lymphedema-1221028741841468-8
Transcript of lymphedema-1221028741841468-8
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TRENDS in
Lmphedema Management Dr. Mansoor Khan MBBS,
FCPS-I
Surgical “D” unit,
Khyber Teaching Hospital,
Peshawar
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“Accumulation of abnormal amount of protein rich fluid in the interstitium
due to compromised lymphatic system with (near) normal net
capillary filtration”
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In United States
Highest incidence is observed following breast cancer surgery with radiotherapy (10 – 40%).
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Worldwide
140-250 million cases of lymphedema are estimated to
exist with filariasis as the most common cause
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Lymphatic filariasis affects more than 90 million people
in the world
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According to WHO
Lymphatic Filariasis is the 2nd leading cause of permanent & long term disability in the world
after leprosy
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Basics of Lymphatic System
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Develops from 4 primitive cystic spaces, 2 in the neck and 2 in the groin
Cisterns elongate & develop communications
Condensations along the connections are lymph nodes
* Persistence of primitive cisterns are cystic hygromas
Embryology of lymphatic system
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Embryology
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Lymphatic capillaries
Blind ended
Large intercellular & intracellular
fenestrations
Allowing macromolecular influx (1000 kDa)
Collagen fibers attachment on outer surface
Dermal papillae
Micronatomy of lymphatic system
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Sub papillary pre-collectors
Sub-dermal collector lymphatics
Epifacial, valved, muscular lymphatics
with lymphangions
Subfascial lymphatics
Interconnections at inguinal, anticubital,
axillary levels
Microanatomy of lymphatic system
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Capillaries Pre-collectors
Collectors
Deep lymphatic trunk
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Anatomy
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Pathophysiology
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90% 10%
Pathophysiology
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Collagen deposition
lymphostasis
Obstruction
Aplasiahypoplasia
Hypocon-tractility
Valvular incompetence
Dermal thickening
Sub dermalfibrosis
LYMPH-EDEMA
Pat
ho
ph
ysio
log
y
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LYMPHEDEMA
Primary lymphedema Secondary lymphedema
Congenital Praecox Tarda
Etiology of lymphedema
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Congenital lymphedema
< 1year of age
10-25% of all primary lymphedema
Sporadic or familial (Milroy's disease)
More common in males
Lower extremity is involved 3 times more frequently than the upper extremity
2/3 patients have bilateral lymphedema
Aplasia pattern without subcutaneous lymphatic trunks involvement
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Evident after birth and before age 35 years
Most often arises during puberty
65-80% of all primary lymphedema cases
Females are affected 4 times
70% of cases are unilateral, with the left lower extremity being involved
Hypoplastic pattern, with the lymphatics reduced in caliber and number
Lymphedema Precox
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Clinically not evident until 35 years or older
Rarest form of primary lymphedema
Only 10% of cases
Hyperplasic pattern, with tortuous lymphatics increased in caliber and number
Absent or incompetent valves
Lymphedema Tarda (Meige disease )
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Secondary Lymphedema
Most common lymphedema having well recognized causes
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Filariasis
Commonest cause worldwide
Endemic in 72 countries
Affecting 5-10% population Africa, India, South America
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Endemic areas of Filariasis
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Filariasis
Wuchereria Bancrofti (90%)
Brugia malayi
Brugia timori
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Other causes of Secondary Lymphedema
Breast surgery with radiotherapy
Primary malignancy
Prostate, cervical cancer, malignant melanoma
Trauma to lymphatics
Surgical excision of lymph nodes
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Presentation of lymphedema
Age of onset
Painless swelling
Presence or absence of family history
Coexistent pathology
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Presentation of lymphedema
Characteristically foot involvement
Ankle contours are lost with infilling of the submalleolar depressions
Buffalo hump on foot dorsum
Square shaped toes
Stemmer’s sign
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Skin changes
Chronic eczema
Dermatophytosis
Fissuring
Verrucae
Ulcerations
Stewart Treves syndrome
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Presentation of lymphedema
Chyluria, chylous ascites, chylothorax,
Lymphorrhoea
MEGALYMPHATICS
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Brunner Classification
0 Histological abnormalitiesNot clinical evident
I Pitting edema, Subsides with elevation
II Non pitting edemaNot relieved with elevation
III Irreversible skin changes,fibrosis, papillae
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Investigations
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Investigations
Infrequently required to establish the diagnosis
To determine residual lymphatic function
To establish treatment preferences
To evaluate therapy
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Contrast Lymphangiography
Was gold standard for mapping
Damages the normal lymphatic channels due to inflammation
Very painful procedure and needs GA
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Lymphangiogram
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Lymphangiogram
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Isotope Lymphoscintigraphy
Replaced the earlier
Technetium labeled antimony sulphide
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Dye needs to be injected in toe web through a 27 G needle
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Lymphoscintigram
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An indication for CT scan or MRI
is suspicion of malignancy,
for which these tests offer the most information
MRI Scan
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Blood slide (Microfilaria)
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Blood slide
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Adult worms in lymph nodes
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Others
Eosinophilia
Increased IgE levels
Compliment fixation test
Antigens of filaria
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Treatment
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TREATMENT
Conservative Surgical
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Conservative
Physical Medication
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Complex Lymphedema Therapy (CLT)
Manual lymphatic drainage (MLD)*
(massage to make the flow to normal lymphatics)
Low stretch bandaging
(to prevent re-accumulation)
*Vodder and/or Leduc techniques
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CLT
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Intermittent pneumatic pump compression therapy
Effectively milking the lymph
from the extremity
Compression garment
To help prevent return of fluid
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Skin care
(Examine, dry, moisturizers)
Exercises
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Psychological support
& occupational therapy
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Antiparasitic agents
Diethylecarbimazole 6mg/kg single dose or 1-3wk
(Don’t use in pregnancy, infants, elderly)
Ivermectin (400mcg/kg/d)
Tetracycline
Doxycycline (100mg/day for 6-8 wks)
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Antibiotic
For skin infections
Penicillin V 500mg tds for streptococcal
Flucloxacilline 250mg qid for staphylococcal
Infections
Miconazole 1% skin ointment
Or systemic antifungal
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Hydroxyrutosides/ coumadins
Binds wit proteins, engulfed by macrophages leading to proteolysis
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Surgical Procedures for Lymphedema
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Surgical
Ablative/reduction Bypass surgeries
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Ablative surgeries
Sistrunk procedure
Homan procedure
Thompson procedure
Charles procedure
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Sistrunk Procedure (1918)
Wedge of skin & subcutaneous tissue excised & wound closed
primarily
Most commonly used to reduce girth of thigh
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Homan Procedure
Skin flaps are elevated
Subcutaneous tissue excised
Skin flap trimmed & closed
Usually staged procedure with lateral & medial
separated by 3-6 months to avoid necrosis
Mostly for calf
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Thompson Procedure (1962)
Denuded skin flaps sutured to deep fascia & buried
(buried dermal flap)
To establish connection b/w superficial and deep
systems
Formation of pilonidal sinus
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Charles Procedure (1912)
Excision of all skin/subcutaneous tissue
down to deep fascia
Covering by split thickness skin grafts from the excised
skin
Girth can be greatly reduced
Unsatisfactory cosmetic results
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Bypass surgeries
Lymph node anastamosis with veins
Lymphovenous anastamosis
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Lym
ph
edem
a
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Thanks