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We talk about it with Prof. Sandro Michelini – By Nadia Clementi
The Villa Regina nursing home in Arco is a Trentino excellence specialized in lymphedema treatments
The Villa Regina nursing home is located in Arco and is the first specialized clinic in Italy where intensive lymphological rehabilitation treatments are carried out, on an inpatient basis, totally paid for by the National Health System, for cases of primary and secondary lymphedema.
Peripheral lymphedema is a chronic, progressive, debilitating disease caused by the pathological accumulation of fluid (lymph) in the tissues (lymphostasis) of the upper or lower limbs and, more rarely, in other body regions (face, external genitalia, abdomen, chest).
The main forms of lymphedema are primary, due to malformations of the vessels of the lymphatic system, or secondary, due to external adverse events that alter the normal function of the lymphatic system.
Lymphedema causes abnormal thickening of the skin and underlying connective tissue, especially of the legs and male genitalia.
It is one of the most common causes of disability in the world. In Italy, there are a total of about 40,000 new cases of lymphedema per year.
The nursing home Villa Regina is an all Trentino excellence and has as its primary objective the taking care of the patient and the definition of a personalized rehabilitation path in order to improve the quality of life and to encourage the maintenance of autonomy of patients in accordance with their degree of disability.
In addition, every year the nursing home makes significant structural investments to accommodate patients in a beautiful and comfortable environment, with high levels of hotel quality and personal services, to make the stay more pleasant and make the guest feel at home.
It has 184 licensed beds of which 161 are accredited with the national health service, of which 151 beds for long-term care and extensive rehabilitation and 10 beds for intensive lymphological rehabilitation.
The facility provides medical care, nursing, rehabilitation treatments, access to radiology services and laboratory analysis, 24-hour internal medical service, day and night, specialist consultations with high standing professionals.
We interviewed Prof. Sandro Michelini, a high-level specialist in personalized therapeutic treatments for all types of lymphedema.
Translated with www.DeepL.com/Translator (free version)
|Who is prof. Sandro Michelini
Specialist in General Surgery, for over 35 years he has been involved in vascular rehabilitation, with particular reference to primary and secondary lymphedema.
He has conducted numerous clinical and experimental studies on these pathologies concerning, in particular, genetic, epidemiological, clinical and rehabilitation aspects of the pathologies in question.
Lecturer in Training Courses (in Italy and abroad) and University Masters in Lymphology.
Former President of the European Society of Lymphology and of the International Society of Lymphology.
Current President of the Scientific Association ITA.L.F. (acronym of Italian Lymphedema Framework).
Prof. Michelini, lymphedema is the disease that affects lymph and the lymphatic system. But what is lymph and what is the lymphatic system?
“Thomas Mann said, in his book The Magic Mountain: Lymph is the best, most secret and delicate product of all the workings of the body. People always talk about the blood and its mysteries, they call it a special mood, but it is the Lymph that is the true mood of the humors, the essence, the juice of the blood, a great and delicious force.
“The Lymph in essence is a fluid containing elements common to the blood circulation (proteins, sugars, fats, mineral salts, water) expression of cellular turnover, which are reabsorbed from the tissue spaces within the Lymphatic System.
“This, which is present in all organs and tissues, can be likened to a highway system composed of pathways (lymphatic collectors) and toll booths (Lymph nodes). When the whole System is designed and maintained intact, fluids flow regularly and tissues are purified of their waste; vice versa, when the System is designed and implemented incompletely or malfunctioning (Primary Lymphedemas) or part of it is destroyed or altered in its functioning (Secondary Lymphedemas), then a highway traffic jam is created, which in clinical terms corresponds to the accumulation of tissue fluids that materialize in EDEMA.”
What is meant by “primary” lymphedema and “secondary” lymphedema?
“Primary lymphedemas arise at birth (connatal forms), in the first decade of life (early) or, more frequently (about 90%) in the second, third, fourth and fifth decades of life (late), often as a result of a trivial trauma on a constitutional predisposition (genetic).
“In about 5% of cases there is a familiarity of the disease, in about 90%, conversely, it is not possible to identify other members of the Family who are affected.
“In another 5% of cases, lymphedema is one of the clinical aspects of a more complex syndromic picture (at least 10 different syndromes, with associations in individual cases of other malformations).
“Secondary Lymphedema occurs in subjects who are born with an intact and functioning lymphatic system but, in the course of life, part of this is injured or removed (typical, in this regard, is the axillary Lymphadenectomy performed to radicalize the treatment against Breast Cancer).”
How does lymphedema manifest itself, does it affect more women or men in which age group?
“Lymphedema manifests itself as swelling of a specific body region, which in primary forms progresses from the distal to the proximal portion (for example, in the lower limb it arises in the foot and progressively gains the leg and thigh), while in secondary forms it has a generally opposite progression.
