Primary lower limb lymphedema: a focus on its functional, social and emotional impact

**This is actually an older article that has recently become available through PubMed.  It was written in 2010 and after you read this, you will be thinking "three years later and almost no progress has been made!. It speaks of quality of life. Sad and very frustrating.  Pat**

Int J Med Sci. 2010; 7(6): 353–357.

Published online 2010 October 22.

Emmanouil K Symvoulakis, Dimitrios I Anyfantakis, and Christos Lionis

Author information ► Article notes ► Copyright and License information ►

Abstract

Primary lymphedema is a rare, chronic and distressing condition with negative effects on physical, social and emotional level. The purpose of these reports was to present and discuss two different cases of primary lower limb lymphedema with a focus on its physical and mental impact and on some qualitative aspects of patients' self-reported experiences. The patients were recruited as they used occasional services within the University Hospital of Heraklion (Crete, Greece). The functional and mental impact of primary lymphedema was measured using the generic Medical Outcome Study short form-36 questionnaire and open-ended questions led to give more emphasis to patients' experiences. The analysis of short form-36 results in the first patient disclosed a significant functional impairment with a minor impact of the condition on emotional and social domains. For the second patient quality of life scores in the emotional and social domains were affected. Our findings support further the statement that physicians should pay full attention to appraise the patient's physical and emotional condition. General practitioners have the opportunity to monitor the long-term impact of chronic disorders. Posing simple open-ended questions and assessing the level of physical and mental deficits in terms of well-being through the use of specific metric tools can effectively follow-up rare conditions in the community.

Full text article:

NIH-International Journal of Medical Sciences

Lower-Limb Drainage Mapping for Lymphedema Risk Reduction After Pelvic Lymphadenectomy for Endometrial Cancer.

Jan 2013

Bats AS, Nos C, Bensaïd C, Le Frère-Belda MA, Collignon MA, Faraggi M, Lècuru F.

Source

Department of Medicine and.

Abstract

Objectives

Pelvic lymphadenectomy is associated with a significant risk of lower-limb lymphedema. In this proof-of-concept study, we evaluated the feasibility of identifying the lower-limb drainage nodes (LLDNs) during pelvic lymphadenectomy for endometrial cancer. Secondary objectives were to map lower-limb drainage and to assess the diagnostic value of our mapping technique.

Methods 

This prospective study included patients with endometrial cancer requiring pelvic lymphadenectomy, without neoadjuvant radiotherapy or chemotherapy and without history of lower-limb surgery. A radio pharmaceutical was injected into both feet on the day before surgery. LLDNs were identified using preoperative lymphoscintigraphy and intraoperative isotopic probe detection, then removed before complete pelvic lymphadenectomy. LLDNs and pelvic lymphadenectomy specimens underwent separate histological analysis.

Results 

Of the 12 patients with early-stage endometrial cancer, 10 underwent preoperative lymphoscintigraphy, which consistently identified inguinal, femoral, and pelvic LLDNs (detection rate: 100%). The intraoperative detection rate was 83% (10/12). Median number of hot nodes per patient was 5 nodes (range: 3-7) on the right and 3 nodes (range: 2-6) on the left. Of 107 LLDNs, 106 were in the external iliac area, including 38 in the lateral group and 45 in the intermediate and medial 

PubMed

A case report: elephantiasis

2012

[Article in Turkish]

Karagöz E, Karaahmetoğlu G, Acar A, Turhan V, Oncül O, Görenek L.

Source

Gülhane Askeri Tıp Akademisi Haydarpaşa Eğitim Hastanesi, Enfeksiyon Hastalıkları ve Klinik Mikrobiyoloji Servisi, İstanbul, Türkiye. drgkara@gmail.com

Abstract

Klippel-Trenaunay syndrome (KTS) is a rare disease and a syndrome that is characterized by the triad of congenital port wine stains, venous malformations with or without varicose veins, bone or soft tissue hypertrophy. Lymphatic filariasis is a filarial disease which usually occurs with genital anomalies, pathologies associated with lymphedema or elephantiasis caused by a filarial infectious agent. In this case report, a 20-year-old male patient admitted to our clinic for diagnosis and treatment with right leg edema and lesions compatible with dermatological manifestations. In the list of differential diagnosis, filarial elephantiasis was also thought, consequently KTS was diagnosed. (Turkiye Parazitol Derg 2012; 36: 188-90).

