Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 394 - файл
.pdf
92 Lymphoedema and ChroniC SweLLing
https://t.me/medicina_free
FIGURE 2.7 Posterior view of the patient in Figure2.6.
FIGURE 2.8 Type III late stage 2 with chronic oedema of lower legs and
feet, anterior view. Note the more pronounced ankle ‘cu’ and irregular
texture of the skin.
FIGURE 2.9 Same patient as gure 2.8, lateral view. The ‘hood’ of excess
https://t.me/medicina_free
tissue over the knees becomes more pronounced as lipoedema progresses.
FIGURE 2.10 Same patient as gures 2.8 and 2.9, posterior view.
94 Lymphoedema and ChroniC SweLLing
https://t.me/medicina_free
why lipoedema patients often report frequent and unexplained bruising. Hypermobility, where joints can extend beyond their normal
range of motion, is also common among lipoedema patients and it is
again thought that this is linked to weakened connective tissue.
Hypermobility is discussed further in Chapter4.
Diagnosing Lipoedema
There are currently no diagnostic tests for lipoedema and the condition is therefore diagnosed based on the patient’s history and clinical
examination. This is typically done by specialist servicesasit can be
dicult to diagnose due to the similarities with obesity and lymphoedema. Lipoedema can be very unpredictable and patients do not
allpresent with the same features. If lipoedema is suspected then
referral to a specialist service should be arranged to conrm the diagnosis and ensure appropriate management. There are no dedicated
lipoedema services in the United Kingdom and not all lymphoedema
services will see lipoedema patients. Depending on the service, referrals may need to come from a doctor, so it is essential this is discussed
with the patient’s GP. Patients could also be signposted to groups
such as Lipoedema UK.
A clear diagnosis should describe the location and progression of
the condition, although it may be dicult to distinguish the true
extent if there is lymphoedema or obesity present as well. Classication systems exist for both lipoedema location and severity. Tables2.23
and 2.24 are collated in the Best Practice Statement (Wounds
UK2017) based on the work of multiple studies.
TABLE 2.23
Type Area aected
Type I Pelvis, buttocks and hips
Type II Buttocks to knees
Type III Buttocks to ankles
Type IV Arms
Type V Lower legs
Classication oflipoedema based onanatomy.
Lymphoedema and Chronic Swelling 95
https://t.me/medicina_free
TABLE 2.24
Stage Description
Stage 1 Smooth appearance to the skin
Stage 2 Skin has an irregular dimpled texture like orange peel
Stage 3 Skin texture becomes more irregular than in Stage 2.
Stage 4 Lipoedema with lymphoedema
Classication oflipoedema according todisease progression.
Small nodules or grainy texture felt beneath the skin
Nodules beneath the skin can become st sized
Fat deposits grow ever larger, particularly around the knees
and thighs, signicantly distorting limb shape
Sometimes referred to as lipo-
lymphoedema
Impact ofLipoedema
As explained earlier in the chapter, lipoedema fat does not reduce in
the same way as normal body fat in response to dieting. This means
that weight is lost mainly from areas unaected by lipoedema, generally from the waist up, and patients sometimes describe themselves as
‘pear- shaped’ because of their disproportionate body shape. The
pathophysiology behind this is not understood, but patients often
report a long history of unsuccessful dieting before becoming aware of
their lipoedema. Research has shown that weight loss in the aected
areas through dietary means is not impossible, but cannot be expected
to the same extent as for nondieting with little or no improvement is understandably very upsetting
for patients and can have a profound eect on their mental health.
Due to the distorted limb shape, lipoedema patients also often report
diculty buying clothes and shoes, and many describe embarrassment and feeling that they need to hide their legs. This can lead to
isolation and restricted social interaction, further feeding into the signicant psychological impact that lipoedema can have.
lipoedema fat. This common pattern of
Treatment andManagement ofLipoedema
Current treatment for lipoedema is limited, but its management
should always be holistic. Despite diculty losing weight being a key
feature, it is important that patients are supported to maintain their
96 Lymphoedema and ChroniC SweLLing
https://t.me/medicina_free
current weight as much as possible. This is because lipoedema deposition is exacerbated by further weight gain. There is increasing
evidence that a ketogenic or anti- inammatory diet can improve
lipoedema symptoms (Jin etal.2022). Such diets may not be appropriate for all patients, so referral to a dietitian for expert advice is sensible.
