Lymphedema

5,588 views

Published on

0 Comments
3 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
5,588
On SlideShare
0
From Embeds
0
Number of Embeds
5
Actions
Shares
0
Downloads
123
Comments
0
Likes
3
Embeds 0
No embeds

No notes for slide

Lymphedema

  1. 1. Filariasisunusual complication <br />Surgery unit I<br />Prof & HOD-Dr. N. K. Ray<br />Asst Prof – Dr. R. N. Singh<br /> Presenter: Dr. SkSabir Ahmed<br />
  2. 2. History<br /> 32yrs old Rajanna was suffering from elephantiasis of his right leg for 16yrs. He was treated in Victoria hospital for the same <br />He has undergone plastic surgery procedure for the swollen limb, which failed &<br /> 14 yrs back above knee amputation was done. He was asymptomatic for 6yrs.<br /> 8 yrs back he has noticed one swelling in his Rt inguinal region which was gradually progressing.<br /> 2 yrs the swelling progressed rapidly to present size.<br /> dragging type of pain in the swelling, also heaviness in limb the since last 2months. <br />
  3. 3. No H/O fever with chills <br /> & rigors.<br /> No H/O cough,<br /> No H/O any other swelling,<br /> No H/O difficulty in passing urine.<br /> No H/O passage of milky urine. <br />No H/O –DM<br /> - HTN<br /> - TB<br />Family history:<br /> not significant<br />Personal history:<br /> diet- mixed<br /> bowel & bladder- normal<br /> sleep- disturbed due to pain<br /> habits: alcoholic since 3 yrs( 1 quarter/day)<br /> smoker, chew betel nut occasionally <br />
  4. 4. General physical examination <br />Patient is Rt sided above knee amputee & moderately nourished, conscious & cooperative. <br />Vitals – stable<br />pallor - present,<br />No- icterus, cyanosis, clubbing.<br />No generalized lymphadenopathy. <br />
  5. 5. Local examination <br />Single irregular swelling, 20x 15x15cm in size situated over right groin extending from right anterior superior iliac spine(ASIS) to pubic symphysis & root of the right scrotum to 10 cm below the ASIS. Surface of the swelling bosselated. Hypo pigmented patch over the swelling. <br />On palpation tenderness present, no local rise of temperature, consistency firm to hard , restricted mobility in all the direction.<br />Skin adherent throughout except the periphery.<br />Penis & scrotum is deviated to opposite side.<br />
  6. 6. Systemic examination:<br />CVS : <br />RS: NAD <br />PA: <br />CNS: <br />
  7. 7. Investigation<br />Hb - 10gm <br />TC - 8,600 <br />Platelets - 2.5Lakhs <br />RBS - 147mg% <br />BU -12mg%<br />Sr Cr -0.7mg%<br />BT - 2.5min<br />CT -3min<br />HIV/HBsAg-negative<br />Bldgrp -o+ve<br />FNAC:<br /> microfilaria against an edematous & inflammatory background.<br />
  8. 8. Plain X ray- <br /> calcified lesion in Rt groin. <br />
  9. 9. CT scan:<br /> multiple calcified lesion in the Right inguinal & thigh region. <br />
  10. 10. Provisional diagnosis: Filarial lymphadenopathy.<br />Pre-op preparation was done : 1 pint blood given to improve anemia.<br />
  11. 11. Under GA an elliptical incision was made below <br /> the summit of <br /> the swelling <br />
  12. 12. flaps were raised <br /> laterally <br /> over the swelling <br /> up to the muscle <br /> plane. <br />
  13. 13.
  14. 14.
  15. 15.
  16. 16.
  17. 17. Femoral vessels,<br /> the right spermatic cord & <br />root of the penis were protected.<br />
  18. 18. swelling was ultimately dissected off the femoral triangle.<br />
  19. 19. Perfect hemostasis secured during the whole surgery. <br />
  20. 20. Specimen sent for histopathology.<br />
  21. 21. Histopathology report:<br /> soft tissue mass with<br /> extensive fibrosis,<br /> calcification <br /> & ossification.<br />
  22. 22. Post operative patient had lymphorrhea for about 15 days.<br />Lymphorrhea subsided & patient was discharged 1 month after operation<br />
  23. 23.
  24. 24. Discussion <br />Lymphedema of leg:<br />Accumulation of the lymph in the subcutaneous tissue results in enlargement of the limb. Fluid collects in the extracellular, extravascular compartment.<br />
  25. 25. Causes of lymphadenitis <br />Primary: <br />Lymphatic aplasia: number of lymphatic channels & nodes are grossly reduced <br />Lymphatic hypoplasia: lymphatic channels are small in caliber.<br />Secondary : <br />Filarial elephantiasis<br />Following lymph node block dissection<br />Following radiotherapy<br />Advanced malignancy <br />
  26. 26. filariasis<br />This is the most common cause of lymphoedema worldwide, affecting up to <br /> 100 million individuals. It is particularly prevalent in Africa, India & south America where 5-10% of population may be affected.<br />filarial elephantiasis is caused by wuchereriabancrofti, transmitted by the mosquito(Culexfatigans). The disease is caused by adult worms which have the affinity towards lymphatic vessels & lymph nodes.<br />
