Bioelectrical impedance analysis; a new method to evaluate lymphoedema, fluid status, and tissue damage after gynaecological surgery – A systematic review

Madeleine Asklöfa, Preben Kjølhedea, Ninnie Borendal Wodlina, Lena Nilssonb. European Journal of Obstetrics & Gynecology and Reproductive Biology 228 (2018) 111–119

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Bioelectrical impedance analysis; a new method to evaluate lymphoedema, fluid status, and tissue damage after gynaecological surgery – A systematic review

Madeleine Asklöfa, Preben Kjølhedea,*, Ninnie Borendal Wodlina, Lena Nilssonb. European Journal of Obstetrics & Gynecology and Reproductive Biology 228 (2018) 111–119

The aim of this descriptive review is to summarise the current knowledge of non-invasive bioelectrical impedance analysis (BIA) used with gynaecological surgical patients in regard to postoperative development of lymphoedema and determination of perioperative fluid balance, and as a prognostic factor in cancer mortality and a predictor of postoperative complications.

The databases PubMed, MEDLINE, Scopus Web of Science, the Cochrane Library, and reference lists of selected articles were searched for relevant articles published during the period January 2008–April 2018. Only papers published in English were retrieved. Thirty-seven articles were evaluated. Where gynaecological studies were lacking, studies with a study population from neighbouring clinical fields were used instead.

Studies on the clinical use of BIA with gynaecological surgical patients were divided into three categories: the postoperative development of lower limb lymphoedema (n = 7), perioperative hydration measuring (n = 3), and the BIA parameter phase angle as a prognostic factor in cancer survival and as predictive for postoperative complications (n = 6). Of these 16 studies only three used a pure gynaecological study population. Three different methods of BIA were used in these articles: single frequency-BIA, multifrequency-BIA and bioimpedance spectroscopy. BIA was found to detect lymphoedema with a sensitivity of 73% and a specificity of 84%. Studies indicated that BIA was able to detect lower limb lymphoedema at an early stage even before it became clinically detectable. During postoperative hydration measurements, an increase in extracellular fluid volume and extracellular fluid volume in relation to total body fluid volume, as well as a decrease in phase angle, were associated with higher frequencies of postoperative complications. Moreover, low values for the phase angle have been associated with increased mortality in cancer patients. However, the number of studies in this field was limited.

From our review, BIA seems to be a useful tool for use in the clinical setting of the gynaecological surgical patient. The theoretical approach of using bioelectrical impedance values to measure the fluid distribution in the body compartments offers wide opportunities in the clinical setting. However, so far, all studies have set up cut-off limits within the study population, and reference values for a general population need to be defined. There are also rather few studies on a gynaecological study population. Hence, there is a need for further studies within gynaecological surgery focusing on early detection of lower limb lymphoedema, perioperative fluid balance, and postoperative complications in order to establish the value of BIA in clinical praxis.

Main findings

  • Only 3 studies out of 16 studies used a pure gynaecological study population.
  • The phase angle (PhA) is interpreted as a direct measure of cell stability and is an indicator of cell membrane integrity. A low PhA suggests cell death or decreased cell integrity, while a high PhA implies a large quantity of intact cells. Thus, PhA may be seen as a measure of tissue damage. The suggested reference values for PhA range from 4.8 to 8, depending on gender and age. PhA has been used as a predictor of skeletal muscle mass, as a prognostic factor in cancer patients and as a predictor of postoperative complications.
  • All the articles dealing with cancer concluded that a lower PhA at baseline indicated poorer prognosis. However, one study found that an increase in PhA during fluid therapy also predicted shorter survival. None of the studies presented a consensus of the cut off value of PhA.
  • A PhA  lower than   6indicated  worse  prognosis  and,   generally,  the       PhA  was slightlylowerinwomen  than  in  men  due  to  women’s  lower    muscle mass,and  PhA  increased   with  obesity  due  tothe  increased  number of  adipocytes.
  • The patients who had undergone lymphadenectomy had an increased ECV/TBV in the lower limbs and trunk compared to patients without lymphadenectomy in the study that took the measurements on postoperative day 7. Hayes et al. found that 37% of the women in their study at the 24-month follow-up had evidence of LLL as assessed by BIS. At the same time, the self-report of LLL was 45%. LLL was considered to be present when the BIS ratio of impedance at zero frequency of the arm/leg exceeded one standard deviation of the mean of normative ratios.
  • None of the studies have looked at the predictive value of BIA for prediction of LO/LLL.
  • The BIA had high reliability for detecting lymphoedema in the lower extremities. As LLL has a better treatment prognosis the earlier it is detected, the BIA may be a useful tool for detecting lymphoedema early in the course.
  • There seems to be a wide range of promising applications for the BIA for predicting and eventually preventing clinical complications in the gynaecological surgical patient as listed below:
    • BIA can detect lymphoedema at a subclinical level and may therefore be an important tool for diagnosing lymphoedema at an early stage. Early detection provides the opportunity to prevent, treat or reduce the progress of LO. However, in order to detect early development of LLL after gynaecological cancer surgery with lymphadenectomy the predictive value of consecutive measurements of BIA in the perioperative course remains to be investigated.
    • BIA studies have shown that the ECV increased more than the ICV postoperatively. The clinical impact of this merits further investigation concerning the possible association with the development of postoperative complications and long-term adverse side effects.
    • The PhA can be used as an estimate of intracellular health and cell membrane integrity. This appears promising for measuring post-surgery inflammation and the occurrence of postoperative complications.