Ce diaporama a bien été signalé.
Nous utilisons votre profil LinkedIn et vos données d’activité pour vous proposer des publicités personnalisées et pertinentes. Vous pouvez changer vos préférences de publicités à tout moment.

Soirée dr vignes lymphoedeme 23mai2013

2 165 vues

Publié le

Publié dans : Voyages, Business
  • Free Video Reveals 1 Weird Trick To Cure Vitiligo In 45 Days! Click Here: ✄✄✄ https://bit.ly/3kTNHDZ
       Répondre 
    Voulez-vous vraiment ?  Oui  Non
    Votre message apparaîtra ici
  • I pasted a website that might be helpful to you: ⇒ www.HelpWriting.net ⇐ Good luck!
       Répondre 
    Voulez-vous vraiment ?  Oui  Non
    Votre message apparaîtra ici
  • 5 Steps To Cure Your Vitiligo. Drug And Pharmaceutical Companies Hate This! Click Here To See How ✱✱✱ http://tinyurl.com/y4p92al9
       Répondre 
    Voulez-vous vraiment ?  Oui  Non
    Votre message apparaîtra ici
  • Soyez le premier à aimer ceci

Soirée dr vignes lymphoedeme 23mai2013

  1. 1. LymphœdèmesS. Vignes, Unité de Lymphologie,Hôpital Cognacq Jay, Paris
  2. 2. Que faire devant l’apparitiond’un lymphœdème du MS ?•  Délai d’apparition variable :post-op. è 20-30 ans après…•  FDR : curage axillaire, RT,obésité, réduction activitéphysique, mastectomie•  S’assurer du suivi oncologiquesurtout si douleurs, déficitsensitif/moteur•  Echo-Doppler veineux éventuel
  3. 3. Lymphœdèmes primaires•  Membre inférieur +++•  Formes sporadiques (1/6000)–  sex ratio : 8 F / 2 H–  âge < 25 ans (après 35 ans : rare)•  Atteinte–  unilatérale : tout le membre–  bilatérale distale : sous gonale•  Maladie de Milroy : formesfamiliales congénitale, mutationVEGFR-3Kinmonth JB et al. Br J Surg 1957;45:1
  4. 4. LO secondaires des MI•  Atteinte aires ganglionnaires inguinales–  biopsie, exérèse–  maladies malignes : mélanomeMI, cancer marge anale, verge,vulve,…–  lymphomes non hodgkiniens oude Hodgkin: biopsie ou radioT•  Atteintes aires ganglionnairespelviennes–  cancer utérin (col, corps),ovaires–  cancer de la prostate, vessie, rectum
  5. 5. Lymphœdème : signes cliniques•  Diagnostic clinique•  Œdème élastique du dos du pied•  Accentuation des plis de flexions•  Signe de Stemmer•  Orteils "carrés", papillomatosedes orteils•  Tendance des ongles à êtreverticalisés
  6. 6. Szuba A & Rockson S. Vasc Med 1997;2:321Physiopathologie du lymphœdème
  7. 7. Explorations
  8. 8. Eliminer les autres diagnostics•  Rénaux : protéinurie•  Cardiaques : échographie•  Compressions abdominales oupelviennes (sujet > 40 ans)–  échographie–  voire scanner•  Echo-doppler veineux MI•  Aucun examen n’estindispensable
  9. 9. Lymphoscintigraphie MI•  Examen–  simple–  peu invasif–  reproductible•  Possible chez lenfant•  Colloïdes résorbés par le systèmelymphatique (sulfocolloïde de rhénium oudalbumine)•  Etude morphologique
  10. 10. Erysipèle•  Et non lymphangite•  Principale complication :risque × 71 / membre sain•  Clinique–  signes généraux ++++(fièvre brutale, frissons,parfois vomissements,…)–  PUIS signes locaux
  11. 11. Erysipèle•  Traitement : 10-14 j–  amoxicilline, 3 g/j en 3 prises ou–  pristinamycine, 3 g/j en 3 prises(Pyostacine®)•  Interdits : AINS, corticoïdes +++•  Non indiqués : anticoagulants•  Reprise le plus tôt possible de la compressionBecq-Giraudon B. Ann Dermatol Venereol 2001;128:368
