Introduction
Lymphoedema is a chronic disease which requires a lymphological rehabilitative team which, after the evaluation of the functioning of the person, decides the overall care of the patient with the opening of the rehabilitative project, containing the personalized rehabilitative plan as well as the therapeutic education, not before having verified the patient's and any caregiver's awareness of own illness.
Aims of study
Considering that lymphoedema is a chronic disease, the rehabilitative program is designed to achieve not only short-medium term results, due to therapeutic strategy, but above all the long term one through the therapeutic education which includes making the patient and any caregiver aware of disease and the therapeutic path.
Methods
The first step to achieving awareness of the disease and the therapeutic path, is always to achieve the patient and any caregiver’s adherence through optimal communication from the team that has to respect their characteristics and the personal latency time; this ability cannot ignore the rehabilitation team of skills such as the use of simple language, the empathy and to the ability to listen-understand the patient's discomfort. The second step is to make sure the patient has understood self-management strategies, sometimes with the help of the caregiver, through the information about the hygienic-behavioural rules, teaching of the combined self-management (simplified manual drainage-bandage-gymnastics) and the compression garment management.
Results
The team, whose goal has always been the improvement of patients’quality of life, by seeking a psycho-physical balance, has to be able to verify the awareness and acceptance of the chronicity of their disease in patients to whom self-care was taught. Furthermore, these patients forwarded fewer requests for repetitive and useless treatment over a short period of time and in the meantime the results obtained with intensive treatment remained more stable until the following check-up.
Conclusions
Lymphological rehabilitative team’s challenge is to get patient's adherence to the therapeutic educational strategy designed in order to induce increased patient awareness of their limits and possibilities for an optimal self-management, in order to control of their chronic disease and to avoid or at least limit the clinical worsening. Furthermore, through therapeutic education, patients also need to be less dependent on the rehabilitation team, which remains however their point of reference and intervenes in the intensive treatment when necessary. Although teaching and learning things that one cannot fully accept in oneself is always a difficult task, it is not impossible.
Keywords: lipoedema, lipohypertrophy, non-lipoedema obesity, three-dimensional (3D) ultrasound diagnostics
Objective
The diagnosis of lipoedema is based on clinical examination, however, the three-dimensional (3D) ultrasound is very useful, in all clinical stages, in the evaluation of structural assessment of adipo-fascia, having a view on three planes of space with possible processing of the image with suitable software. Moreover, 3D ultrasound is also useful in the evaluation of features of adipo-fascia in lipohypertrophy and non-lipoedema obesity (gynoid), highlighting differences with pure lipoedema.
Material and Method
In this study in progress, it was decided to apply 3D ultrasound diagnostics in the tissue evaluation using an adequate instrument (SonoScape 20-3D - probe17 MHz) through longitudinal-transversal scans on constant bilateral symmetric marker points in patients with lipoedema (38 stage 1, 44 stage 2, 30 stage 3 - all type III - non obese - aged 18-55 years), lipohypertrophy (48 non obese patients aged 18-44 years) and no-lipoedema obesity (34 patients aged 24-52 years - obesisty class I-II) who had arrived at the Pianeta Linfedema Study Center. In this study, chronic venosus disease, due to primary varicose veins or post-DVT disease and primary or secondary lymphoedema were absent in all patients. Moreover, lymphoscintigraphy exam of the lower limbs was required for the evaluation of the lymphatic system in order to explain some ultrasound features in clinical stages 2 and 3 of pure lipoedema.
Results
3D ultrasound diagnostics, regardless of the clinical stage, has highlighted a normal ultrasound representation of the epidermis-dermis complex in all stages as well as the increased thickness of the subcutaneous tissue, due to hypertrophy of the adipose lobules, not adherent to each other but separated by thickened connective septa, more marked in stage 2 and stage 3; moreover the thickness of the fibres that connect the derma to superficial fascia and an irregular profile of the junction dermo-hypodermis
TIPOLOGIA DI LAVORO:
Ricerca clinica
Ricerca di base
Studio multicentrico
Revisione sistematica/meta-analisi
Caso clinico o note di tecnica
INTRODUZIONE/SCOPO DELLO STUDIO
La diagnosi di lipedema è basata sulla valutazione clinica, ma l’esame strumentale ecografico ad alta risoluzione, non invasivo, ripetibile ed affidabile, anche se operatore dipendente, risulta utile nello studio tissutale sopra-fasciale utilizzando apparecchiature ad alta tecnologia. Una evoluzione dell’ecografia standard è l’imaging tridimensionale (3D) di alta qualità che avendo una visione su tre piani dello spazio, risulta interessante nello studio strutturale tissutale anche per la possibile elaborazione dell’immagine con adeguato software.
