Lymphedema by Dr.dawit surgical resident@ Jimma university

LYMPHEDEMA
12/02/17 Lymphedema by Dawit M (gsr3)
BY- Dr. Dawit Mekonnen GSR3

OUTLINE OF THE PRESENTATION
• Introduction
• Types of lymphedema
• Staging of lymphedema
• Diagnosis
• Common management options

INTRODUCTION
• Defn:- Accumulation of protein-rich interstitial
fluid within the skin and subcutaneous tissues
• occurs as a result of lymphatic dysfunction.
• There are approximately 140 million cases
throughout the world.
• There is no cure for lymphedema
• The aim of medical and surgical therapy is to
reduce swelling and to prevent complications.

According to WHO
Lymphatic Filariasis is the 2nd
leading cause of permanent &
long term disability in the world
after leprosy

LYMPHEDEMA
Primary lymphedema Secondary lymphedema
Congenital Praecox Tarda
Etiology of lymphedema

PRIMARY LYMPHEDEMA
LYMPHOEDEMA CONGENITA
• onset at or within a year of birth
• 10-25% of all primary lymphedema
• Females affected 2x
• Lower extremity 3x
• Familial( Milroy’s d/ss)
• Mutation in the VEGF3 receptor

LYMPHOEDEMA PRAECOX
• 65%-80%
• 70% unilateral limb
• onset from 1 to 35 years of age
• common in 4x females than males
• peak incidence shortly after menarche
• Cause:- Reduced in caliber and number Lymphatic
channels
• familial form is referred to as Meige’s disease

LYMPHOEDEMA TARDA
• 10%
• after the age of 35 years
• histologically, lymph nodes are replaced with fatty
and fibrous tissue
• Tortuous lymphatic & incompetent or absent
lymphatic valves
• lymphoedema often commences proximally in
the thigh rather than distally .

Secondary Lymphedema
Most common lymphedema having
well recognized causes

Filariasis
•Commonest cause worldwide
•Affects more than 90 million people in the
world
•Endemic in 72 countries
•Affecting 5-10% population Africa, India,
South America

Endemic areas of Filariasis

Filariasis
Wuchereria
Bancrofti (90%)
Brugia
malayi
Brugia
timori

MALIGNANCY
• The most common cause of lymphoedema
in developed countries
• More often lymphoedema is a result of treatment
(surgical excision and/or radiotherapy)
• Hodgkin’s and non-Hodgkin’s lymphoma
• Malignant melanoma
• Malignancy of the pelvic organs (ovary, uterus,
bladder),
• Breast Ca ( RM=60%, MRM=20% )
• Ca of anus, prostate, testes and penis.

OTHER CAUSES
• Trauma
• Acute cellulites
• Tuberculosis,
• Rheumatoid arthritis
• Snake and insect bites

BRUNNER CLASSIFICATION
0 Histological abnormalities
Not clinical evident
I Pitting edema,
Subsides with elevation
II Non pitting edema
Not relieved with elevation
III Irreversible skin changes,
fibrosis, papillae

Diagnosis
Hx
• Painless swelling
• Age
• Family Hx
• Coexisting pathology
P/E
• Contour of ankle lost
• ‘buffalo hump’ dorsum of foot
• Square toes
• Stemmer sign – skin on dorsum of toes cannot be
pinched
• Non-pitting
• Advanced cases – chronic eczema,
-
-dermatophytosis,
-onychomycosis, fissuring,
-verrucae, papillae…
• Ulcerations

Investigation of Lymphedema
• Lymphoscintigraphy
• Perometry
• Bioimpedance spectroscopy
• Contrast lymphangiography
(visual lymphangiography)
• CT/MRI
• Pathological examination

Lymphoscintigram

lymphangiogram

An indication for CT scan
or MRI
is suspicion of
malignancy,
for which these tests offer
the most information
MRI Scan

Blood slide (Microfilaria)

COMPLICATIONS
• Recurrent lymphangitis
• Cellulites
• Fibrosis of the subcutaneous tissue
• Functional impairment
• Skin changes
• Lymphangiosarcoma (generally appears
approximately 10 years after the onset of
lymphedema most commonly with postmastectomy
lymphedema)

Stuart-treves syndrome.

DIFFERENTIAL DIAGNOSIS
• Edema of cardiac, renal, or hepatic insufficiency.
• Bony or soft tissue tumor
• Ruptured Baker’s cyst
• Varicose veins
• DVT
• Post- thrombotic syndrome
• False aneurysm
• Lipedema ( Lipodystrophy )

TREATMEN
T
Conservative Surgical

Conservative
Physical Medication

Pneumatic Compression Pumps
Advantages:
1. Can be used at home by patients
2. Fast application
Disadvantages:
1. Disregards the fact that the ipsilateral trunk can be involved in the lymphedema
2. In LE edema, the pump can cause genital edema; in UE edema, the pump can
cause breast edema
3. Does not address tissue fibrosis and extended use can cause additional fibrosis
4. Requires many hours a day with the affected limb elevated
5. The pump can traumatize residual, functioning lymphatics, especially of the UE

Components of CDT/complete decongestive
therapy
• MLD
• Compression
bandaging
• Exercise
• Skin and nail care
• Instructions in self
care

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)

Surgical Procedures for
Lymphedema

LYMPHATIC–LYMPHATIC BY PASS
• by transferring a soft tissue graft containing
superficial lymphatics from the anterior thigh to the
affected limb and
• connecting the collecting lymphatics of the graft to
lymphatic channels in the lymphedematous region.

LIMB REDUCTION PROCEDURES
• Indicated when a limb is so swollen that it
interferes with mobility and livelihood.
1, Sistrunk Procedure (1918)
• Wedge of skin & subcutaneous tissue excised &
wound closed primarily
• Most commonly used to reduce girth of thigh

2,Thompson Procedure (1962)
•Denuded skin flaps sutured to deep
fascia & buried (buried dermal flap)
•To establish connection b/w superficial
and deep systems

3,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

4.Charles4.Charles.. This operationThis operation
was initially designed forwas initially designed for
filariasisfilariasis andand
involved excision of all theinvolved excision of all the
skin and subcutaneousskin and subcutaneous
tissues downtissues down to deepto deep
fasciafascia with coveragewith coverage
usingusing split skinsplit skin
graftsgrafts
unsatisfactory cosmeticunsatisfactory cosmetic
result and graft failure isresult and graft failure is
common.common.
Useful in pt withUseful in pt with severesevere
skin changesskin changes

• reserved liposuction for the Rx of non-pitting
upper extremity lymphedema that has failed
conservative management for at least 3
months with volume differences of at least
600 cc
• when compared with the unaffected limb,
absence of active cancer or metastasis, and no
clotting abnormalities or circulatory
compromise.

THANK YOU ALL!

References
• Grabb & Smith’s Plastic Surgery,7th
edition
• Bailey & Love’s
• Uptodate
• Internate sources

Lymphedema by Dr.dawit surgical resident@ Jimma university

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Lymphedema by Dr.dawit surgical resident@ Jimma university

Similar to Lymphedema by Dr.dawit surgical resident@ Jimma university (20)

Recently uploaded

Recently uploaded (20)

Lymphedema by Dr.dawit surgical resident@ Jimma university