  12. 12. Erysipèle•  Traitements porte entrée si retrouvée–  intertrigo interdigital : Mycoster®, et Ttchaussures (poudre)–  fissures talon (pédicurie, hydratation)•  Récidives fréquentes (2-3/an)–  antibioprophylaxie : Extencilline®, 2,4MUI/2 (3) semaines IM, avec 1 ml deXylocaïne®, 1 ml à 1% voire Oracilline® (2/jen deux prises)–  si « allergie » : tests cutanés etréintroduction +++–  tolérance dépendante de l’IDE–  durée prolongée : 18-24 mois voire plus–  effet suspensif ++++
  13. 13. Diagnostic différentiel :lipœdème
  14. 14. Lipœdème•  Terme anglo-saxon "lipedema",décrit en 1940 chez 5 femmes obèses,débutant à partir de la puberté (<1% :homme)•  Définition : accumulation de tissusadipeux du bassin jusquaux chevilles•  Touchant presque exclusivementfemmes obèses : entité plutôt quemaladieAllen EV et al. Proc Staff Mayo Clin 1940;15:1984Harwood CA et al. Br J Dermatol 1996;134:1
  15. 15. Lipœdème•  Terme peu approprié car pasdœdème vrai sauf aprèsorthostatisme•  Autres dénominations utiliséesdans la littérature :"lipodystrophy", "painful fatsyndrome"•  Confusion fréquente avec lelymphœdème des MI
  16. 16. Lipœdème : signes cliniques•  Critères diagnostiques lipœdème•  Début à la puberté, avant 20 ans•  Atteinte familiale fréquente (≈50%), (mère, grand-mère, sœur)•  Atteinte MI–  bilatérale parfois asymétrique :cuisse–  épargnant le pied (mais atteinteaprès une longue évolution ?)Wold LE. Ann Intern Med 1949;34:1243
  17. 17. Lipœdème : signes cliniques•  Gêne à la marche si volumeimportant•  Peau–  souple–  pincement douloureux("cellulalgies")–  douleurs superficielles : ↑avec âge–  ecchymoses faciles (bleus)
  18. 18. Lipœdème : signes cliniques•  Œdème–  absent au repos–  apparaissant après longue périodeorthostatisme, prenant le godet :modérés, ↑ lourdeurs•  Signes associés dinsuffisance veineusefavorisés•  Evolution vers un lipo-lymphœdèmeavec atteinte du pied, érysipèle,…
  19. 19. Traitement du lipœdème•  Mais entité > maladie•  Difficile, non codifié•  Demande importante : caractèreinesthétique MI, insistance femmesjeunes•  Perte de poids : peu deffet sur lamorphologie MI, à la ≠ reste corps,reste essentielle pour évitercomplications locales de lobésité(gonarthrose, insuf. veineuse)
  20. 20. Traitement du lipœdème•  Objectif : compression des MI•  Traitement lymphœdème : inefficace•  Compression élastique–  morphologie : difficulté enfilage,utilisation difficile, ↓ souplesse–  tolérance ± bonne (plis cheville, pied)–  principal intérêt : œdème aprèsorthostatisme•  Hydratation de la peau•  Natation, aquagym ++++•  Liposuccion possible
  21. 21. Traitements des varices etlymphœdèmes
  22. 22. Positionnement du problèmeIntrication de trois questions1.  Stripping interdit en cas delymphœdème ?2.  Déclenchement d’unlymphœdème après stripping3.  Distinction du stripping desautres traitements de l’IVC
  23. 23. Insuffisance veineuse et lymphœdème•  Association très rare•  Ne pas confondre avec l’IVC,stade C3-C6 (œdème), avec lelipœdème•  Lymphœdème secondaires–  après traitement descancers–  femmes > 50 ans
  24. 24. Insuffisance veineuse et lymphœdème•  Lymphœdème primaire–  femmes jeunes–  atteinte distale bilatérale,ou unilatérale complète•  Excepté en présence d’unemutation du gène FOXC2
  25. 25. Traitement des lymphœdèmes MICompression élastique•  Pression élevée : classe 3(20-36 mmHg), 4 (>36 mmHg)•  Superposition de compressiontrès fréquente : 3+3, 3+4,4+4…è Quelle place reste-t-il autraitement de l’IVC ?
