Robert Gayle, MD. 26 April Presenter name Diagnosis and Management Title of Date. Lymphedema

Transcription

1 Robert Gayle, MD 26 April 2014 Diagnosis and Management of Lymphedema

2 Introduction Vascular Therapies 2013 The Swollen Leg Edema Defined: Visible and palpable swelling caused by increased fluid content of the interstitial space. Lymphedema Defined: Protein rich fluid accumulation in the interstitial space.

3 Introduction: Interstitial Fluid Flow

4 Introduction: Interstitial Fluid Flow

5 Lymphatic: Basics

6 Lymphatic Basics

7 Lymphatic Basics

8 Lymphatic Basics

9 Lymph: Function

10 Lymphatic Function

11 Lymphatic Function

12 Lymphatic Function Normal Function Discontinuous fluid column Little effect of gravity

13 Lymphatic Function Lymphatic obstruction Lymphatic overload Continuous fluid column

14 Lymphatic Dysfunction

15 Lymphedema Staging Stage 0 Latent Stage of excess fluid accumulation, fibrosis seen around lymphatics but no clinical edema. Stage 1 Edema pits with pressure, resolves with elevation. No clinical fibrosis Stage 2 Edema non pitting, not resolved by elevation

16 Lymphedema Staging Stage 3 Edema irreversible, repeated inflammatory episodes, fibrosis, sclerosis of skin and sub q. Lymphostatic elephantasis.

17 Lymphedema Staging

18 Lymphedema Classification

19 Classification by Morphology Aplasia: Absence of lymph collecting vessels Hypoplasia: Diminished number of vessels seen Numerical Hyperplasia: Increased number of lymph vessels seen Hyperplasia: Increased number of vessels with incompetence, tortuosity and size increase.

20 Morphology

21 Classification by Morphology Distal 1/3 agenesis, hypoplasia, or obstruction Proximal lymphatic vessels normal Usually bilateral and mild (distal edema) Most are mild and stabilize within a year. Frequently Familial

22 Classification by Morphology Proximal Obstruction of proximal lymphatic vessels Initially normal distal vessels become abnormal. Progressive and becomes severe.

23 Classification by Clinical Setting Inheritance Clusters Milroy s < 1 Year Old Meig s (Praecox) Many forms of lymphedema associated syndromes.

24 Classification by Clinical Setting Secondary World wide filariasis is the most common (90 million) North America and Europe surgery, radiation and cancer are the most common. Other causes include pregnancy, Presenter burns, name large wounds and rheumatoid disease.

25 Clinical Evaluation

26 Clinical Evaluation Later Stage Lymphedema indurated Skin is woody and thickened Toes squared,nails yellow Skin verrocous Dorsal hump

27 Clinical Evaluation Late skin changes: Thickening, hyperkeratosis Lichenification,excoriation, verrucae,

28 Clinical Evaluation

29 Clinical: Complications Infection: cellulitis,lymphangitis, common Causes further fibrosis and obstruction of channels.

30 Clinical: Complications Lymphangiosarcoma Kaposi s Sarcoma Squamous Cell Carcinoma

31 Clinical: Imaging Lymphoscintigraphy: anatomic and functional CAT scan: Lymphedema has a distinctive picture. MRI: Detects masses, liposclerosis

32 Non Operative Treatment Elevation Activity/Exercise Diet (chyle reflux) External Compression Medication Complex Decongestive Therapy (CDT)

33 Non Operative Treatment Elevation: degree elevation of extremity Bed rest for 3-5 days Sling, wedge, bed support blocks Exercise: general gently stretching muscle group specific

34 Non Operative Treatment Diet: Marginal in rare cases Medications: Diuretics: Marginal in most. Benzoprones: Stimulate tissue macrophages, not approved. Coumarin: Reduced limb volume but liver toxicity.

35 Non Operative Treatment Complex Decongestive Therapy (CDT) Phase one Volume Reduction Phase two- Maintenance

36 CDT Phase I Elevation Exercise Manual Lymphatic Drainage (massage) Compressive Therapy

37 Phase I Technique MLD MLD Concepts: Stimulate contraction of lymphatics Begin with trunk opposite affected extremity. Progress to same side of trunk then proximal to distal on extremity, sequentially opening and draining lymphatics. Technique demonstrated effective

38 Simple ROM Phase I Technique Exercise Muscle Specific exercises. Contract muscle in specific sequence, distal to proximal. Best in conjunction with external compression.

39 Phase I Technique Compression Low stretch wraps. (Maintain hydrostatic pressure gradient during exercise) Use 24 hours /day during initial phase of CDT at night, gradient elastic garment during the During maintenance phase low stretch wraps day.

40 CDT Phase II Daily Use of Pressure Garmet Continue Nightly Wrapping Self Administered MLD Continue Exercise and Skin Care

41 CDT Results Mayo Clinic: Good results with motivated stage I,II and some III patients. Predictors of failure: Morbid obesity Tumor Recurrence Non Compliant

42 Compression Garments Elastic OTC 7-15 mm Hg Anti Embolism Therapeutic 20-30, 30-40,40-50,50-60 Application At least for lymphedema (If tolerated)

43 Treatment Results

44 Charles Procedure Surgical Treatment Excisional

45 Surgical Treatment Current Lympho-Lympho anastomosis Lympho-Venous anastomosis Free Lymphatic bypass grafts Liposuction

46 Conclusion Lymphedema remains a huge problem for millions of people. There is no cure but with a motivated patient and a good management team there is help and hope for many.