High flow failure of the lymph circulation

Liposuction in Arm Lymphedema Treatment

Breast cancer is the most common disease in women, and up to 38 % develop lymphedema of the arm following mastectomy, standard axillary node dissection and postoperative irradiation. Limb reductions have been reported utilizing various conservative therapies such as manual lymph and pressure therapy. Some patients with long-standing pronounced lymphedema do not respond to these conservative treatments because slow or absent lymph flow causes the formation of excess subcutaneous adipose tissue.

Previous surgical regimes utilizing bridging procedures, total excision with skin grafting or reduction plasty seldom achieved acceptable cosmetic and functional results. Microsurgical reconstruction involving lympho-venous shunts or transplantation of lymph vessels has also been investigated. Although attractive in concept, the common failure of microsurgery to provide complete reduction is due to the persistence of newly formed subcutaneous adipose tissue, which is not removed in patients with chronic non-pitting lymphedema.

Liposuction removes the hypertrophied adipose tissue and is a prerequisite to achieve complete reduction. The new equilibrium is maintained through constant (24-hour) use of compression garments postoperatively. Long-term follow up (7 years) does not show any recurrence of the edema.

Disorders of lymph flow

Disturbances in blood capillary exchange of fluid, macromolecules, and cells across intact and abnormal microvessels and deranged lymphatic transport are integral, interacting components in disorders of tissue swelling. Lymphedema or low-output failure of the lymph circulation is often indolent for many years before lymphatic insufficiency (failure) and tissue swelling emerge and persist. Superimposed occult or overt infection (lymphangitis) are probably major contributors to progressive limb deformity (elephantiasis). Long-standing lymphedema is characterized by trapping in the skin and subcutaneous tissue of fluid, extravasated plasma proteins, and other macromolecules: impaired immune cell trafficking; abnormal processing of autologous and foreign antigens; heightened susceptibility to superimposed infection; local immunodysregulation; defective lymphatic (lymphangion) propulsion from an imbalance of mediators regulating vasomotion; soft-tissue overgrowth; scarring and hypertrophy; and exuberant angiogenesis occasionally culminating in vascular tumors (Fig. 8). In contrast to the blood circulation, where flow depends primarily on the propulsive force of the myocardium, lymph propulsion depends predominately on intrinsic truncal contraction, a phylogenetic vestige of amphibian lymph hearts. Whereas venous "plasma" flows rapidly (2-3 l/min) against low vascular resistance, lymph flows slowly (1-2 ml/min) against high vascular resistance. On occasion, impaired transport of intestinal lymph may be associated with reflux and accumulation and leakage of intestinal chyle in a swollen leg. Although the term "lymphedema" is usually reserved for extremity swelling, the pathogenesis of a wide variety of visceral disorders also may be traceable to defective tissue fluid and macromolecular circulation and impaired cell trafficking of lymphocytes and macrophages. Thus, lymph stasis, with impaired tissue fluid flow, underlies or complicates an indolent subclinical course with a long latent period and sporadic episodes of lymphangitis, which culminates in intense scarring. Examples are pulmonary fibrosis (e.g., pneumoconiosis), regional enteritis, retroperitoneal fibrosis, and perhaps chronic pancreatitis and cirrhosis of the liver. Transdifferentiation and ultimately transformation of endothelial and other vascular accessory cells during lymph stasis also may be pivotal to a wide range of dysplastic and neoplastic vascular disorders, including Stewart-Treves angiosarcoma, AIDS-associated Kaposi's sarcoma, and lymphangitic metastatic carcinomatosis. Lymphscintigraphy has now replaced conventional lymphography as the procedure of choice to corroborate the diagnosis of peripheral lymphedema, whereas MR imaging using paramagnetic and superparamagnetic contrast agents has the potential to yield huge dividends in furthering understanding of a variety of enigmatic edematous states, including lymphedema. Not only are better explanations and insights into swelling disorders likely to be forthcoming, but, equally important, these new, safe, noninvasive imaging techniques can and should be used to monitor the evolution and document the efficacy of commonly advocated operations and nonoperative remedies for defective lymph transport and function.

Prevalence and hemodynamic correlates of malnutrition in severe congestive heart failure secondary to ischemic or idiopathic dilated cardiomyopathy

Whereas cardiac cachexia is well recognized, the frequency and hemodynamic correlates of malnutrition in severe congestive heart failure (CHF) have not been established. Anthropometric and serum albumin assessment of nutritional status was compared with hemodynamic, echocardiographic and serum chemistry evaluation in 48 patients with severe CHF (ejection fraction 0.17 +/- 0.05). Malnutrition, as defined by decreases in percent body fat determined from skinfold thicknesses, weight/height index or serum albumin, was present in 24 of 48 (50%) patients, who did not differ from the 24 well-nourished patients in cardiac index (1.9 +/- 0.6 vs 2.1 +/- 0.6 liters/min/m2) and pulmonary artery wedge pressure (30 +/- 6 vs 27 +/- 10 mm Hg), but had higher right atrial pressure (16 +/- 5 vs 9 +/- 6 mm Hg, p less than 0.01) and more severe tricuspid regurgitation by semiquantitative Doppler grading on a 0 to 3 scale (2.0 +/- 0.9 vs 0.9 +/- 0.8, p less than 0.01). Right atrial pressure was the only independent hemodynamic predictor of malnutrition (p less than 0.0002). Malnourished patients had lower serum sodium (134 +/- 4 vs 139 +/- 4 mEq/liter, p less than 0.01) and total triiodothyronine levels (89 +/- 30 vs 115 +/- 26 ng/dl, p less than 0.01) and higher creatinine levels (1.6 +/- 0.7 vs 1.2 +/- 0.4, p less than 0.03). None of the other biochemical markers of nutritional status differed between the groups except lower serum triglyceride levels (115 +/- 73 vs 186 +/- 97 mg/dl, p less than 0.05) in malnourished patients. Malnutrition is common in patients with severe CHF and is associated with increased right atrial pressure and tricuspid regurgitation.