  26. 26. Traitement de l’IVC•  Risque : aggraver le lymphœdème•  Thérapeutiques et nonesthétiques•  Indications rares car compressionfortes•  Une méthode est-elle préférable àune autre: stripping, traitementendoveineux, scléroses ?
  27. 27. •  261 patients de 1989 à 1997–  lymphœdème : 68–  lipo-lymphœdème : 103–  lipœdème : 90•  Stripping, ligatures saphènes, phlébectomies•  Lymphœdème (appréciation subjective)–  aggravation : 71%–  stabilité : 28%–  amélioration : 1%
  28. 28. Risque de lymphœdème après stripping•  4,5% des lymphœdèmes: aprèsstripping ou phlébectomies (BrunnerU. Phlebol u Protokol 1975;4:266)•  63% : anomalies lymphatiquesscintigraphiques après stripping(Timi JR et al. Revista Panamerica de Flebologia y Linfologia1988;31:17)•  Risque de complications non pré-existantes: érysipèles (Fischer R & Frü G.Phlebol 1991;20;9)
  29. 29. Lymphatic complications after varicose veins surgery:risk factors and how to avoid themP Pittaluga*† and S Chastanet*†*Riviera Vein Institut, Nice, France; †Riviera Vein Institut, Monte Carlo, MonacoAbstractIntroduction: Lymphatic complication (LC) after varicose veins (VVs) surgery is an annoyingevent with a variable frequency in the literature.Method: Retrospective study reviewing all surgeries carried out for VVs from January 2000 toOctober 2010. Postoperative LC we reported: lymphatic fistula, lymphocele including theminor ones and lymphoedema.Results: During the period studied, 5407 surgical procedures for VVs were performed in 3407patients (74.7% women) with a mean age of 53.4 years. A postoperative LC occurred in 118cases (2.2%): lymphocele on limb in 1.3%, inguinal LC (fistula or lymphocele) in 0.7% and alymphoedema in 0.2%. The population with a LC was older (59.6 vs. 53.3 years, P , 0.05),had a higher frequency of C4–C6 (22.0% vs. 6.5%, P , 0.05), a higher incidence of obesity(31.4% vs. 5.4%, P , 0.05) and was more often treated by a redo surgery or a crossectomystripping (48.3% vs. 13.4% and 38.1% vs. 21.8%, respectively, P , 0.05). We have observeda dramatic decrease in incidence of LC after January 2004 (1.3% vs. 5.3%, P , 0.05)corresponding to a new surgical practice for the treatment of VVs: stripping, crossectomyand redo surgery at the groin were less frequent (74.6% vs. 7.7%, 74.6% vs. 0.2% and11.3% vs. 0.1%, respectively, P , 0.05), while isolated phlebectomy was more oftenperformed during this period (78.4% vs. 8.4%, P , 0.05).Conclusion: LC after VVs surgery is not rare but frequently limited to lymphocele on limbs.Older age, more advanced clinical stage and obesity were associated with a higher frequencyof LC. A mini-invasive and selective surgery has significantly reduced the occurrence of LC.Keywords: varicose vein; varicose vein surgery; lymphatic complication; lymphocele;lymphodema; lymphatic fistula; risk factorsperative data (demographics, signs, symptoms,body mass index [BMI]), the preoperative venoushaemodynamics (presence and location of venousomanuary 2012DOI: 10.1258/phleb.2012.012S12. Phlebology 2012;27 Suppl 1:139–142To evaluate the possible preoperative risk factorsfor the appearance of LC after surgery we com-pared the data of the patients with LC (118 cases)with those without LC complications (5289 cases)(Table 3). For the group in which an LC occurredafter the surgery the mean age was older (59.6%vs. 53.3%, P , 0.05), the frequency of C4–C6 washigher (22.0% vs. 6.5%, P , 0.05), the average BMIOwTacoAFeCPrABMBMTable 1 Lymphatic complications after varicose veins surgeryLymphatic complications %Total 118 2.2Lymphocele on lower limbs 68 1.3Inguinal lymphocele or fistula 37 0.7Lymphoedema 13 0.21.  Etude rétrospective de janvier 2000 à octobre20102.  5407 patients
