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Friday, December 28, 2012

Lymphedema Strategies for Investigation and Treatment: A Review

Lymphedema Strategies for Investigation and Treatment: A Review

Oct/Dec 2012


Pankaj Tiwari MD 
Michelle Coriddi MD 
Susan Lamp BSN, RN, CPSN 


Plastic Surgical Nursing


**For information only.  There is much controversery regarding surgical treatment for lymphedema**


Abstract

The goal of this article was to define lymphedema as a disease entity, to introduce the American Lymphedema Framework Project, and to summarize current surgical strategies on the horizon in the surgical treatment of lymphedema.

LYMPHEDEMA DEFINED

Alongside the arterial and venous vasculature, the lymphatic system is a part of the circulatory system. Lymphatic channels primarily regulate the flow of fluid in the interstitium (Ellis, 2006). Under normal conditions, venous capillaries reabsorb 90% of the fluid in the tissues, and lymphatic channels absorb the remaining 10% of lymph fluid, proteins, and other molecules (Warren, Brorson, Borud, & Slavin, 2007). Lymphatic fluid passes to regional lymph node basins. Ultimately, the lymphatic fluid is transported back into the subclavian vein to enter the venous system via the thoracic duct.

Lymphedema is an external or internal manifestation of lymphatic insufficiency and deranged lymph transport (International Society of Lymphology, 2009). This insufficiency causes an accumulation of protein-rich interstitial fluid, leading to distention, proliferation of fatty tissue, and progressive fibrosis. Skin changes such as thickening and hair loss may occur. Progressive lymphedema without adequate management can lead to functional impairment, compromised quality of life, and deformity. Clinically, lymphedema is noted as swelling of the involved extremity. The head and neck, breast, or genitalia may also be affected (McWayne, & Heiney, 2005Rockson, 2010Smeltzer, & Stickler, 1985).

Lymphedema is generally classified as either primary or secondary. Primary lymphedema (hereditary) is related to congenital malformation of the lymphatic channels. Secondary lymphedema results from disruption to the lymphatic system. Primary lymphedema can result from any one of a number of disorders that may be sporadic or hereditary. Syndromes such as Milroy's disease and Prader-Willi syndrome have lymphedema as an element of their clinical manifestations to varying degrees. The estimated prevalence of primary lymphedema is 1.15 in 100,000 persons under the age of 20 years Milroy's Disease (Smeltzer & Stickler, 1985). In children, the two main causes are Milroy's disease and lymphedema distichiasis (International Society of Lymphology, 2009).

Secondary lymphedema is a consequence of removal or damage to lymph nodes, fibrosis of the nodes (postradiotherapy), and trauma or infection secondary_lymphedema Rockson, 2010). Upper extremity lymphedema is commonly associated with the treatment of breast cancer. The degree of lymphedema has been well recognized to correlate with the number of lymph nodes that have been removed and the extent of radiotherapy to the axillary region. Lower extremity lymphedema is most often seen in survivors of uterine and prostate cancer, as well as melanoma and lymphoma survivors (Meneses & McNees, 2007). Most cancer survivors develop lymphedema within 3 years of treatment (Petrek, Senie, Peters, & Rosen, 2001).

In addition to cancer ablation, side effects of advanced diseases such as congestive heart failure, neurological and liver disease, and end-stage renal disease can cause chronic edema. An increase in the bariatric population has also seen an increase in lymphedema incidence. Lympedema caused by the parasite wucheria bancrofti and transmitted by mosquitoes remains the most common cause of lymphedema worldwide. Unfortunately, no strategies employed to prevent the onset of lymphedema have proven fruitful to date. The term chronic edema has been adopted by European investigators to define a population of patients with long-standing edema (>3 months). Prevalence estimates for chronic edema are between 1.3 and 1.5 per thousand.

New clinical data suggest that some patients may have a primary disposition to lymphedema but that this first becomes clinically evident after a secondary eliciting event (Rockson, 2010). Lymphedema tarda is defined as debut after the age of 35 years. It is often associated with an eliciting factor such as trauma or an inflammatory reaction (Kerchner, Fleischer, & Yosipovitch, 2008).

Complete text:



Sunday, December 23, 2012

Microsurgical Techniques for the Treatment of Breast Cancer-related Lymphedema: a Systematic Review.


Microsurgical Techniques for the Treatment of Breast Cancer-related Lymphedema: a Systematic Review.


Dec 2012

Source

Department of General Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands.

Abstract


Background 
Upper limb lymphedema is one of the most underestimated and debilitating complications of breast cancer treatment. The aim of this review is to summarize the recent literature for evidence of the effectiveness of lymphatic microsurgery for the treatment of breast cancer-related lymphedema (BCRL).

