Persistent lipedema pain in patients after bariatric surgery: a case series of 13 patients

Proposed Framework for Research Case Definitions of Lipedema

Background: Our aim is to propose a framework for the development of a research case definition of lipedema, based on current available literature and those observations that can be applied to future lipedema research with the intent to standardize and strengthen the scientific evidence base. Methods and Results: We conducted a narrative review of the literature, and identified consensus characteristics and disputed characteristics that could be included in a research case definition of lipedema. After considering the strength of the evidence and how each characteristic might be measured in a research study, we recommended an approach for the development of a research case definition of lipedema that would be based on consideration of five agreed-upon characteristics, and five disputed, or less substantiated, characteristics as additional evidence to enhance specificity. Conclusions: We present a case definition framework for lipedema drawn from the scientific literature that can be applied to future studies on lipedema. Utilizing this framework should help to increase the sensitivity and specificity of case definition and provide an opportunity for meta-analysis of clinical studies and facilitate future research intercomparisons.

Body mass index vs. waist-to-height-ratio in patients with lipohyperplasia dolorosa (vulgo lipedema)

BACKGROUND

Lipedema, also known as lipohyperplasia dolorosa (LiDo), is a painful condition affecting women, causing a disproportionate accumulation of subcutaneous adipose tissue in the extremities. It carries a lower risk of diabetes and cardio-metabolic dysfunctions compared to obesity, but coincident obesity can complicate diagnosis and treatment.

PATIENTS AND METHODS

This retrospective study included 607 female LiDo patients, ≥ 18 years, stage 1-3, from Germany, the UK, and Spain. Data were collected as part of the standard initial assessment for LiDo patients.

RESULTS

Based on waist-to-height-ratio (WHtR), 15.2% of patients were underweight, 45.5% normal weight, 22.1% overweight and 17.3% obese. There was a significant association between WHtR category and age group. Body mass index (BMI) is often overestimated, leading to misdiagnosis of obesity.

CONCLUSIONS

The use of BMI also affects the recent decision of the German Federal Joint Committee on the reimbursement of liposuction costs by health insurance funds. Patients with BMI of more than 40 kg/m2 are excluded from cost coverage, and those with BMI between 35 kg/m2 and 40 kg/m2 must first receive conservative obesity therapy. In conclusion, the sole use of BMI in lipedema is unreliable and, in contrast to WHtR, leads to inaccurate diagnoses overestimating overweight and obesity.

Body-Mass-Index vs. Taille-zu-Größe-Verhältnis bei Patientinnen mit Lipohyperplasia dolorosa (vulgo Lipödem)

Hintergrund

Das Lipödem, auch Lipohyperplasia dolorosa (LiDo) genannt, ist eine schmerzhafte Erkrankung von Frauen, die zu einer unverhältnismäßigen Ansammlung von subkutanem Fettgewebe in den Extremitäten führt. Das Risiko für Diabetes und kardiometabolische Störungen ist im Vergleich zur Adipositas geringer, doch kann eine gleichzeitige Adipositas die Diagnose und Behandlung erschweren.

Patientinnen und Methodik

Diese retrospektive Studie umfasste 607 LiDo‐Patientinnen, ≥ 18 Jahre, Stadium 1–3, aus Deutschland, dem Vereinigten Königreich und Spanien. Die Daten wurden im Rahmen der Standard‐Erstuntersuchung erhoben.

Ergebnisse

Basierend auf dem Verhältnis von Taillenumfang zu Körpergröße (Waist‐to‐Height‐Ratio; WHtR) waren 15,2% der Patientinnen untergewichtig, 45,5% normalgewichtig, 22,1% übergewichtig und 17,3% adipös. Es bestand ein signifikanter Zusammenhang zwischen der WHtR‐Kategorie und der Altersgruppe. Der Body‐Mass‐Index (BMI) wird häufig überschätzt, was zu Fehldiagnosen von Fettleibigkeit führt.

Schlussfolgerungen

Die Verwendung des BMI hat auch Auswirkungen auf die jüngste Entscheidung des Gemeinsamen Bundesausschusses über die Kostenerstattung von Fettabsaugungen durch die Krankenkassen. Patientinnen mit einem BMI von über 40 kg/m2 sind von der Kostenübernahme ausgeschlossen, und Patientinnen mit einem BMI zwischen 35 kg/m2 und 40 kg/m2 müssen zunächst eine konservative Adipositastherapie erhalten. Die alleinige Verwendung des BMI bei Lipödemen ist unzuverlässig und führt im Gegensatz zum WHtR zu ungenauen Diagnosen, die Übergewicht und Adipositas überbewerten.

