SURGICAL TREATMENT OF ELEPHANTIASIS OF THE FEET IN CONGENITAL LYMPHEDEMA TO FACILITATE THE USE OF A COMPRESSION MECHANISM
The aim of the current study is to report on the minimal surgical treatment of elephantiasis of the feet to facilitate the use of compression mechanisms. The cases of two patients with congenital lymphedema that evolved to elephantiasis involving the feet are reported. Intensive treatment of the lymphedema was performed with a significant reduction in size thus allowing a better identification of the limits of tissue masses for the surgical approach. This reduction enabled primary suturing of the lesions to be carried out and fast healing of the wounds. The surgery greatly improved large deformities of the toes and feet and facilitated further treatment of the lymphedema using bandaging. Thus, the skin was preserved, there was a reduction in the size of the feet, and the patients were able to start wearing shoes.
SENSITIVITY AND SPECIFICITY OF COMBINED PERIMETRIC AND VOLUMETRIC EVALUATIONS IN THE DIAGNOSIS OF ARM LYMPHEDEMA
The objective of the current study was to evaluate the sensitivity and the specificity of perimetry combined with volumetry in the treatment of lymphedema. Ninety women, who had been submitted to breast cancer surgery, were randomly selected in the Government Healthcare Clinic for this study. Only patients who underwent surgical treatment of breast cancer with some degree of lymphadenectomy were included in the study cohort. Individuals with activedisease, whether local or otherwise, functional alterations of the upper limbs before breast cancer surgery were not included. The following possibilities were considered: 1 – the perimetry evaluation was considered positive when the difference between the affected and unaffected sides was ³ 2 cm for any one of the seven measurements and volumetry was ³ 100 mL; 2 – perimetry ³ 2 cm and volumetry ³ 200 mL; 3 – a difference > 10% between the two limbs in volumetry and perimetry. Prevalence, sensitivity, specificity, positive predictive value, negative predictive value and accuracy were evaluated statistically with an alpha error of 5% considered acceptable (p-value < 0.05). The mean age of the women was 54.8 ± 11.7 years. The sensitivity, negative predictive value and accuracy were higher using perimetry when a volume ³ 2 cm were considered. The specificity and positive predictive values were better when the difference was greater than 10% between the two limbs by both perimetry and volumetry. Perimetry is a reliable method in the diagnosis of lymphedema when differences > 2 cm between the two limbs should be considered.
QUALITY OF LIFE AND PERIPHERAL LYMPHEDEMA
PREOPERATIVE PREPARATION OF A PATIENT WITH GRADE II LEG LYMPHEDEMAFOR HIS THIRD HIP REPLACEMENT SURGERY
INTRODUCTION: The treatment of lymphedema remains a challenge to modern medicine, due to thecharacteristics of the disease.CASE PRESENTATION: Report on the case of a 75-year-old patient with lower limb lymphedema for treat-ment prior to surgery. At age 45, he made the first hip replacement surgery in the left leg. One year laterhe performed the same surgery on the right leg. At that time his legs had slight ankle edema mainly ofthe left leg and the entire left leg was affected by lymphedema. At 68 years old the patient returned tothe surgeon, who indicated a third surgery to replace the left hip prosthesis. The patient was evaluatedby bioimpedance, which measured the volumes of right and left legs at 5.52 and 7.24 l, respectively. Fivedays of intensive treatment were proposed using Mechanical Lymphatic Therapy (RAGodoy®), ManualLymphatic Therapy and compression therapy with a grosgrain stocking for 24 h per day. On the fifth day,there was significant improvement in the volume (right leg 4.45 l and left leg 5.57 l).DISCUSSION: In this case report intensive treatment was used to reduce the volume of leg edema priorto a surgery to replace a hip prosthesis in a patient with grade II leg lymphedema. Small positive andnegative changes, which are common in the evolution of this type of case but the end result was a totalreduction of the edema.
POSTURAL HYPOTENSION ASSOCIATED WITH NONELASTIC PANTYHOSE DURING LYMPHEDEMA TREATMENT
The case of a 72-year-old female patient with elephantiasis is reported. The patient was submitted to two surgeries to remove the edema. After surgery, the leg again evolved to elephantiasis and eventually she was referred to the Clinica Godoy for clinical treatment. Intensive treatment was carried out (6 to 8 hours per day) and the patient lostmore than 70% of the limb volume within one week. After this loss, the volume was maintained using grosgrain compression pantyhose for 24 hours per day. During the return appointment, the patient suffered from systemic hypotension (a drop of more than 30mmHg within three minutes) while she was standing after removing the stocking. A further investigation showed that the symptoms only appeared when the stocking was worn for 24 hours. Thus, the patient was advised to use the stocking only during the day thereby avoiding the symptoms of hypotension.
PHANTOM BREAST SYNDROME IN WOMEN AFTER MASTECTOMY
The phenomenon of phantom pain was first associated to amputation of injured limbs during the war (1). Individuals who had lost a limb consistently reported a feeling that it still existed, associated in some cases, to severe pain. This type of feeling appears to be common after mastectomies and is often accompanied by other psychological symptoms; even so these syndromes are often underdiagnosed (2). The phantom symptoms can present as a persistent feeling of heaviness, itching or tingling called phantom breast sensation, or just pain, known as phantom breast pain; both can occur in all or part of the phantom breast (3). The pathophysiology of phantom breast pain is not fully understood and it is less studied than phantom limb pain (4). Some studies report a frequency of phantom breast pain ranging from 7 to 17.4% (5,6). On the other hand it is essential to differentiate between phantom pain and chronic pain which is quite commonly felt by women after mastectomies, especially with conservative surgery. Moreover, mastectomy for many women is a stigma of mutilation that is associated with psychological symptoms and severe phantom breast pain is referred to as a symptom of these changes. The aim of this study was to evaluate the presence of phantom breast syndrome and report symptoms such as pain and its intensity, manner of coping, the search for physical and psychological treatment, as well as socio-demo-graphic aspects of mastectomized women.