“One of the characteristics of these forms is the more or less precocious increase in the consistency of the tissues that are affected, linked to fibrosis induced by the presence of high protein content of the lymphatic fluid itself, unlike all other forms of edema (cardiac, liver, kidney, drugs) in which the tissues are poor and the consistency itself is softer.
“The condition affects indifferently both sexes and, practically, all age groups.”
What are the main causes that determine this pathology?
“As already mentioned, the primary and syndromic forms recognize a genetic etiopathogenesis: there are many genes that, if they encounter a mutation, can generate a primary or syndromic lymphedema.
“At this moment more than 30 possible genes responsible for primary or syndromic Lymphedema have been identified (and some of them by our Italian study group).
“For secondary forms we have already mentioned surgical excisions of lymphoglandular packages performed in compliance with the criteria of therapeutic radicality towards tumors, but also applications of radiotherapy, trauma, or some infectious or parasitic manifestations can induce secondary Lymphedema.”
What is Villa Regina Nursing Home’s excellence in diagnosis and treatment?
“Diagnosis is not a problem. The patient who arrives at the facility at a mostly advanced stage of development of the pathology has generally already been studied in the area before reaching intensive treatment.
“With a high-resolution ultrasound equipped with colorDoppler, a study is carried out, prior to treatment, both on the ultrasound characteristics of the tissues involved and on the state of the arterial and venous circulation (essential for the formulation of the most correct therapeutic protocol). “The instrument is also useful for monitoring the pathology.
With regard to the therapeutic aspect, it is impossible not to emphasize the specific experience of the operators (particularly experienced in lymphatic drainage and bandages that, in some patients, may require more than 20 bandages in relation to their daily packaging).
“Additional strengths are the use of Lymphotaping and, in the treatment of fibrotic areas, radial shock waves.
“Nordik Walking, group therapies and pool activities complete the therapeutic protocols that frequently result in weight loss that after three or four weeks of treatment can exceed even 25 kilograms, with clear functional and coenesthetic improvement of patients who further implement functional autonomy in performing the activities of daily living.
“But the aspect even more significant for the purpose of improving the quality of life of the patient who undergoes the cycle of therapy at the Facility is represented by the information and training.
“During hospitalization (unlike, however, that in the other ‘care settings’) the patient learns how to manage the chronic pathology in order to best maintain and consolidate the results of intensive therapy obtained at the time of discharge; the latter occurs only when the patient is provided with the definitive elastic garment that must be successfully tested and that he will have to wear on a daily basis once he returns to his home and to normal work and extra-work activities.”
What to do once lymphedema is diagnosed?
“The persistence of proteins in tissue spaces is a predisposing factor to fibrosis (due to the stimulus of fibroblasts, a type of cells normally present in tissues, to produce collagen fibers); this is why a well-known French lymphologist, Professor Cluzan, liked to repeat that when one is in the presence of lymphedema one is in the presence of an urgent need, at least, of a physiokinesitherapeutic type.
“In the case of lymphedema, more than for other pathologies, an early diagnosis is always desirable (which is still very difficult in some cases), followed by an equally early treatment in specifically trained facilities and operators.
“The therapeutic approach, which must include all aspects of physical rehabilitation, combined in the early stages, with the help of drugs or supplements with specific ‘draining’ effect and, in a few very well-selected cases, any surgical treatment, may recognize one or more steps at the territorial structures of reference (outpatient clinics or Centers ex Article 26).”
Dr Andrea Boni, a graduate in physiotherapy, collaborates with Villa Regina.
Dr. Boni, we ask you what does manual lymphatic drainage consist of and for which cases is it indicated?
“The term manual lymphatic drainage groups under the same vocabulary numerous massage methods that aim to promote the physiological function of lymph drainage.
“These specific massage techniques should not be proposed as monotherapy, but integrated with the conservative physical treatment of lymphedema, which, in addition to manual lymphatic drainage, also includes multi-component bandaging, skin care and physical activity.
“Manual lymphatic drainage is always indicated whenever edema appears unless there are contraindications such as: Phlebitis, thrombosis, acute phase infections, heart failure and/or renal/cardiac failure.”
What happens instead in more severe forms?
“In the most complex forms, which often require clinical monitoring in 24 hours, or related to problems of intrasportability or social fragility, is required, in fact, an intensive treatment that can be ensured, combined with continuous medical surveillance, physiotherapy and nursing, only at dedicated facilities such as, in fact, Villa Regina.”
Oncologic surgery is among the most frequent causes of secondary lymphedema, can you elaborate?