A focus on preserving and promoting mobility is also important
as this often deteriorates as lipoedema progresses. Movement can be
limited by pain caused by the inamed fatty tissue, and if there are
other factors such as venous disease or arthritis this will further exacerbate pain. Activity avoidance because of pain also contributes to
the cycle of deteriorating mobility.
Genu valgum (knock knees) is common, as is degenerative knee
pain, and this can lock a patient into a vicious cycle of deteriorating
mobility and weight gain. It is felt that this structural weakness is
partly due to the weakening of connective tissues in the joints.
Another factor is the sheer size and weight of the excess limb bulk,
which pulls joints out of alignment and aects gait, thus further
restricting mobility. Lipoedema patients often develop a swaying gait,
rocking from side to side as they walk, and this is caused in part simply by an involuntary attempt to avoid chang of the thighs (Stutz
and am Wald2011). Support from therapy teams to optimise mobility
is important, particularly if patients are felt to be at high risk of falls.
Referral to podiatry, for biomechanical assessment and gait analysis,
is also highly recommended, as supportive footwear and orthotics
can better align the joints, leading to improved calf muscle pump
function, optimised mobility and reduced pain.
As with most lower limb conditions, a core treatment for
lipoedema is compression. For lymphoedema the aim of compression is to encourage the movement of uid through the lymphatics to
reduce swelling. Sadly, with lipoedema no amount of compression
will reduce the aected fatty tissue and so the focus is to provide comfort and support, and thus a reduction of pain, to the aected limbs.
The lymphatics will still be inuenced, however, and so a wellcompression garment will help to reduce or prevent any secondary
swelling that may occur.
Due to the shape distortion of lipoedema, custom- made at- knit
garments are often required, although o- the- shelf circular- knit
garments can be appropriate in the early stages. Softer fabrics may
be better tolerated because of the hypersensitivity some patients
tting
Lymphoedema and Chronic Swelling 97
https://t.me/medicina_free
experience, but these are not always appropriate in terms of required
support. If lipoedema extends above the knees into the hips or buttocks, then full- length garments such as leggings or tights should be
considered. This may not be practical for some patients though, so a
combination of below- knee stockings with Capri pants may be more
appropriate. As with all compression, garments must be suited to
what is therapeutic for the patient but also to what they can physically manage and are prepared to wear.
Non- cosmetic liposuction (NCL) can be performed to signicantly reduce limb bulk and impressive results are possible. The procedure is not suitable in all cases and is not currently available on the
NHS. There has been recent campaigning by patient groups, most
notably Lipoedema UK, to obtain National Institute for Health and
Care Excellence (NICE) approval for NCL for lipoedema. NICE
acknowledged the debilitating impact on patients’ lives that
lipoedema can have, but concluded that the condition remains
under- recognised and requires more research (NICE2022).
SUMMARY
Lipoedema is poorly recognised and poorly understood creating distress for people who have this long term condition. Eective specialist assessment and management can dramatically improve a person’s
mobility and their quality of life.
REFERENCES
Alcorso, J. and Sherman, K.A. (2016). Factors associated with psychological
distress in women with breast cancer- related lymphoedema. Psycho-
Oncology 25 (7): 865–872. https://doi.org/10.1002/pon.4021.
Al- Ghadban, S., Teeler, M.L., and Bunnell, B.A. (2021). Estrogen as a contrib-
uting factor to the development of lipedema. In: Hot Topics in Endocri-
nology and Metabolism (ed. H.M. Heshmati), ch. 6. London: IntechOpen
https://www.intechopen.com/online- rst/estrogen- as- a- contributing-
factor- to- the- development- of- lipedema.
Al- Kofahi, M., Yun, J.W., Minagar, A., and Alexander, J.S. (2017). Anatomy
and roles of lymphatics in inammatory diseases. Clinical and Experi-
mental Neuroimmunology 8: 199–214.
98 Lymphoedema and ChroniC SweLLing
https://t.me/medicina_free
Allen, M., Schwartz, M., and Herbst, K.L. (2020). Interstitial uid in lipedema
and control skin.
org/10.1089/whr.2020.0086.
