Lymphedema (eBook)

Foreword 5
Preface 6
Table of Contents 8
1 Structure and Function of the Lymphatic System 9
Early Investigations 9
Lymphatic Embryology 12
Configuration of the Lymphatic System 13
Prelymphatic Tissue Channels 13
Lymph Capillaries 13
Lymph Precollectors 13
Lymph Collectors 14
Peyer Patches 14
Lymph Ducts 14
Lymph Nodes 15
Functions of the Lymphatic System 16
Interstitial Fluid/Edema 16
Fluid Exchanges 16
Diffusion 16
Osmosis 17
Spontaneous Contractions 17
Immune System 17
Natural, Nonspecific Immunity 17
Specific Immunity 18
Antibodies 18
Summary 18
References 18
2 Differential Diagnosis of Lymphedema 20
Pathophysiology of Edema 20
Lymphatic Causes of Edema 20
Primary Lymphedema 20
Secondary Lymphedema 20
Infection 20
Inflammation 21
Cancer Treatment and Other Types of Trauma 21
Other Causes of Edema 23
Chronic Venous Insufficiency 23
Hypoalbuminemia 23
Drug-induced Edema 23
Differential Diagnosis of Edema 23
Duration and Distribution 23
Dermatologic Changes 24
Diagnostic Laboratory Tests for Systemic Disease 24
Testing for Venous Disease 24
Testing for Lymphedema 24
Lipedema 26
Summary 28
References 28
3 Classification and Staging of Lymphedema 29
Introduction 29
Condition 29
Classification 29
Primary Lymphedema 29
Secondary Lymphedema 30
Staging 31
Current Staging Methods 31
Földi Method of Staging 33
Pitting Edema Scale 33
Staging by Limb Size 33
Staging by Clinical Symptoms 33
Location, Volume, Fibrosis Scale 34
Proposed Staging of Lymphedema 34
Clinical Staging 34
Laboratory Staging: Lymphangioscintigraphy 35
Quality of Life 35
Outcome Measurements 36
Summary 37
References 37
4 Lymphatic Malformation 39
Truncular Forms 39
Primary Lymphedema 39
Diagnosis 39
Management 40
Outcome Assessment 40
Extratruncular Forms 41
Diagnosis 41
Management 41
Sclerotherapy 42
Excision 43
Outcome Assessment 44
Lymphangiosarcoma 44
Lymphangioma Circumscriptum 44
Lymphangiomatosis 45
Diagnosis 45
Management 45
Hemangioma 46
Lymphovenous Malformation 46
Klippel-Trenaunay Syndrome 46
Parkes Weber Syndrome 47
Diagnosis 47
Treatment 47
Genetic Prospects 48
Summary 48
References 48
5 Medical Management of Lymphedema 51
Historical Review 51
Successful Treatment for Lymphedema 52
Two-Phase Intervention 55
Manual Lymph Drainage 56
Starting Manual Lymph Drainage 56
Skin Care 57
Wound Care 57
Bandaging 57
Types of Bandages 58
Exercise 58
Compression Garments 59
Compression Garment Selection 59
Compression Pumps 59
Comprehensive Approach 59
Nutritional Counseling 59
Psychosocial Intervention 60
Patient Instruction 60
Phase II, Self-management 60
Summary 60
References 61
6 Surgical Management of Lymphedema 63
Introduction 63
Excisional/Ablative Surgery 63
Early Debulking Operations 63
Selection of Candidates for Excisional Surgery 64
Excisional Surgery 64
Liposuction 64
Lymphatic Reconstructive Surgery 65
Selection of Candidates for Anastomotic/Reconstructive Surgery 66
Preoperative Evaluation 66
Lymphovenous Anastomotic Surgery 66
Lympholymphatic Anastomotic Surgery 66
Free Lymph Node Transplantation 66
Vein Grafting 67
Postoperative Management 67
Evaluation of Bypass Surgery Results 68
Clinical Experience 68
Excisional Surgery Group 69
Lymphovenous Anastomotic Surgery Group 69
Free Lymph Node Transplantation Group 69
Summary 69
References 70
7 Chronic Lymphovenous Disease 72
Introduction 72
Healthy Leg Veins 72
Chronic Venous Insufficiency 72
Endoluminal Venous Obstruction 73
Extraluminal Venous Obstruction 73
Muscle Pump Failure/Dependent Leg Syndrome 73
Classification of Venous Disease 74
Evaluation of Lymphovenous Disease 74
Planning a Treatment Program 74
Surgical Techniques 74
Endoluminal Ablation 75
Results of Surgical Treatment 75
Summary 78
References 78
Index 79