“Many malignant neoplasms metastasize (i.e., spread) preferentially through loco-regional lymphatic pathways. For these reasons, the Surgeon is often forced, in the most concrete attempt to avoid disease progression, to perform the removal ofoghiandular packages to which it is possible that some tumor cells, flaking from the primitive mass, have been directed (despite the technique of the so-called sentinel lymph node, in some cases, today, allows to preserve some of the lymph nodes constituting the package itself).
“This interruption caused by the surgical act prevents, in a very variable period of time (in some cases early, in others even years later) the normal lymphatic drainage of the area ‘excluded’ from the continuity of the pathway, so that the edema appears clinically.
“Physical decongestive treatment must then intervene to decongest the edematous anatomical area and this can and must be carried out even in the case of ongoing oncological disease (as reported in the latest version of the Consensus Document of the International Society of Lymphology), since any disease progression does not occur due to mechanical or hydraulic causes (draining techniques) but is the result of a delicate biological balance that on the one hand places the biological aggressiveness of the tumor itself and on the other the immunological defensive capabilities of the patient.”
From lymphedema can be cured?
“Lymphedema is a chronic disease and as such must be managed over a lifetime. Even some surgical schools that, until recently, proposed to cure lymphedema through surgery, have now changed their approach, stating that surgery helps and improves the results of physical treatment itself and that, in any case, the elastic garment should be maintained.
“Lymphedema is not cured but must be treated, and well treated!”
Who are the patients with risk factors and what is recommended?
“Patients with primary or secondary lymphedema who are most at risk are those who are particularly immunocompromised (because of the risk of developing infectious complications) and those who work in high-risk professions (requiring frequent car or plane travel, especially if long or for whom several hours of work in an orthostatic position or prolonged sitting during the day are expected). Careful local and general hygiene and wearing the prescribed elastic garment are always the two cornerstones, not only of treatment but also of secondary prevention.”
What are the treatment services offered at Villa Regina Nursing Home?
“In addition to medical and nursing care and rehabilitation treatment by specially trained physiotherapists, at the Facility the patient is also subjected to nutritionist and psychological evaluation that complete an integrated, interdisciplinary and multi-professional caretaking for the satisfaction of all care needs.”
Do patients from outside the region also come to Villa Regina? How many cases do you manage on average in a year?
“The Province of Trento has conceived, in agreement with the Facility, a Convention in which, in addition to the care of patients from Trentino, treatment is also provided for other patients from other Regions.
“In fact, in the first three years of specific activity exercised by the Facility, patients from almost all Italian Regions have been hosted and treated, with a current potential (which we hope will soon be increased in view of the considerable number of hospitalization requests that Villa Regina receives) of approximately 150-160 patients per year.”
What are the methods of access to the facility?
“Acceptance, following contact by the patient who aspires to hospitalization, requires a series of information, clinical documentation and any specific tests, which complete a detailed anamnestic and clinical report carried out by the general practitioner and a physiatrist or other dedicated specialist from a public facility.
“An internal commission analyzes the individual case in relation to the congruity and appropriateness necessary for admission to lymphological rehabilitation; when the patient is judged suitable for admission he is contacted and summoned for admission at which, following specific view, the period of admission itself is indicated (usually three or four weeks of intensive treatment).”
What does the National Health System provide for patients with Lymphedema?
“With the signing of the Document of the Ministry of Health on the guidelines on lymphedema and related pathologies, signed by the State-Regions Conference on September 15, 2016 (to the drafting of which the writer, as an external expert, collaborated with the ministerial technicians), the patient with Lymphedema, both primary and secondary, falls, in its own right, within the essential levels of care; for him, all types of care settings, from outpatient to inpatient rehabilitation, are provided for at the expense of the NHS.
“The Document advocates the establishment of at least one reference Hub for each Region or Autonomous Province and several Spokes, as well as a series of territorial references. In addition, with the Prime Ministerial Decree of January 2017, primary lymphedema was recognized as a rare disease (in Annex 7 of the Decree it appears as a rare disease of the circulatory system) and, in relation to the renewal of the Nomenclatore tariffario, Annex 5 of the same Decree contains the codes with which the National Health System provides, both to patients with primary and secondary lymphedema, elastic maintenance garments, which are periodically renewable.
“Some Regions, for the implementation of the latter, are waiting for the publication of the relevant implementing decrees by the Ministry; others (such as, for example, Lazio) have already for some time allocated specific extra-tariff funds to immediately satisfy this specific aspect of care need on the part of the patient, a need that can certainly be assimilated to the provision of antihypertensive medication to the hypertensive patient or antidiabetic medication to the patient with diabetes mellitus (a statement that, at the proposal of the writer, has long been included in the Consensus Document of the International Society of Lymphology). ”
Nadia Clementi – email@example.com
Prof. Sandro Michelini – Dott. Andrea Boni
firstname.lastname@example.org – tel. 0464-517525 – https://www.reginaarco.it/