Appelen, D., van Loo, E., Prins, M.H. etal. (2017). Compression therapy for
prevention of postSystematic Reviews 9: CD004174. https://doi.org/10.1002/14651858.CD
004174.pub3.
Atkin, L. (2016). Cellulitis of the lower limbs: incidence, diagnosis and man-
agement.
Atkin, L., Bullock, L., Chadwick, P. etal. (2021). Making legs matter: a case
for system change and transformation in lower- limb management. Jour-
nal of Wound Care 30 (Sup11): S1. https://doi.org/10.12968/jowc.2021.
30.Sup11.S1.
Azhar, S.H., Lim, H.Y., Tan, B.K., and Angeli, V. (2020). The unresolved
pathophysiology of lymphedema.
https://doi.org/10.3389/fphys.2020.00137.
Baxter, G.D., Liu, L., Petrich, S. etal. (2017). Low level laser therapy (photo-
biomodulation therapy) for breast cancertematic review.
017- 3852- x.
Bazigou, E. and Makinen, T. (2013). Flow control in our vessels: vascular
valves make sure there is no way back. Cellular and Molecular
Life Sciences 70 (6): 1055–1066. https://doi.org/10.1007/s00018- 012 1110- 6.
Bowman, C., Piedalue, K.-
quality of life and psychosocial implications of cancerextremity lymphedema: a systematic review of the literature. Journal of
Clinical Medicine 9: 3200. https://doi.org/10.3390/jcm9103200.
British Lymphology Society (2016). Professional roles in the care of lym-
phoedema. https://www.thebls.com/public/uploads/documents/docu
ment-
British Lymphology Society (2020). What is lymphoedema? https://www.
thebls.com/public/uploads/documents/document- 78261580330781.pdf
British Lymphology Society (2021). Skin care for people with lymphoedema.
https://www.thebls.com/search?query=skin%20care
British Lymphology Society (2022a) Self lymphatic drainage. https://www.
thebls.com/search?query=self%20lymphatic
British Lymphology Society (2022b) Modern surgical options for
lymphoedema. https://www.thebls.com/documents- library/lymph- facts modern- surgical- options- for- lymphoedema
British Lymphology Society (BLS) (2022c). Guidelines on the management
of cellulitis in lymphoedema. https://www.thebls.com/documents-
library/guidelines- on- the- management- of- cellulitis- in- lymphoedema
Wounds UK 12 (2): 38–41.
25011520254971.pdf
Women’s Health Reports 1 (1): 480–487. https://doi.
thrombotic syndrome. Cochrane Database of
Frontiers in Physiology 17 (11): 137.
related lymphedema: asys-
BMC Cancer 17 (1): 833. https://doi.org/10.1186/s12885-
A., Baydoun, M., and Carlson, L.E. (2020). The
related lower-
Lymphoedema and Chronic Swelling 99
https://t.me/medicina_free
British Lymphology Society (2023). Understanding and managing lymphor-
rhoea in the community. https://www.thebls.com/search?query=
understanding%20and%20managing
British Lymphology Society and Lymphoedema Support Network (2016).
Consensus document on the management of cellulitis in lymphoedema.
https://www.thebls.com/public/uploads/documents/document-
75091530863967.pdf
Bromham, N., Schmidt-
for operable primary breast cancer.
Reviews1: CD004561. https://doi.org/10.1002/14651858.CD004561.pub3.
Brouillard, P., Witte, M.H., Erickson, R.P. et al. (2021). Primary lymphoe-
dema. Nature Reviews. Disease Primers 7: 77. https://doi.org/10.1038/
s41572-
021- 00309- 7.
Burian, E.A., Karlsmark, T., Franks, P.J. etal. (2021). Cellulitis in chronic
oedema of the lower leg: an international cross- sectional study.
British Journal of Dermatology 185: 110–118. https://doi.org/10.1111/
bjd.19803.
Campisi, C., Eretta, C., Pertile, D. etal. (2007). Microsurgery for treatment of
peripheral lymphedema: long-
Microsurgery 27 (4): 333–338. https://doi.org/10.1002/micr.20346.