  30. 30. At last, a preoperative skin marking guided byultrasounds was performed in 82.4% after January2004 and only in 20.9% before.DiscussionOur study showed that an LC after surgery for VVswas not rare, occurring in 2.2% after the surgicalTable 3 Comparison of population with and without a lymphaticcomplication after varicose veins surgeryLymphaticcomplicationNo lymph.complicationP118 5289Age (averageyears)59.6 53.3 ,0.0001Female 75.4% 74.9% NSC4–C6 22.0% 6.5% ,0.05Preopsymptomatic70.3% 70.1% NSAverage BMI 28.7 23.9 ,0.05BMI . 30 31.4% 5.4% ,0.05BMI, body mass index; NS, non-significantLymphatic complications after varicose veins surgery:risk factors and how to avoid themP Pittaluga*† and S Chastanet*†*Riviera Vein Institut, Nice, France; †Riviera Vein Institut, Monte Carlo, MonacoAbstractIntroduction: Lymphatic complication (LC) after varicose veins (VVs) surgery is an annoyingevent with a variable frequency in the literature.Method: Retrospective study reviewing all surgeries carried out for VVs from January 2000 toOctober 2010. Postoperative LC we reported: lymphatic fistula, lymphocele including theminor ones and lymphoedema.Results: During the period studied, 5407 surgical procedures for VVs were performed in 3407patients (74.7% women) with a mean age of 53.4 years. A postoperative LC occurred in 118cases (2.2%): lymphocele on limb in 1.3%, inguinal LC (fistula or lymphocele) in 0.7% and alymphoedema in 0.2%. The population with a LC was older (59.6 vs. 53.3 years, P , 0.05),had a higher frequency of C4–C6 (22.0% vs. 6.5%, P , 0.05), a higher incidence of obesity(31.4% vs. 5.4%, P , 0.05) and was more often treated by a redo surgery or a crossectomystripping (48.3% vs. 13.4% and 38.1% vs. 21.8%, respectively, P , 0.05). We have observeda dramatic decrease in incidence of LC after January 2004 (1.3% vs. 5.3%, P , 0.05)corresponding to a new surgical practice for the treatment of VVs: stripping, crossectomyand redo surgery at the groin were less frequent (74.6% vs. 7.7%, 74.6% vs. 0.2% and11.3% vs. 0.1%, respectively, P , 0.05), while isolated phlebectomy was more oftenperformed during this period (78.4% vs. 8.4%, P , 0.05).Conclusion: LC after VVs surgery is not rare but frequently limited to lymphocele on limbs.Older age, more advanced clinical stage and obesity were associated with a higher frequencyof LC. A mini-invasive and selective surgery has significantly reduced the occurrence of LC.Keywords: varicose vein; varicose vein surgery; lymphatic complication; lymphocele;lymphodema; lymphatic fistula; risk factorsperative data (demographics, signs, symptoms,body mass index [BMI]), the preoperative venoushaemodynamics (presence and location of venousmnuary 2012DOI: 10.1258/phleb.2012.012S12. Phlebology 2012;27 Suppl 1:139–142procedures. Nevertheless, in the wide majority ofhe cases the LC was minor, represented by aable 4 Comparison of the frequency of different types of lym-hatic complication in obese (BMI . 30) and non-obese patientsBMI,30)Obese Non-obese P RatioN 324 5083ymphocele on limb 4.0% 1.1% ,0.05 3.6nguinal complication 5.9% 0.4% ,0.05 14.7ymphoedema 1.5% 0.2% ,0.05 7.5MI, body mass indexTable 6 Comparison of postoperative lymphatic complications andprocedures carried out before and after 2004 for the treatment ofvaricose veinsBeforeJanuary2004 (%)After January2004 (%)PLymphatic complications 5.3 1.3 ,0.05Strippingþcrossectomy 74.6 0.2 ,0.05Redo surgery at the groin 11.3 0.1 ,0.05Endovascular or mini-invasive ablation0.0 7.7 ,0.05Isolated phlebectomy 8.4 92.3 ,0.05Preoperative skin marking 20.9 82.4 ,0.05Pittaluga and S Chastanet. Lymphatic complications after varicose veins surgery Original article