[Microcannular liposuction in tumescent anesthesia in lipedema patients: an analysis of 519 liposuctions]

This is a retrospective analysis of all lipedema patients treated by tumescent liposuction at our department in the years 2007-2021: We performed 519 liposuctions in 178 patients with a mean age of 45 ± 15.5 years. By the stage of lipedema the mean age increased significantly, what underlines the concept of lipedema as a chronic progressive disorder. Three-thirds of patients reported at least one comorbidity. The most common were arterial hypertension (32.58%), obesity (24.16%), and hypothyroidism (20.79%). We removed a mean lipoaspirate volume of 4905 ± 2800 mL. A major target for treatment is pain reduction. All patients reported at least a 50% pain reduction after liposuction, while 96 achieved a pain reduction ≥ 90%. The pre-operative pain intensity (p = 0.000) and the lipedema stage (p = 0.032) exerted a significant impact on absolute pain reduction. There was no association of pain reduction to volume loss. The post-operative rate of adverse events was 2.89%. Liposuction in tumescent anesthesia is an effective and safe method to reduce both pain and volume in patients with lipedema.

[Lipohyperplasia dolorosa : About facts and fiction, clinical presentation and examination]

Lipohyperplasia dolorosa, also known by the misnomer "lipedema", is a clinical picture first described more than 80 years ago, that in the last 25 years has received increasing attention in medical practices, but also lymphological discussion circles which are otherwise rare in the scientific community. Unfortunately, to put it casually, discussions in social media accelerate the amount of supposed knowledge, an unusual occurrence in the otherwise slow and cautious field of science. Media influences and considerable economic interests resharpen and focus the view, but thus also cloud many women's view of the disease. Combining clinical presentation and a simple clinical examination with a few palpatory findings results in a clear diagnosis that excludes differential diagnoses, in particular obesity. Therapy should only be offered once a precise diagnosis is made. Once the diagnosis is confirmed, it is irreversible and means a lifelong change to the patient's quality of life. Care is, therefore, as always, the first duty of the diagnostician.

[Lipedema pain-the neglected symptom]

Pain, which is a central characteristic of lipedema, allows differentiation from other fat tissue diseases. The analysis of the multiple aspects of pain beyond a quantification of pain scale scores could make molecular disease and therapy mechanisms accessible. Lipedema pain is causally linked to lipedema fat. First robust data show peripheral sensory changes. Tissue weight and systemic inflammation are becoming less likely as causes for the experianced pain. Furthermore, genetics and hormonal influences need to be investigated. Lipedema pain cannot currently be treated with drugs. Physical therapy shows transient relief. Liposuction has been shown to have a long-term effect on pain. The potential of modulating the perception of pain with psychotherapeutic approaches is emerging as a potentially effective new therapeutic approach.

Differentiation of lipoedema from bilateral lower limb lymphoedema by imaging assessment of indocyanine green lymphography

Lipoedema is characterized by disproportionate painful fat accumulation mostly in the lower limbs. The presence of lymphoedema in lipoedema remains controversial. This study aimed to assess the presence or absence of lymphoedema in the lower limbs of women with lipoedema using indocyanine green (ICG) lymphography. A cross-sectional retrospective study was undertaken in women with a clinical diagnosis of lipoedema whose lower limbs were examined with ICG lymphography. MD Anderson Cancer Center (MDACC) ICG staging was used to determine lymphoedema presence and severity. Patient characteristics, ICG lymphography findings, Stemmer sign, body mass index, waist-to-hip ratio, limb volume and bioimpedance spectroscopy measures were recorded. Forty women with lipoedema underwent ICG lymphography for the lower limbs from January 2018 to July 2022. Thirty-four women (85.0%) were determined by ICG lymphography as MDACC ICG Stage 0 representing normal lymphatics. Of the six women who demonstrated dermal backflow on ICG lymphography, all were determined as ICG Stage 1, four had localized traumatic dermal backflow area at their ankles, one had previously diagnosed with primary lymphoedema and one was classified as lipoedema stage 4. ICG lymphography findings suggested the absence of lymphoedema in a clear majority of women with lower limb lipoedema.

Surgical lymphology. Therapy option for lymphoedema and lipohyperplasia dolorosa

The typical therapy in lymphology is conservative. However, reconstructive and resective treatments for primary and secondary lymphoedema as well as resective procedures for lipohyperplasia dolorosa (LiDo) "lipedema" have been available for several decades. Each of these procedures has its clear indication and decades of successful history. These therapies represent a paradigm shift in lymphology. In reconstruction, the basic idea is to restore lymph flow, to bypass the obstacle to drainage in the vascular system. The combination procedures of two-stage application of resection and reconstruction in lymphoedema are just as much a "work in progress" as the concept of prophylactic lymphatic venous anastomosis (LVA). In the case of resective procedures, the focus is not only on improving the silhouette, but also on reducing the complex decongestion therapy (CDT) and - in the case of LiDo - freedom from pain by improving imaging procedures and the early use of surgical therapy options, the development of higher stages of lymphoedema should be a thing of the past. For LiDo, the application of surgical procedures avoids lifelong CDT and achieves painlessness. All surgical procedures, but especially the resection procedures, are now possible in a way that is gentle on the lymphatic vessels and should be offered to patients with lymphoedema or lipohyperplasia dolorosa without reservation if the goals - reduction in circumference, avoidance of lifelong CDT and, in the case of LiDo, painlessness - cannot be achieved by other means.