Chira, S. and Miller, L.G. (2010). Staphylococcus aureus is the most common
identied cause of cellulitis: a systemic review. Epidemiology and Infec-
tion 138: 313–317.
Cobbe, S. (2021). Lymphoedema and oedema in palliative care patients.
ish Journal of Community Nursing 26 (Sup4): S6–S15. https://doi.
org/10.12968/bjcn.2021.26.Sup4.S6.
Cox, N.H. (2009). Streptococcal cellulitis/erysipelas of the lower leg. In:
Evidence- Based Dermatology, 2e: ch. 41 (ed. H. Williams, M. Bigby,
T.Diepan, etal.). Oxford: Blackwell Publishing.
Dessources, K., Aviki, E., and Leitao, M.M. Jr. (2020). Lower extremity
lymphedema in patients with gynecologic malignancies.
Journal of Gynecological Cancer 30 (2): 252–260. https://doi.org/10.1136/
ijgc- 2019- 001032.
DiSipio, T., Rye, S., Newman, B., and Hayes, S. (2013). Incidence of unilateral
arm lymphoedema after breast cancer: a systematic review and meta-
analysis. Lancet Oncology 14 (6): 500–515. https://doi.org/10.1016/
S1470- 2045(13)70076- 7.
Doherty, D.C., Morgan, P.A., and Moatt, C.J. (2006). Role of hosiery in lower
limb lymphoedema. In: Compression Hosiery in Lymphoedema (ed. L.
MacGregor), 10–21. London: MEP.
Doherty, D. and Williams, A. (2004). The physiological eects of massage on
individuals with lymphoedema/chronic oedema, and its role in the
development of clinical techniques used in practice: a systematic review.
Hansen, M., Astin, M. etal. (2017). Axillary treatment
Cochrane Database of Systematic
term outcome and future perspectives.
Brit-
International
100 Lymphoedema and ChroniC SweLLing
https://t.me/medicina_free
JBI Library of Systematic Reviews 2 (5): 1–17. https://doi.org/10.11124/
2004- 664.
jbisrir-
Dunn, N., Williams, E.M., Dolan, G., and Davies, J.H. (2022). Intermittent
pneumatic compression for the treatment of lower limb lymphedema: a
pilot trial of sequencing to mimic manual lymphatic drainage versus
traditional graduated sequential compression. Lymphatic Research and
Biology 20 (5): 514–521. https://doi.org/10.1089/lrb.2021.0025.
Edwards, G., Freeman, K., Llewelyn, M.J., and Hayward, G. (2020). What
diagnostic strategies can help dierentiate cellulitis from other causes of
red legs in primary care?
Elwell R (2020). Red legs pathway. Licheld: British Lymphology Society.
https://www.thebls.com/public/uploads/documents/document-
84341639738140.pdf
Fife, C.E., Farrow, W., Hebert, A.A. et al. (2017). Skin and wound care in
lymphedema patients: a taxonomy, primer, and literature review.
Advances in Skin & Wound Care 30 (7): 305–318. https://doi.org/10.
1097/01.ASW.0000520501.23702.82.
Fu, M.R., Ridner, S.H., Hu, S.H. et al. (2013). Psychosocial impact of
lymphedema: a systematic review of literature from 2004 to 2011.
chooncology 22 (7): 1466–1484. https://doi.org/10.1002/pon.3201.
Gasparis, A.P., Kim, P.S., Dean, S.M. etal. (2020). Diagnostic approach to
lower limb edema. Phlebology 35 (9): 650–655. https://doi.org/
10.1177/0268355520938283.
Gordon, K. and Morgan, P.A. (2007). Lymphoedema: an underestimated
health problem.
Gordon, S.J., Murray, S.G., Sutton, T. etal. (2019). LIMPRINT in Australia.
Lymphatic Research and Biology 17 (2): 173–177. https://doi.org/
10.1089/lrb.2018.0087.
Goswami, A.K., Khaja, M.S., Downing, T. etal. (2020). Lymphatic anatomy
and physiology.
https://doi.org/10.1055/s- 0040- 1713440.
Greene, A.K. and Goss, J.A. (2018). Vascular anomalies: from a clinicohisto-
logic to a genetic framework. Plastic and Reconstructive Surgery 141 (5):
709e–717e. https://doi.org/10.1097/PRS.0000000000004294.
