1. TRENDS in Lmphedema Management Dr. Mansoor Khan MBBS, FCPS-I Surgical “D” unit, Khyber Teaching Hospital, Peshawar
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4. “ Accumulation of abnormal amount of protein rich fluid in the interstitium due to compromised lymphatic system with (near) normal net capillary filtration ”
5. In United States Highest incidence is observed following breast cancer surgery with radiotherapy (10 – 40%).
6. Worldwide 140-250 million cases of lymphedema are estimated to exist with filariasis as the most common cause
10. 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
22. 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
23. 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
24. 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 )
32. Other causes of Secondary Lymphedema Breast surgery with radiotherapy Primary malignancy Prostate, cervical cancer, malignant melanoma Trauma to lymphatics Surgical excision of lymph nodes
33. Presentation of lymphedema Age of onset Painless swelling Presence or absence of family history Coexistent pathology
34. 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
38. 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
40. Investigations Infrequently required to establish the diagnosis To determine residual lymphatic function To establish treatment preferences To evaluate therapy
41. Contrast Lymphangiography Was gold standard for mapping Damages the normal lymphatic channels due to inflammation Very painful procedure and needs GA
57. Intermittent pneumatic pump compression therapy Effectively milking the lymph from the extremity Compression garment To help prevent return of fluid
58. Skin care (Examine, dry, moisturizers) Exercises
60. 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)
61. Antibiotic For skin infections Penicillin V 500mg tds for streptococcal Flucloxacilline 250mg qid for staphylococcal Infections Miconazole 1% skin ointment Or systemic antifungal
66. Sistrunk Procedure (1918) Wedge of skin & subcutaneous tissue excised & wound closed primarily Most commonly used to reduce girth of thigh
67. 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
68. 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
69. 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