PENILE AND SEXUAL REHABILITATION IN A PATIENT WITH LYMPHEDEMA OF THE PENIS
The aim of this study is to report on penile rehabilitation in lymphedema of the penis with a new compression mechanism and the implantation of a penile prosthesis for sexual rehabilitation. The case of a 72-year-old patient with a history of edema of the penis for 6 years is reported. The patient reported that he had had periods of edema and redness and that the swelling had worsened over time. A clinical diagnosis of lymphedema of unknown etiology was made; the hypotheses were that the etiology was late congenital lymphedema of the penis or lymphedema aggravated by inflammation and/or infection. A new compression mechanism made using a cotton-polyester fabric (low elasticity and ribbed) was employed. The continued use of compression therapy led to almost complete reduction of the edema and the patient tried to return to be sexually active. A specific
medication was used for erectile dysfunction; however, it resulted in no improvement and so a penile prosthesis was implanted. The development of lymphedema in advanced disease is distressing for patients and their carers and can prove difficult to manage for health care professionals involved in their care  . Penile and scrotal lymphedema produces a monstrous deformity with psychological impact and occasionally extreme mental anguish. Erection and sexual intercourse are very difficult or impossible, and the
scrotal enlargement interferes with walking  . Surgical treatment is an option in the treatment of lymphedema  . The use of compression garments is a well-established
practice in treating lymphedema of the penis  . The aim of this paper is to report on penile rehabilitation in lymphedema of the penis with a new compression mechanism and the implantation of a penile prosthesis for sexual rehabilitation.The case of a 72-year-old patient with a history of edema of the penis for 6 years is reported ( fig. 1 ). The patient
reported that he had had periods of edema and redness and that the swelling had worsened over time. A clinical diagnosis of lymphedema of unknown etiology aggravated by inflammation and/or infection was made. Infectious causes were ruled out and treatment of acute lymphedema was proposed at the moment of treatment.
PAIN IN BREAST CANCER TREATMENT: AGGRAVATING FACTORS AND COPING MECHANISMS
The objective of this study was to evaluate pain in women with breast cancer-related lymphedema and the characteristics of aggravating factors and coping mechanisms. The study was conducted in the Clinica Godoy, São Jose do Rio Preto, with a group of 46 women who had undergone surgery for the treatment of breast cancer.The following variables were evaluated: type and length of surgery; number of radiotherapy and chemotherapy sessions; continued feeling of the removed breast (phantomlimb), infection, intensity of pain, and factors that improve and worsen the pain.Thepercentage of events was used for statistical analysis. About half the participants (52.1%) performed modified radical surgery, with 91.3% removing only one breast; 82.6% of the participants did not perform breast reconstruction surgery. Insignificant pain was reported by 32.60% of the women and 67.3% said they suffered pain; it wasmild in 28.8% of the cases (scale 1–5),moderate in 34.8% (scale 6–9), and severe in 4.3%. The main mechanisms used to cope with pain were painkillers in 41.30% of participants, rest in 21.73%, religious ceremonies in 17.39%, and chatting with friends in 8.69%. In conclusion, many mastectomized patients with lymphedema complain of pain, but pain is often underrecognized and undertreated.
MECHANISMS USED TO FACE DIFFICULTIES ENCOUNTERED FOLLOWING SURGICAL TREATMENT FOR BREAST CANCER
Qualitative studies report factors that may affect the quality of life (QoL) of patients after breast cancer treatment. These range from lack of information provided by healthcare professions, in relation to complications, which include lymphedema and inflammatory processes, to emotional problems including shock, fear, revulsion, frustration, a negative body image, anxiety and depression.1,2. Another aspect that is stressed are the social sequelae that include changes in role, lack of social support, pain and aptitude. Pain is an important aspect for psychological and social morbidity resulting in a reduction of the QoL. It has been suggested that researchers should use psychological and social measures, together with the physiological parameters, to evaluate these patients.3 It is important to stress the necessity to evaluate functional losses among breast cancer survivors and to look for an appropriate form of rehabilitation.4,5 Thus, rehabilitation programs for patients after breast cancer treatment show that this approach can improve the QoL by reducing their suffering.2,4 However, mechanisms used by patients to face the difficulties are generally not considered. The objective of the current study was to investigate mechanisms used by patients after breast cancer treatment to overcome difficulties that they encounter.
LYMPHEDEMA POST-BREAST CANCER SURGERY: A POPULATIONAL STUDY
Aim: The aim of this study was to evaluate lymphedema post-breast cancer surgery in a small town in Brazil.
Design: Study census-type populational of the town of Palmares Paulista, Brazil in the period from September 2008 to May 2009. Method: The prevalence of lymphedema post breast cancer surgery was evaluated in 1583 women. Home visits were made on Saturdays and Sundays by a physician, physiotherapists and an occupational therapist. In a single visit, female residents were questioned about surgical treatment of breast cancer, time of surgery, outbreaks of erysipelas and the presence of edema after the surgery. A diagnosis of edema was reached from the patients’ personal feeling that the arm became swollen after treatment. Results: Of the 1583 women who participated in the study, 32 had been submitted to the surgical treatment of breast cancer with axillary dissection, with 12 (37.5%) reporting subsequent edema of the arm. Only one episode of erysipelas or cellulitis was reported. The time from surgery varied between 2 and 12 years with a mean of 7 years. Conclusion: Patients submitted to breast cancer surgery suffer a high rate of lymphedema but a low incidence of arm infections.