Hague, A., Bragg, T., Thomas, M. etal. (2020). Severe lower limb lymphoe-
dema successfully treated with a two- stage debulking procedure: a case
report. Case Reports in Plastic Surgery and Hand Surgery 7 (1): 38–42.
https://doi.org/10.1080/23320885.2020.1736943.
Health Service Executive (Ireland) (2019). Lymphoedema and lipoedema
treatment in Ireland: a model of care for Ireland. https://www.hse.ie/
eng/services/publications/lymphoedema- model- of- care.pdf
Healthy London Partnership (2020). Commissioning guidance for
lymphoedema services for adults living with and beyond cancer.
BMJ 368: m54. https://doi.org/10.1136/bmj.m54.
Psy-
Journal of Lymphoedema 2 (1): 3–10.
Seminars in Interventional Radiology 37 (3): 227–236.
Lymphoedema and Chronic Swelling 101
https://t.me/medicina_free
https://www.healthylondon.org/wp- content/uploads/2020/03/Lymphoedema-
CommissioningHo, B., Gordon, K., and Mortimer, P.S. (2018). A genetic approach to the clas-
sication of primary lymphoedema and lymphatic malformations.
European Journal of Vascular and Endovascular Surgery 56 (4): 465–466.
https://doi.org/10.1016/j.ejvs.2018.07.001.
Houwen, F., Stemkens, J., de Schipper, P.J. etal. (2022). Estimates for assess-
ment of lymphedema: reliability and validity of extremity measure-
ments. Lymphatic Research and Biology 20 (1): 48–52. https://doi.
org/10.1089/lrb.2019.0082.
International Lymphoedema Framework and Canadian Lymphoedema
Framework (2010). The management of lymphoedema in advanced
cancer and oedema at the end of life. https://www.lympho.org/uploads/
les/les/PalliativeInternational Society of Lymphology (2013). The diagnosis and treatment of
peripheral lymphedema: 2013 consensus document of the International
Society of Lymphology.
Jin, Y., Benzine, R., Dunford, L. etal. (2022). An investigation into the
impact of diet and lifestyle on the management of lipoedema. Current
Developments in Nutrition 6: 1064–1064. https://doi.org/10.1093/cdn/
nzac070.023.
Kamijo, E., Ishizuka, K., Shikino, K. etal. (2021). Physical ndings and tests
useful for dierentiating lymphedema.
cine 22: 227–228. https://doi.org/10.1002/jgf2.425.
Kataru, R.P., Wiser, I., Baik, J.E. et al. (2019). Fibrosis and secondary
lymphedema: chicken or egg? Translational Research 209: 68–76.
Keast, D.H., Moatt, C., and Janmohammad, A. (2019). Lymphedema impact
and prevalence international study: the Canadian data. Lymphatic
Research and Biology 17: 178–186.
Keeley, V., Crooks, S., Locke, J. etal. (2010). A quality of life measure for limb
lymphoedema (LYMQOL). Journal of Lymphoedema 10 (5): 26–37.
Koshima, I., Nanba, Y., Tsutsui, T. etal. (2003). Long- term follow- up after
lymphaticovenular anastomosis for lymphedema in the leg. Journal of
Reconstructive Microsurgery 19 (4): 209–215. https://doi.org/10.1055/
s- 2003- 40575.
Largeau, B., Cracowski, J.- L., Lengellé, C. etal. (2021). Drug- induced periph-
eral oedema: an aetiology- based review. British Journal of Clinical Phar-
macology 87: 3043–3055. https://doi.org/10.1111/bcp.14752.
Levick, J.R. and Michel, C.C. (2010). Microvascular uid exchange and the
revised Starling principle. Cardiovascular Research 87 (2): 198–210.
https://doi.org/10.1093/cvr/cvq062.
Lukowicz, D., Sauter, M., and Lipp, A. (2021). All About Lipedema. Kolinburg:
Scout Medien.
Guidance- 2020.pdf
Document.pdf
Lymphology 46 (1): 1–11.
Journal of General Family Medi-
Соседние файлы в папке @xirurgi_2025