MATERIALE E METODI
Per lo studio tissutale, che comprende il complesso epidermide-derma e il tessuto sottocutaneo, si sono utilizzate sia l’ecografia standard (sonda lineare 10 MHz) che l’ecografia tri-dimensionale (sonda lineare 17 Mhz) al fine di valutare la differenza tra le due metodiche negli stessi punti markers di applicazione.
Introduction
The diagnosis of lipoedema, is based on clinical examination, however, the three-dimensional ultrasound is very useful in providing tissue information as well as lymphoscintigraphy exam for the evaluation of transit of the radiotracer.
Aims of study
It was decided to apply three ultrasound diagnostics in the evaluation of structural assessment of adipo-fascia, having a view on three planes of space with possible processing of image with suitable software, and to assess the requested lymphoscintigraphy exam in order to explain some ultrasound features in different clinical stages.
Methods
The tissue evaluation was performed using an adequate instrument (SonoScape 20 - probe 17 MHz) through longitudinal-transversal scans on constant bilateral symmetric marker points in non obese females with lipoedema, aged 18-55 years, (30 stage 1, 40 stage 2,
25 stage 3 - all type III). Venous or lymphatic involvement (physical examination-duplex ultrasound evaluation) was not present in any of the patients. Furthermore lymphoscintigraphy exam was required (subcutaneous injection with 99mTc-Nanocoll®).
Results
In all clinical stages, three ultrasound diagnostics highlighted a normal ultrasound representation of the epidermis-dermis complex as well as the increased thickness of the subcutaneous tissue, due to hypertrophy of the adipose lobules not adherent to each other but separated by thickened connective septa, both more marked in stage 2 and stage 3. In addition, in view of the presence of increased anechogenicity due to fluid, along the superficial fascial path, as well as the deep one too, the author carried out an experimental study, awaiting publication, that has showed that the fluid is bound to the fascia and not free. Furthermore, in the stage 2 and stage 3 the lobules, in a non-homogeneous way, show an increased anechogenicity, which according to the author, it is partly due to free fluid, but also linked to glycosaminoglycans in gel phase; also in the septa, the presence of an increased anechogenicity due to fluid was noted, reabsorbed and removed by pre-collectors, albeit slowly in consideration of the slow lymphatic flow highlighted by lymphoscintigraphy exam.
Conclusions
High-quality three ultrasound diagnostics resulted in being considerably useful in the evaluation of lipoedema tissue, because it provides important structural details of adipo-fascia, while lymphoscintigraphy exam could explain some ultrasound features in the stage 2 and stage 3.
TIPOLOGIA DI LAVORO:
Ricerca clinica
Ricerca di base
Studio multicentrico
Revisione sistematica/meta-analisi
Caso clinico o note di tecnica
INTRODUZIONE/SCOPO DELLO STUDIO
Il follow-up post-chirurgico sia per il linfedema che per il lipedema, è sempre necessario al fine di analizzare il risultato raggiunto e valutare il management personalizzato più adeguato.
MATERIALE E METODI
Il follow-up post-chirurgia linfologica, attraverso la valutazione clinica e l’esame ecografico ad alta risoluzione, verificando il risultato della chirurgia, guida nella scelta del percorso terapeutico personalizzato più adeguato che può includere una eventuale nuova strategia terapeutica di tipo conservativo, così come l’apprendimento, se non precedentemente effettuato, del self-management attraverso l’educazione terapeutica e la prescrizione-collaudo dell’indumento elastico, rivalutato rispetto al precedente indossato, sia per le misure che per la classe di compressione.
Per quanto riguarda il lipedema, nell’immediato post-chirurgico si rendono necessari il drenaggio dei tessuti connettivali e l’utilizzo della guaina compressiva prescritta dal chirurgo; successivamente per un periodo di tempo variabile che dipende dalla valutazione clinico-ecografica, si prosegue con il linfodrenaggio manuale e il bendaggio compressivo, per poi passare all’indumento elastico rivalutato, anche in questo caso, sia per le misure che per la classe di compressione, rispetto al precedente se indossato.