Transcript Document

By
Prof. Dr. Abdel Fatah Ali Ismael
Head of Vascular Surgery Department
Al Azhar University
F.R.C.S Lon.
F.R.C.S Ed.
Introduction
 Ultrafiltration of fluid from the leg of the
capillaries must be removed from interstitial
compartment and if not it will lead to edema, If
ISF compartment is doubled edema will be
clinically detectable this usually occur when
lymphatics are unable to clear the ISF
compartment. Particles enter the initial
lymphatics through inter endothelial openings
and pores, large particles are actively
phagocytosed by macrophages and transported
through the lymphatic system intracellularly.
 2-4 liter of lymph are transported to the
venous system every day.
 Lymph pulsation include active, passive
motion, squeezes lymph from ISF space
through lymphatics aided by arterial
pulsation,
respiration,
massage
and
contraction of lymphangioms.
 Valves prevent back flow of lymph.
LYMPHEDEMA
Definition:
 Abnormal collection of interstitial lymph
fluid due to congenital maldevelopment of
lymphatics or due to 2nd lymphatic
obstruction.
 It affect 2% of population causing limb
swelling.
Scope of the clinical problem:
 It causes severe emotional, psychological
distress particularly in late cases and on
occurrence of complication.
 If early diagnosed simple measures can be
highly effective at this stage and can
prevent the development of disabling, late
disease which is often very difficult to treat.
Etiology:
 Lymphedema may be 1ry or 2ry
(A) 1ry lymphedema:
 It is due to “developmental error” in the
lymphatics. According to the severity of this
error, the lymphedema may appear:
a) At birth (<1 year)  Lymphedema congenita (if
familial, it is called Milroy’s disease).
b) Between 1-35 years of age  Lymphedema
praecox.
c) Later (> 35 years)  lymphedema tarda.
 This congenital variety may be hereditary or familial
(Milroy’s disease) which is very rare.
 The edema may involve one or both lower limbs.
 It continues throughout life & does not of itself
produce any constitutional disturbance.
According to Lymphography: Abnormality may
assume one of 4 patterns:
1. Aplasia (15%): The main SC lymph trunks can not be demonstrated,
while the dermal lymphatic plexus is dilated.
2. Hypoplasia (55%): The main SC lymphatics are few & underdeveloped i.e.  in number & diameter (only one minute lymph
vessel can be visualized at the ankle).
3. Hyperplasia (35%): Lymph trunks are dilated & varicosed ( in
number & length & become tortuous) + incompetent valves. It may
be associated with cong. A-V fistula or with dermal backflow.
4. Dermal backflow (Chylous reflux): The retrograde flow causes
abnormal filling of the dermal plexus.
Predisposing factors:
 These factors may cause the “developmental
error” to be evident:
1. Any inflammatory process ends by resolution or
“fibrosis” which will strangle the remaining
lymphatics & will end by the appearance of
lymphedema.
2. Trauma: it may be mild (a blow), or severe (fracture).
3. Pregnancy.
4. Puerperal sepsis.
5. However, most cases of 1ry lymphedema appear
spontaneously without any precipitating factor.
Secondary lymphoedema:
Causes:
 Trauma (operative – accidental).
 Inflammation.
 Filariasis.
 Post-phlebitic leg.
 Irradiation.
 Malignancy.
 Allergy.
Filariasis:
 This is the most common cause of lymphedema
more prevalent in Africa, India, South America
(5-10%).
 Caused by Wuchreria bancrofti, spread by
mosquito.
 It causes proximal lymphatic obstruction by adult
parasites and associated lymphatic inflammation
due to immune response of the host.
In lead to:
 Fever.
 Headache.
 Malaise.
 Lymphadenopathy.
 Lymphangitis.
 Cellulites.
 Abscess (in the acute stage) and lymphedema –
hydrocele and abdominal lymphatic varices in the
chronic stage.
 Diagnosed by night blood film and complement
fixation test.
 Treated by diethyl carbamazine.
Clinical classification of lymphedema:
Subclinical
(latent)
There is excess interstitial fluid and histological
abnormalities in lymphatics and lymph nodes, but
no clinically apparent lymphedema
I
Edema pits on pressure and swelling largely, or
completely disappears on elevation and bed rest.
II
Edema does not pit and does not significantly
reduce upon elevation
III
Edema is associated with irreversible skin changes,
i.e. fibrosis, popillae
Symptoms frequently experienced by patients
with lymphedema:
 Constant dull ache, even severe pain.
