Prevention of Recurrent Erysipelas of Lymphovenous Drainage

The dissertation is devoted to the problem of prevention of recurrent erysipelas in patients with extremity lymphedema using the lymphovenous drainage method. The study examined the relationship between the frequency of erysipelas recurrences and the rate of lymphedema progression, developed a diagnostic and treatment algorithm, and justified the necessity of a differentiated approach to choosing surgical tactics. The influence of lymph drainage operations on the dynamics of erysipelas recurrence in the remote period was investigated. A comprehensive treatment methodology combining surgical and conservative methods was proposed, aimed at breaking the vicious cycle between lymphedema and recurrent erysipelas.

Erysipelas caused by streptococcal infection is widely prevalent and has no regional features, and morbidity in Russia and abroad does not differ substantially [143]. A close association of erysipelas, localized most often on the extremities, with lymphoedematous edema of the latter has been noted [14]. The contingent of patients suffering from extremity LE is quite diverse and includes both patients with primary, or congenital, LE caused by hypoplasia or primary lymphangiectasia, and secondary, or acquired, LE developing as a result of chronic secondary LA, LA in postthrombophlebitic syndrome, LA in infectious diseases, or obstruction of lymphatic collectors, which may be caused by metastasizing tumors, damage to lymphatic vessels as a result of surgical intervention, trauma, irradiation, or lymphoedema [2), 90].

RW develops under favorable conditions arising as a result of lymphatic edema of the extremities: the presence of depression of local immunity and nutritional environment in the pili-epithelial tissue [60]. RW, having begun, tends to reinvasion; repeatedly occurring lymphangitis-lymphostasis leads to an increase in the degree of obliteration of the lymphatic vascular bed, exacerbation of LE [75], and formation of a vicious circle leading ultimately to the terminal stage of LE, formation of stable limb deformity, and disability of patients (82).

According to the literature, there is currently no single clearly defined scheme for treating patients with extremity lymphedema and recurrent erysipelas. Both domestic and foreign methods of noninvasive prevention of these conditions have been proposed, aimed at suppressing the pathological process but not at eliminating the vicious circle characteristic of LE and RRW. The noninvasiveness of prevention [3] allows elimination of the mechanical cause [10] — obstruction of lymphatic vessels — and preserves conditions for the development of RRW and further transition of LE to stage IV, when traumatic resective methods remain the treatment of choice, which far from always yield satisfactory results and have a high rate of postoperative complications. The question of RRW prevention by lymphovenous drainage as a stage of comprehensive treatment of patients with extremity LE and RRW has been practically unexplored in the literature [1].

Given the absence of a trend toward reducing the number of patients with RRW and extremity LE, the variability of the pathology underlying these diseases, which at late stages leads to disability of patients of working age, changes in their psychological status, and requires high-traumatic resective operations, the proposal of minimally invasive surgical methods aimed at prevention and breaking the connection between RRW and extremity LE is considered extremely relevant, which became the basis for performing this work.

Goals and objectives of the research

To localize the advantages of applying lymph drainage operations in comprehensive treatment of patients with extremity lymphedema and recurrent erysipelas compared to traditional conservative therapy.

Research tasks

1. To study the relationship between the frequency of erysipelas recurrences and the rate of lymphedema progression.

2. To develop a diagnostic and treatment algorithm for patients with extremity lymphedema and recurrent erysipelas.

3. To study the influence of lymph drainage operations on the frequency of erysipelas recurrences in the remote period.

4. To conduct a comparative evaluation of lymph drainage operations in patients with extremity lymphedema for the purpose of preventing recurrent erysipelas compared to traditional treatment methods.

Place and time of the work

The dependence of the frequency and timing of erysipelas recurrence on the diagnostic and treatment tactic and their influence on the treatment outcomes of patients with extremity lymphedema has been specifically demonstrated.

The necessity of a differentiated approach to choosing the treatment tactic for patients with extremity lymphedema based on the dynamics of recurrent erysipelas has been justified.

The influence of lymph drainage operations on the dynamics of erysipelas recurrence in patients with extremity lymphedema has been determined.

A methodology for treating patients with extremity lymphedema with RRW using lymphovenous drainage (LVD) has been developed, which made it possible to reduce the frequency of recurrences and completely eliminate RRW in patients with extremity lymphedema and ensured the performance of surgical interventions as a stage of comprehensive treatment of this patient contingent.

The necessity of performing lymphovenous operations as part of the prevention of recurrent erysipelas in patients with extremity lymphedema has been justified.

It has been established that optimization of the treatment tactic for prevention purposes in patients with extremity lymphedema and recurrent erysipelas allows achieving stabilization and regression of lymphatic edema and reducing the frequency of erysipelas recurrence.

Practical significance of the work

The application of lymph drainage operations using microsurgical technique makes it possible to reduce the number of erysipelas recurrences, combines the use of cutting-edge and proven methods of treatment and prevention of extremity LE and recurrent erysipelas within the structure of a comprehensive approach to therapy for patients of this category.

Improvement of the treatment algorithm for extremity LE in combination with prevention of recurrent erysipelas contributes to stabilization and regression of lymphatic edema, reduces the number of erysipelas recurrences, and lowers the risk of progression of lymphedema to irreversible stages.

The use of the developed treatment methodology for LE in prevention of erysipelas recurrences makes it possible to break the vicious circle arising from the assimilation of these two diseases, ensures timely physiological lymphatic drainage, creates the possibility of simultaneous application of operative and conservative methods in treating extremity lymphedema and preventing erysipelas recurrences, reduced the speed of progression of lymphatic edema, and decreased the probability of transition of lymphedema to terminal stages requiring extensive traumatic resective operations.

Presentation of the work

The dissertation materials were reported at a meeting of hospital surgery section No. 1 of the Moscow Medical Academy named after I.M. Sechenov (2005), at a meeting of the Department of Surgery of the University Hospital Center Hopital de Hautepierre, Strasbourg (2005), at the Eth Congress of Lymphologists of Russia, Moscow (2003), at a joint meeting of the microsurgery section of City Hospital No. 56, Moscow (2003).

Practice implementation

The main provisions of the work have been implemented in the practice of the microsurgery department of City Hospital No. 56 in Moscow.

Scientific publications

Five printed works have been published by the author on the dissertation topic.

Overall structure of the dissertation

The dissertation is typed in Times New Roman (Microsoft Word) and consists of an introduction, a review of literature, a description of the author's own clinical material and research methods, four chapters, conclusions, practical recommendations, and a bibliography. The dissertation is illustrated with 17 tables, 21 diagrams, and figures. The bibliography contains 52 domestic and 74 foreign works.