  31. 31. A systematic review and meta-analysis of thetreatments of varicose veinsM. Hassan Murad, MD, MPH,a,b,cFernando Coto-Yglesias, MD,a,dMagaly Zumaeta-Garcia, MD,aMohamed B. Elamin, MBBS,aMurali K. Duggirala, MD,a,cPatricia J. Erwin, MLS,aVictor M. Montori, MD, MSc,a,c,eand Peter Gloviczki, MD,fRochester, Minn; and San José, Costa RicaObjectives: Several treatment options exist for varicose veins. In this review we summarize the available evidence derivedfrom comparative studies about the relative safety and efficacy of these treatments.Methods: We searched MEDLINE, Embase, Current Contents, Cochrane Central Register of Controlled Trials(CENTRAL) expert files, and the reference section of included articles. Eligible studies compared two or more of theavailable treatments (surgery, liquid or foam sclerotherapy, laser, radiofrequency ablations, or conservative therapywith compression stockings). Two independent reviewers determined study eligibility and extracted descriptive,methodologic, and outcome data. We used random-effects meta-analysis to pool relative risks (RR) and 95%confidence intervals (CI) across studies.Results: We found 39 eligible studies (30 were randomized trials) enrolling 8285 participants. Surgery was associated witha nonsignificant reduction in the risk of varicose vein recurrence compared with liquid sclerotherapy (RR, 0.56; 95% CI,0.29-1.06) and all endoluminal interventions (RR, 0.63; 95% CI, 0.37-1.07). Studies of laser and radiofrequencyablation and foam sclerotherapy demonstrated short-term effectiveness and safety. The quality of evidence presented inthis review was limited by imprecision (small number of events), short-term follow-up, and indirectness (use of surrogateoutcomes).Conclusion: Low-quality evidence supports long-term safety and efficacy of surgery for the treatment of varicose veins.Short-term studies support the efficacy of less invasive treatments, which are associated with less periprocedural disabilityand pain. (J Vasc Surg 2011;53:49S-65S.)Approximately one-third of men and women aged 18to 64 years have varicose veins.1The high prevalence leadsto significant health care expenditure on treatments ofknowledge, no contemporary systematic synthesis is avaable to compare all available treatments.The Society for Vascular Surgery (SVS) partnered wifidence intervals (CI) across studies.ults: We found 39 eligible studies (30 were randomized trials) enrolling 8285 participants. Suonsignificant reduction in the risk of varicose vein recurrence compared with liquid sclerothe9-1.06) and all endoluminal interventions (RR, 0.63; 95% CI, 0.37-1.07). Studies of lation and foam sclerotherapy demonstrated short-term effectiveness and safety. The qualitys review was limited by imprecision (small number of events), short-term follow-up, and indircomes).nclusion: Low-quality evidence supports long-term safety and efficacy of surgery for the treort-term studies support the efficacy of less invasive treatments, which are associated with lessd pain. (J Vasc Surg 2011;53:49S-65S.)proximately one-third of men and women aged 18ears have varicose veins.1The high prevalence leadsificant health care expenditure on treatments ofe veins.2Surgical treatment of varicose veins in-high ligation and saphenous vein stripping, with ort phlebectomy; until the past few years, this proce-ad been used most commonly by surgeons world-5However, several