 Burning and bursting sensations.
 General tiredness and debility.
 Sensitivity to heat.
 Pins and needles.
 Cramps.
 Skin problems, including dehydration, flakiness,
weeping, excoriation and breakdown.
 Immobility, leading to obesity and muscle wasting.
 Backache and joint problems.
 Athelet’s foot.
 Acute infective episodes.
Signs of lymphedema:
High molecular weight substances will lead to the
development of hyperplasic fibrotic dermal thickening,
hyperkeratosis, chronic eczema, fissuring, verrucae,
papillae (warts), it also will lead to fungal injection of the
skin and nails.
Investigation of lymphedema:
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Routine tests:
Lymphangiography.
Isotope lymphosintigraphy.
Computerized tomography. (CT).
Magnetic resonance imaging (MRI).
Ultrasound.
Pathological examination.
Causes of a “Swollen Limb”
Central
Peripheral
Medical causes
Bilateral edema
Surgical causes
Unilateral edema
 Cardiac: CHF- constrictive
pericarditis.
 Renal: acute nephritis-nephrotic
syndrome.
 Hepatic: cirrhosis, end-stage liver
disease (ESLD) or liver failure (LF).
 Nutritional: protein-losing
enteropathy, thiamine deficiency.
 Endocrinal: cushing syndromemyxedema.
 Allergic.
 Venous disease: DVT.
 Aterio-venous disease: A-V fistula.
 Lymphatic disease: Lymphedema
(1st-2nd).
 Miscellaneous:
1. Lipidema
(lipodystrophy/lipomatosis).
2. Neurofibromatosis.
3. Erythrocyanosis frigida.
4. Injuries: fractures-muscle
contusion.
5. Tight bandage or plaster.
6. Infection: cellulitis.
7. Tumors: deep cavernous
heamangioma!
Complications:
 Local infection.
 Systemic infection.
 Lymphangiosarcoma, kaposi’s, sarcoma
basal cell carcinoma and lymphoma.
Treatment of lymphedema:
 Early treatment is highly effective, late disease is
very difficult to treat.
 Patient cooperation in the treatment is essential
as the patient will take the most important part
of the treatment by himself, every patient with
lymphedema should receive the following:
 An explanation as to why their limb is swollen
and the underlying cause of lymphedema and he
should be instructed to:
 Use an electric razor to depilate.
 Never let the skin become macerated.
 Treat cuts and grazes promptly (wash, dry, application
of antiseptic and a plaster).
 Use insect repellent sprays and treat bites promptly
with antiseptics and antihistamines.
 Seek medical attention as soon as limb becomes hot,
painful or more swollen.
 Do not allow blood to be taken from, or injections to be
given into the affected arm (and avoid blood pressure
measurement).
 Protect the affected skin from sun (shade, high factor
sun block).
 Consider taking antibiotics if going on holiday.
 Guidance on skin hygiene and care and,
specifically, the avoidance of acute infective
episodes.
 Antifungal prophylactic therapy to prevent
athelet’s foot.
 Rapid access to antibiotic therapy and, if
necessary, hospital admission for acute infective
episodes.
 Protect hands when washing up or gardening,
wear a thimble when sewing.
 Never walk barefoot and wear protective
footwear outside.
 Appropriate instructions regarding exercise
therapy.
 Manual lymphatic drainage (MLD).
 Multilayer lymphedema bandaging (MLLB).
 Compression garments and, if appropriate,
specialized footwear.
 Advice on diet.
 Access to support services and networks.
I-Medical treatment including the
following:
 Relief of pain by non opioid and opioid
analgesics.
 Reduce swelling by decongestive lymphtherapy (DLT).
a. Manual lymph therapy (MLT) manual
massage).
b. Multilayer lymph bandage + exercise
(MLLB).
c. Skin care
II- Surgical treatment:
1. Bypass surgery (lymphovenous shunt).
2. Reducing surgery:
a) Sistrunk: wedge removal and skin closure.
b) Homans: subcutaneous tissue removed and skin
closure.
c) Thompson: denuded skin sutured to deep fascia.
d) Charles: remove every thing cover raw area by
skin graft.
III- Treatment of complication accordingly
Before treatment
The same limb
after treatment
Before treatment
The same limb
after treatment
Before treatment
The same limb
after treatment
Before treatment
The same limb
after treatment
Before treatment
The same limb
after treatment
Before treatment
The same limb
after treatment