Lipohyperplasia dolorosa (LiDo): Renaming, prima vista Diagnose, Koinzidenz, Palpation und Resektion

Die seit 1940 bekannte Erkrankung „Lipedema“ wird zunehmend besser verstanden. Besonders ein dellbares Ödem ist bei der Fettverteilungsstörung der Frauen an Armen und Beinen nicht bedeutsam. Diese und weitere wissenschaftliche Erkenntnisse sind „work in progress“ mit dem Ziel des Renaming der Erkrankung. Ein „proper name“ ist „Lipohyperplasia dolorosa“ (LiDo). Bei LiDo ist die Volumenzunahme genetisch fixiert, der Schmerz jedoch dynamisch progredient.

Eine LiDo muss von anderen symmetrischen, schmerzlosen Fettverteilungsstörungen an Armen und Beinen prima vista und nach palpatorischer Untersuchung, insbesondere von der gelegentlich koinzidenten Adipositas, unterschieden werden.

Adipositas ist nie komorbid, aber häufig koinzident bei LiDo. Körperliche Aktivität und Ernährungsumstellung können zwar das Übergewicht reduzieren, nicht aber die ausschließlich LiDo-bedingte disproportionale Fettgewebsvermehrung an den Extremitäten beseitigen. Bei mit Adipositas koinzidenten LiDo-Patientinnen gibt es durch Magenchirurgie keine Effekte auf die obligate Schmerzhaftigkeit.

Für LiDo gibt es sowohl konservative als auch operative Behandlungsmöglichkeiten. Ein seit 1997 etabliertes Verfahren ist die chirurgische Behandlung durch die Lymphologische Liposculptur. Im Rahmen dieser Operation entstehen unter der Haut große Wunden, die nach den „Rules of Nine“ bei Behandlung der beiden Arme in einer Sitzung und der Suktion der Beine in 2 Sitzungen pro Eingriff einer Fläche von 18% der body surface entsprechen. Durch ein adäquates postoperatives Management sowie die Gabe von Antibiotika und Antithrombotika kommt es dennoch nur selten zu operationsbedingten lokalen Komplikationen.

Das wichtigste Ergebnis konsequenter operativer Behandlung der Lipohyperplasia dolorosa ist der Einfluss auf die Lebensqualität: „It ruined her life“ wird zu „It improves her life“.

Is subcutaneous adipose tissue expansion in people living with lipedema healthier and reflected by circulating parameters?

Lipedema may be considered a model for healthy expandability of subcutaneous adipose tissue (SAT). This condition is characterized by the disproportional and symmetrical SAT accumulation in the lower-body parts and extremities, avoiding the abdominal area. There are no circulating biomarkers facilitating the diagnosis of lipedema. We tested the hypothesis that women living with lipedema present a distinct pattern of circulating parameters compared to age- and BMI-matched women. In 26 women (Age 48.3 ± 13.9 years, BMI 32.6 ± 5.8 kg/m2; lipedema group: n=13; control group: n=13), we assessed circulating parameters of glucose and lipid metabolism, inflammation, oxidative stress, sex hormones and a proteomics panel. We find that women with lipedema have better glucose metabolism regulation represented by lower HbA1c (5.55 ± 0.62%) compared to controls (6.73 ± 0.85%; p<0.001); and higher adiponectin levels (lipedema: 4.69 ± 1.99 mmol/l; control: 3.28 ± 1.00 mmol/l; p=0.038). Despite normal glycemic parameters, women with lipedema have significantly higher levels of total cholesterol (5.84 ± 0.70 mmol/L vs 4.55 ± 0.77 mmol/L in control; p<0.001), LDL-C (3.38 ± 0.68 mmol/L vs 2.38 ± 0.66 mmol/L in control; p=0.002), as well as higher circulating inflammation (top 6 based on p-values: TNFSF14, CASP8, EN-RAGE, EIF4EBP1, ADA, MCP-1) and oxidative stress markers (malondialdehyde, superoxide dismutase and catalase). Our findings suggest that the expected association between activation of inflammatory and oxidative stress pathways and impaired glucose metabolism are counterbalanced by protective factors in lipedema.