Methods 
A search was conducted for articles published from January 2000 until January 2012. Only studies on secondary lymphedema after breast cancer treatment and those examining the effectiveness of microsurgery were included.

Results 
No randomized clinical trials or comparative studies were available. Ten case-series met inclusion criteria: (composite) tissue transfer (n = 4), lymphatic vessel transfer (n = 2), and derivative microlymphatic surgery (n = 4). Limb volume/circumference reduction varied from 2 to 50% over a follow-up time ranging from 1 to 132 months. Postoperative discontinuation rates of conservative therapy were only reported after composite tissue transfer, ranging from 33 to 100% after 3 to 24 months. Clear selection criteria for lymphatic surgery and lymphatic flow assessment were absent in most studies.

Conclusion
We identified important methodological shortcomings of the available literature. Evidence acquired through comparative studies with uniform patient selection is lacking. Consistent positive findings with regards to limb volume reduction and limited complications are reasons to further explore these techniques in methodologically superior studies.

Tuesday, December 18, 2012

The effect of mechanical lymph drainage accompanied by heat


The effect of mechanical lymph drainage accompanied with heat on lymphedema.

Nov 2012

Mariana VF, de Fátima GG, Maria Pde G.

Source

Associate Professor, Godoy Clinic, Paulista University, São Jose do Rio Preto, Brazil.

Abstract

KEYWORDS: Thermotherapy, Lymphedema, Mechanical Lymph Drainage

BACKGROUND:

Thermotherapy has been indicated by some researchers as a treatment for lymphedema. A study comparing temperatures demonstrated that a temperature of 40°C significantly increased the transportation of lymph compared to other temperatures assessed. The aim of this study was to evaluate the possible benefits of mechanical lymph drainage accompanied with heat in the treatment of lymphedema of the lower limbs.

METHODS:

In a cross-over randomized study, the effect of heat on lymph drainage was evaluated in the treatment of leg lymphedema. The study, performed in the Godoy Clinic in São Jose do Rio Preto, Brazil, involved seven patients (two males and five females) with leg lymphedema. The patients' ages ranged from 18 to 79 years old with a mean of 48.5 years. The subjects underwent a total of 38 assessments including 19 evaluations of mechanical lymph drainage alone and 19 combined with thermotherapy. Heat was applied using an electric blanket which was wrapped around the legs of the patients. The volume of legs was evaluated by water plethysmography before and after treatment sessions. The paired t-test was used for statistical analysis with an alpha error of p = 0.05 being considered as acceptable.

RESULTS:

No statistically significant differences were evidenced between mechanical lymph drainage alone and lymph drainage combined with thermotherapy.

CONCLUSIONS:

There was no obvious synergic effect in the immediate post-treatment period when heat was combined with mechanical lymph drainage in the treatment of lymphedema. 

Journal of Research in Medical Sciences



Sunday, December 9, 2012

Lymphedema Strategies for Investigation and Treatment: A Review

Lymphedema Strategies for Investigation and Treatment: A Review

Pankaj Tiwari MD 
Michelle Coriddi MD 
Susan Lamp BSN, RN, CPSN 


Plastic Surgical Nursing
October/December 2012  
Volume 32 Number 4 
Pages 173 - 177



The goal of this article was to define lymphedema as a disease entity, to introduce the American Lymphedema Framework Project, and to summarize current surgical strategies on the horizon in the surgical treatment of lymphedema.

LYMPHEDEMA DEFINED


Alongside the arterial and venous vasculature, the lymphatic system is a part of the circulatory system. Lymphatic channels primarily regulate the flow of fluid in the interstitium (Ellis, 2006). Under normal conditions, venous capillaries reabsorb 90% of the fluid in the tissues, and lymphatic channels absorb the remaining 10% of lymph fluid, proteins, and other molecules (Warren, Brorson, Borud, & Slavin, 2007). Lymphatic fluid passes to regional lymph node basins. Ultimately, the lymphatic fluid is transported back into the subclavian vein to enter the venous system via the thoracic duct.


Lymphedema is an external or internal manifestation of lymphatic insufficiency and deranged lymph transport (International Society of Lymphology, 2009). This insufficiency causes an accumulation of protein-rich interstitial fluid, leading to distention, proliferation of fatty tissue, and progressive fibrosis. Skin changes such as thickening and hair loss may occur. Progressive lymphedema without adequate management can lead to functional impairment, compromised quality of life, and deformity. Clinically, lymphedema is noted as swelling of the involved extremity. The head and neck, breast, or genitalia may also be affected (McWayne, & Heiney, 2005Rockson, 2010Smeltzer, & Stickler, 1985).

Complete article: