Syndromic Lymphedema: Keys to the Kingdom of Lymphatic Structure and Function?

Congenital Lymphedema of the Foreskin in a 3-Year-Old Boy: A Case Report and Literature Review

Congenital lymphedema of the external genitalia is a rare, disfiguring disorder. We describe here a case of a 3-year-old male with primary foreskin lymphedema persisting since birth. A compact, heterogenous swelling of the foreskin's distal third was observed, inhibiting preputial retraction (phimosis). Right lower extremity lymphedema was also observed in this case, while no further abnormalities were found. Surgery was performed, maintaining the foreskin, producing an excellent result with no recurrence at 10-month follow up.

Lymph Drainage from the Chylocyst-Induced Hemodilution in an In Vivo Rabbit Study

To confirm our previous study that abdominal respiration has induced hemodilution in human subjects, we performed in-vivo experiments involving anesthetized rabbits. Fifteen 6- to 7-month-old male Japanese white rabbits were used in the animal experiments. Anesthesia was maintained with 2.5%-3.0% isoflurane under N₂O + 100% O₂ inhalation. Ventilation was maintained at 40 mL/breath for 20 breaths/min. Physiological saline solution was administered at rated 18 mL/h during the experiments. First, we attempted to evaluate lymph flow through the thoracic duct using Sonazoid-based contrast-enhanced ultrasound (CEUS)-guided method and then investigated the effects of manual lymph drainage of the chylocyst on the numbers of red blood cells (RBC), hematocrit (Ht) levels, and the blood concentrations of total protein (TP) and hemoglobin (Hb). In this study, we established surgical methods for identifying the left venous angle and chylocyst using Evans blue dye in anesthetized rabbits. We also confirmed that a Sonazoid-based CEUS-guided method was the most useful technique for producing real-time images of lymph flow through the thoracic duct in anesthetized rabbits. In addition, in present experiments involving anesthetized rabbits, we confirmed that manually massaging the chylocyst produced significant hemodilution. Thus, the procedure produced significant reductions of TP, RBC, Hb, and Ht level in the rabbits.

Abdominal Respiration Induces Hemodilution and Related Reduction in ADH Concentration of Blood

To establish effective lymph drainage methods and develop concise and accurate clinical techniques for evaluating lymph drainage in healthy individuals and patients with cancer treatment-related lymph edema, we investigated the numbers of red (RBC) and white (WBC) blood cells, and platelets (PLT) in blood, hematocrit (Ht), and the blood concentrations of total protein (TP), albumin (Alb), and anti-diuretic hormone (ADH) before and after 5 min manual lymph drainage, followed by 30 min rest with or without abdominal respiration in the supine or sitting position in 48 healthy volunteers. The 5 min facial, upper and lower extremities lymph drainage, followed by 30 min rest in the supine position induced significant reductions of the TP and Alb in all subjects, and their RBC and Ht levels in some subjects. The 30 min rest only in the supine position without lymph drainage produced also significant reductions of blood TP and Alb. In addition, abdominal respiration in the supine position without manual lymph drainage caused more significant hemodilution, being significant reductions of TP, Alb, RBC, Ht, and ADH in all volunteers. These findings may be related to effective lymph drainage from the chylocyst. Furthermore, it also resulted in a significantly increased micturition desire. In conclusion, abdominal respiration during 30 min rest in the supine position is effective at inducing lymph drainage, and the associated induction of hemodilution and lowering of the blood ADH concentration (and increased micturition desire in some cases) can be used to accurately assess the extent of lymph drainage.

Lymphedema

Aggressively applied decongestive measures (ie, manual lymphatic drainage, low-stretch bandaging, exercise, skin care, application of compressive elastic garments) are the mainstay of lymphatic therapy. Therapeutic regimens should differentiate between the sequential goals of acute volume reduction and maintenance of limb volume. Elastic garments should not be employed until maximal volume reduction has been attained through decongestive lymphatic techniques. It is my opinion that use of intermittent pneumatic compression devices can play an important adjunctive role to decongestive lymphatic therapy but should not be substituted for these techniques. At this time, I am not inclined to use pharmacologic therapy in these patients but anxiously await the results of studies that might demonstrate efficacy for molecular approaches. Surgical intervention is reserved for a small number of well-selected patients. Liposuction for volume reduction appears to be a very promising approach for specific patients.