fakten Teil 4

Um das Lipödem ranken sich zahlreiche Mythen! In diesem vierten Beitrag unserer Artikelserie setzen wir uns mit dem Stellenwert der Liposuktion beim Lipödem auseinander. Wir diskutieren das von vielen die Liposuktion durchführenden Ärzten verbreitete Statement: „Die Liposuktion führt zu ausgeprägter und dauerhafter Verbesserung des Lipödems“. Wir konnten zeigen, dass zwischen den oft euphorischen Versprechungen der chirurgisch tätigen Kollegen und der aktuellen Studienlage zur Liposuktion eine erhebliche Lücke klafft. Sowohl Studienqualität als auch Studiensetting weisen erhebliche Mängel auf, Mängel, die Zweifel an diesem verbreiteten Statement aufkommen lassen. Eine ähnliche Lücke klafft darüber hinaus zwischen den Empfehlungen der S1-Leitlinie Lipödem und der tatsächlichen „Absaugpraxis“ bei adipösen Lipödempatientinnen. Die in den Leitlinien empfohlene „kritische Indikationsstellung“ bei gleichzeitigem Auftreten von Lipödem und Adipositas findet kaum Gehör. Es kann daher nicht genug betont werden, dass Liposuktion keine Methode ist, um Adipositas zu behandeln. Gleichwohl kann die Liposuktion durchaus zu einer Verbesserung des Lipödems beitragen. Entscheidend für den Therapieerfolg ist die Auswahl der Patientinnen, die aufgrund – medizinischer – Kriterien erfolgen muss. Darüber sollte die Liposuktion in ein Gesamtkonzept eingebunden werden, welches psychosoziale, ernährungs- und sportmedizinische Gesichtspunkte berücksichtigt.

Objectivity and accuracy of mammogram interpretation using the BI-RADS final assessment categories in 40- to 49-year-old women

To determine if use of the five final assessment categories of the American College of Radiology's Breast Imaging Reporting and Data System (BI-RADS) improved objectivity or accuracy of mammographic evaluation in 40- to 49-year-old women, fifty mammograms of 40- to 49-year-old women that were obtained at a tertiary referral teaching hospital were classified according to those five final assessment categories. The mammograms were blinded to six American Osteopathic Board of Radiology-certified radiologists who were asked to classify each mammogram within the five final BI-RADS categories based on the mediolateral oblique and craniocaudal views presented. No history was allowed. Use of the BI-RADS five final assessment categories provided moderate interobserver objectivity, moderately high agreement among the radiologists' interpretation (reliability), and moderate accuracy of interpretation (validity) when compared to criterion. Moderate interobserver reliability and accuracy has been previously identified; however, no scientific review of the BI-RADS five final assessment categories in 40- to 49-year-old females was discovered in the current literature. No overall improvement of objectivity or accuracy was demonstrated using the five final assessment categories of the BI-RADS lexicon in 40- to 49-year-old women.