"5 Medical Management of Lymphedema (S. 43-44)

Cheryl L. Morgan

Historical Review

While chapter 1 documents the early lymphatic discoveries, many of today’s interventions developed from investigations into the causes and management of lymphedema over the past 2 centuries. In the 1870s, Still, the founder of the American School of Osteopathy, created an approach to manual therapies acknowledging the lymphatics as a vital system and designed to correct anatomical deviations that interfered with the ? ow of lymph and blood.

Still proposed a relationship in which cerebrospinal ? uid is reabsorbed by the lymph, a relationship supported by recent research (1). In the 1890s, Winiwarter, an Austrian physician from Vienna, described a treatment for swollen limbs that seems surprisingly similar to that recommended today; the conservative treatment included elevation, compression, massage, and exercise. Unfortunately, Winiwarter’s suggestions were not advanced further for some time (2).

A few decades later, in the 1920s, Miller developed the Miller thoracic pump technique, which he described as effective in creating intrathoracic pressure changes on lymphatic ? ow. Many of the conditions that he treated successfully with this technique include forms of edema (3,4). In 1922, Millard published the ? rst osteopathic medical textbook examining only the lymphatic system, Applied Anatomy of the Lymphatics, and was the founder and president of the International Lymphatic Research Society in Kirksville, MO (5). In the 1930s, Vodder and his wife began working with manual techniques to affect lymph ?ow.

Although the Vodders were Danish, the majority of their work was performed and published in France, where they lived and worked from 1928 to 1939. Here they developed their technique, then called lymph drainage massage. They later coined the term manual lymph drainage. The Vodder technique of lymph drainage is the most widely taught component of conservative lymphedema treatment (6,7). In the 1960s, Asdonk, a German physician, scienti? cally tested the Vodder technique of manual lymph drainage in his clinic on 20 000 patients. From this research, he established the indications, contraindications, and effects of the techniques (8).

In the following decade, the Földis combined the Vodders’ manual lymph drainage with bandaging, exercise, and speci? c skin care into the treatment program termed complete decongestive physiotherapy (CDP), later renamed complete decongestive therapy (CDT) (9). The Földis’ many contributions to lymphology include their extensive research as well as directing the Földi Clinic in Germany. The ? rst North American lymphedema treat- ment centers opened in the 1980s, where specially trained therapists initiate the use of CDT to treat lymphedema patients. In the 1990s, an increase of scienti? c literature, patient awareness, and interested therapists and physicians stimulates an increase of treatment centers in the United States. In 1992, Medicare (KS) approves CDT treatment for lymphedema.

In 1999, a new CPT code describing manual therapies, including manual lymph drainage (97140), is approved by the American Medical Association. In recent years, continued use of CDT has encouraged controlled clinical studies and research to focus on quality of life, treatment outcomes, and cost effectiveness. The American Society of Lymphology (ASL) has initiated efforts to standardize educational requirements of health care professionals treating disorders of the lymphatics. Legislation has been introduced by the National Lymphedema Network (NLN) to improve reimbursement for medical supplies for lymphedema.

Research has moved to the forefront thanks to the Lymphatic Research Foundation (LRF). Among individuals, Australian physicians Casley-Smith devoted more than 40 years to research, treatment, and the education of therapists (10). Their abundant and diverse research using the electron microscope has received worldwide recognition. The signi? cant contributions through the Centers for Disease Control and Prevention led by Dreyer and Addiss in the treatment of ? larial lymphedema and vector control (11) have produced extraordinary developments that will bene? t millions suffering with dis? guring conse- quences of parasitic infection."