TPD

Development and Validation of a Self-Report Lower-Extremity Lymphedema Screening Questionnaire in Women.

Jan 2013

Yost KJ, Cheville AL, Weaver AL, Al Hilli M, Dowdy SC.

Source

K.J. Yost, Department of Health Sciences Research, Mayo Clinic, 200 First St W, Rochester, MN 55905 (USA).

Abstract

BACKGROUND:

Patient-reported signs and symptoms are often the first indication of clinically relevant lymphedema.

OBJECTIVE:

Develop and assess the diagnostic accuracy of a screening questionnaire to detect lower extremity lymphedema (LEL) among normal weight and obese women.

DESIGN:

Cross-sectional survey study.

METHODS:

We reviewed existing questionnaires assessing upper extremity lymphedema (UEL) for potential questions and worked with content experts to generate new items. A draft questionnaire with 59 items was reviewed by 5 physicians and 5 physical therapists specialized in lymphedema management and 5 female patients with clinically confirmed secondary LEL. A revised questionnaire with 45 items was administered by mail (n=186) or in a lymphedema clinic waiting area (n=28) to women with clinically confirmed LEL (cases, n=116) or UEL (controls, n=70). A parsimonious subset of items that best discriminated patients with and without LEL was identified using chi-square tests and logistic regression. Sensitivity and specificity for detecting LEL were estimated for the entire sample and for subsamples defined by obesity (BMI ≥30 versus < 30), which may confound the accurate diagnosis of LEL.

RESULTS:

Questionnaires were completed by 127 women (LEL n=88; UEL n=39). A sum of 13 items (score range 0-52) was the most discriminating. Using a cutoff score of ≥5 points, the sensitivity and specificity for detecting LEL among all participants were 95.5% and 86.5%, respectively and 94.8% and 76.5% for obese participants.

LIMITATIONS:

By enumerating a sample with a high prevalence of LEL, we may have introduced spectrum bias, which may affect the accuracy of our screening questionnaire.

CONCLUSIONS:

Our brief, 13-item self-report questionnaire is a sensitive and specific tool for detecting clinically relevant LEL among women, including those with BMI ≥30.

Physical Therapy

Caring for the lymphedema foot

Caring for the lymphedema foot

January 2013

Most people who have leg lymphedema also will have foot involvment. Thus, taking care of our feet becomes even more critical for lymphedema patients.

Feet that have damaged skin, cuts, scrapes or any open areas become entry foci for bacterial infections associated with lymphedema infections. Feet with unhealthy skin can become an open door for foot fungal infections. Both can cause further complications and worsening of our lymphedema.

Keith Smiley

The National Lymphedema Network (NLN) has been flooded with questions regarding foot and ankle care for patients with lower extremity lymphedema. Dr. Joseph Hewitson, a San Francisco Podiatrist, who has worked with many lymphedema patients, provided NLN a list of guidelines and suggestions for proper foot care for people suffering from lower extremity lymphedema. These guidlelines are excerpted from The July NLN newsletter.

Wear shoes.  

I love going barefoot, but with lymphedema, this can be downright dangerous and can give bacteria a splendid opening for an infection.  Resist that temptation to go barefoot.

Make sure you don't provide an opportunity in your shoes for bacteria or fungus spores to hide and grow.  I personally use an antifungal powder in even my street shoes.

Nail Care

Be sure to trim your toenails, but not necessarily straight across. If the corners have grown into the skin, trim the offending border.

If you get an infection, you should remove that side of the nail to resolve the infection. Antibiotics often will not work because an abscess (walled off infection) has occurred. Soaking may only provide temporary relief.

A lymphedema patient should never undergo a chemical matrisectomy (destroying root growth matrix with a chemical to permanently remove nail).

Fungal nails are common in lymphedema patients and should be soaked in 1:1 vinegar/water solution for 20 minutes, with antifungal solution applied afterwards.

Routine foot care every three months with a podiatrist if possible or your physician.