  27. 27.
  28. 28. Pathophysiology of lymphoedema<br />Lymphatic obstruction <br />Lymphatic hypertension<br />& distention <br />Accumulation of ISF, proteins, GF & other active peptide moieties, GAG & particulate matter including bacteria.<br />Increased collagen production by fibroblast<br />Accumulation of inflammatory cells<br />Activation of keratinocytes<br />End result is protein rich edema fluid, increased deposition of ground substance, subdermal fibrosis & dermal thickening & proliferation. <br />
  29. 29. Pathogenesis <br />Initially it causes lymphangitis which clinically presents with high grade fever with chills & rigors, red streaks in the limbs.<br />
  30. 30. Pathogenesis (cond…)<br />The lymph nodes are swollen & tender. <br />
  31. 31. Pathogenesis (cond…)<br />Due to such repeated infections,<br /> fibrosis occurs <br />resulting in lymphatic obstructions. <br />This later gives rise to lymphatic dilatation. Lower limb lymphatics are dilated & tortuous(lymphangiectasis).<br />
  32. 32. Pathogenesis (cond…)<br />To start with lymphoedema is pitting in nature & after some time becomes nonpitting in nature. <br />After repeated infections, the skin over the limb becomes dry thickened, <br />thrown in to folds and even nodules<br /> which break open and results in ulcer, hence called elephant leg.<br />
  33. 33. Reaction to adult worms in the <br />Lymphatic vessels lead to <br /> elephantiasis hydrocele<br />chyluria<br />Acute filarial <br />Lymphangitis abscess tropical <br /> pulmonary <br />eosinophilia<br />lymphadenopathy<br />
  34. 34. Special investigation<br />Lymphangiography :<br /> in this technique the lymphatic of the<br /> lower limb are delineated with<br /> radio opaque dye. <br />Isotope lymphoscintigraphy:<br /> radioactive technetium labeled protein or collied particles are injected into an interdigital web space & specifically taken up by lymphatics & serial radiograph are taken with gamma camera.<br />CT scan:<br />MRI:<br />USG:<br />
  35. 35. Treatment of filarial lymphoedema<br />Conservative line of management:<br /><ul><li>Rest & elevation of the limb.
  36. 36. Elastic crape bandage.
  37. 37. Diuretics.
  38. 38. Antifilarial treatment- </li></li></ul><li>Treatment of filarial lymphoedema<br />II. Surgery : <br />Operation falls into 2 categories<br />Bypass procedure <br /> Reduction procedure<br />Indication: indication:<br /> -proximal ilioingunal -for huge swollen limb<br /> lymphatic obstruction<br /> with normal distal<br /> lymphatic channels<br />
  39. 39. Bypass procedure<br />Omental pedicle graft:<br />Physiologic operations- attempt to link subcutaneous tissue with deep lymphatics or to attach lymphatic bearing pedicles such as omentum or small bowel to the root of the affected limb.<br />
  40. 40.
  41. 41. Nodo venous shunt(Neibulowitz):<br /> dilated, enlarged lymph node in the inguinal region is anatomized to a vein near by, eg.,<br /> long saphaenous vein or femoral vein etc. <br />
  42. 42. Reduction procedure<br />Sistrunk operation :<br /> A wedge of skin & subcutaneous tissue is excised & wound closed primarily. <br />
  43. 43. Reduction procedure<br />Sistrunk operation :<br /> A wedge of skin & subcutaneous tissue is excised & wound closed primarily. <br />
  44. 44. Homans operation:<br />First skin flaps are elevated, <br />Subcutaneous tissue are excised <br />Flaps are trimmed to accommodate the reduced girth of the limb & closed primarily.<br />
  45. 45. Homans operation:<br />First skin flaps are elevated, <br />Subcutaneous tissue are excised <br />Flaps are trimmed to accommodate the reduced girth of the limb & closed primarily.<br />
  46. 46. Swiss roll operation<br /> (Thompson’s): in this a skin flap is raised containing dermis and is buried in to deep tissues (close to vascular bundle). This is a dermal flap prepared by denuding epidermis.<br />
  47. 47. Swiss roll operation<br /> (Thompson’s): in this a skin flap is raised containing dermis and is buried in to deep tissues (close to vascular bundle). This is a dermal flap prepared by denuding epidermis. <br />
  48. 48. Clarke’s excision operation: in this operation , diseased skin and subcutaneous tissue are excised till the healthy underlying structures are seen f/b split skin grafting. <br />
  49. 49. Aim of presentation <br />This case is a rare complication of filariasis.<br />The weight of the swelling was 4.5kg, which was relieved after the surgery.<br />This is the first case of filariasis operated in our hospital.<br />
  50. 50. Thank you<br />

×