Meticulous nail care decreases the chance for inflammation and infection.

Taking Care of your Toes

The inner spaces between your toes need to be kept clean and dry.

Soaking in a 1:1 vinegar/water solution for 20 minutes at least once a week and running a piece of gauze between your toes to remove any debris will help keep your web spaces clean.

Using a drying agent/antifungal solution like Castelani's Paint decrease chances of irritation and infection.

Applying lambs wool (see your pharmacist) between the toes allows the web greater breathability.

Open toed compression garments will also allow greater breathability, as will breathable footwear that is fitted correctly.

Dr. Hewitson says that proper footwear is very important. He says always buy your shoes at the time of day when your foot is most swollen (usually the end of the day). If you wear a compression garment, make sure you fit your shoes to accommodate this. Good athletic shoes are excellent to wear because they are more supportive, and more breathable. For very large feet, a Velcro strap shoe is usually more accommodating.

If you have painful corns and calluses, they should be routinely trimmed by a podiatrist or practitioner. Never use any callous removal pads, because they can cause burns and infections.

Dr. Hewitson also says to always work with reputable practitioners who are willing to further educate themselves on lymphedema. He adds, you may be their best and only teacher.

Suite 101

Simple measures which will promote healthy skin:

1. Inspect the skin daily for any crack, cuts or dry areas. Check carefully areas with reduced sensation or where there are skin folds.

2. Clean skin daily with non-perfumed soap

3. Dry skin completely, especially the area between the toes

4. Keep skin supple. Use a Iow pH lotion as Eucerin to keep the skin moist and pliable.

5. Check fingernails and toenails for any signs of infection, cracks, fungus, or hangnails. Do not cut nails or cuticles. Use an emery board.

6. Call your doctor at the first signs of any infection, redness or high temperature.

For Further Information on the skin, skin care, foot care, possible complications and infections, please see the below listed pages:

Infections Associated with Lymphedema

Skin Care

Blisters

Calluses

Bunions

Fungal Infections Associated with Lymphedema

How to Have Healthy Nails

Corns

Antibiotics

Cellulitis

Lymphorrhea

Skin Conditions and Skin Growths

Skin Infections

Skin Functions

Wrapping Lymphedema Toes - illustrated

Wrapping the Lower Limb (Leg) with Lymphedema - illustrated

Multilayer Compression Bandaging of the Lymphedema Leg

Lymphovenous Microsurgical Shunts in Treatment of Lymphedema of Lower Limbs: A 45-year Experience of One Surgeon/One Center.

Dec 2012

Olszewski WL.

Source

Department of Surgical Research & Transplantology, Medical Research Center, Polish Academy of Sciences, 5 Pawinskiego Str., 02-106 Warsaw, Poland. Electronic address: wlo@cmdik.pal.pl.

Abstract

RATIONALE:

The use of microsurgical lymphovenous shunts is one of the generally accepted treatments for limb lymphedema.

AIM:

The 45-year personal experience of one surgeon in indications, technique and results of lymphovenous shunt operations in lower limb lymphedema of varying etiology is presented.

MATERIAL:

One thousand three hundred patients were followed up in the period 1966-2011. Patients were classified into groups according to the etiology of lymphedema as postinflammatory/posttraumatic, postsurgical, idiopathic and hyperplastic. Decrease in limb circumference, heaviness and pain, and increase in joint flexing were evaluated.

RESULTS:

The most satisfactory results, reaching 80-100% improvement, were obtained in the congenital non-hereditary hyperplastic lymphedema group, with large lymphatics not previously damaged by infection. Results were also satisfactory in the group of cancer patients after iliac lymphadenectomy, reaching 80%. A less satisfactory outcome was observed in the postinflammatory group, not exceeding 30-40%. In idiopathic lymphedema results were satisfactory in only a few cases.

CONCLUSIONS:

Patients with lymphedema with local segmental obstruction but still partly patent distal lymphatics and without an active inflammatory process in the skin, subcutaneous tissue and lymph vessels present satisfactory results.

**Editor's note:  Please understand this procedure while showing great promise is still classified as experimental.  Also, note the particular "types" of lymphedema and patients that appear to have the best results. See RESULTS - Pat**

PubMed