other less invasive treatmentties that are claimed to be as effective as surgery arely available, including radiofrequency or laser abla-the great (GSV) or small saphenous veins (SSV), orknowledge, no contemporary sable to compare all available treThe Society for Vascular Suthe American Venous Forumpractice guidelines to improvevenous disease. To assist in venthe SVS and the AVF commisystematic review and meta-anaavailable evidence about thedifferent treatments of varicoseTable II. Commonly reported adverse eventsSurgery Sclerotherapy Laser ablation Radiofrequency ablation Foam therapy● Wound infection,3%-6%● Skin staining ornecrosis, 3%● Purpura/bruising,11%-23%● Saphenous nerveparesthesia, 13%● Contusion,bruising,hematoma, 61%● Sural or saphenousnerve injury, 10%-23%● Superficial phlebitis,22%-27%● Erythema, 33% ● Superficial phlebitis,0%-20%● Skin pigmentation,51%● Hematoma, 31% ● Hyperpigmentation,57%● Hematoma, 7% ● Headache, 11%● Superficial phlebitis,0%-12%● Hypopigmentation, 2% ● Thermal skin injury, 7%● Blistering/sloughing,7%● Paresthesia, Ͻ1%● Scaring, 13% ● Leg edema, Ͻ1%● Telangiectatic matting,28%● Edema, 15%● Paresthesia, 1%-2%● Superficial phlebitis, 6%JOURNAL OF VASCULAR SURGERYMay Supplement 201162S Murad et al
  32. 32. Conclusions•  Informer par écrit les patients durisque d’aggravation dulymphœdème (May R. Angio 1981;5:265)•  Facteurs favorisants : obésité,âge, C4-C6•  Indications formelles d’untraitement de l’IVC (avec la compression)•  Si doute persistant avant ungeste : lymphoscintigraphie
  33. 33. Traitement des lymphœdèmes
  34. 34. Traitements des lymphœdèmes•  Bandages peu élastiques (contention)•  Compression élastique•  Drainages lymphatiques manuels•  Exercices sous bandages•  Auto-apprentissage des bandages•  Education•  Soins cutanés locaux
  35. 35. Buts du traitement des lymphœdèmes1.  Réduction de volume : phase"intensive"–  hospitalière ou ambulatoire–  bandages peu élastiques2.  Maintien du volume réduit : phase"dentretien" en ambulatoire–  compression élastique et–  bandages (fréquence plus faible)
  36. 36. http://www.has-sante.fr/portail/jcms
  37. 37. Réduction de volume :bandages monotypes peu élastiques•  Bandes à allongement court < 100%(Partsch H, et al. Dermatol Surg 2006;32:224)•  Bandages multicouches (2-4) MAISmonotypes (≠ pathologies vasculaires)•  Intérêt : pression de repos faible maisforte en mvt (gymnastique, marche, vélo)•  Effet contensif >>> compressifHarris SR et al. Lymphology 2001;34:84Cohen SR et al. Cancer 2001;92:980Lymphoedema Framework. Best practice for the management oflymphoedema. International consensus. London: MEP Ltd, 2006
  38. 38. Drainages lymphatiques manuels•  Nombreuses techniques : Vodder,Foldi, Leduc, Ferrandez, Schiltz†, deMicas (www.afpdlm.org)•  Qu’en attendre ?–  court terme :ü  sensation d’allègement,ü  ↓ tension cutanéeü  effet relaxant–  long terme : effet ≈ 0 sur volumesi utilisés seulsBadger C et al. Cochrane Database Syst Rev 2004MacNeely M et al. Breast Cancer Res Treat 2004Vignes S et al. Breast Cancer Breast Treat 2007
  39. 39. Drainages lymphatiques manuels•  Drainages lymphatiques manuels– petite synergie avec lesbandages peu élastiques– utiles dans les LO proximaux(sein, thorax)– utile phase intensive, facultatifphase dentretienBadger C et al. Cochrane Database Syst Rev 2004;3:CD003141Harris SR et al. Lymphology 2001;34:84Lymphoedema Framework. Best practice for the management oflymphoedema. International consensus. London: MEP Ltd, 2006
  40. 40. Compression élastique
  41. 41. Compression etlymphœdèmesClasses élevées: 3, 4Bas cuisse > chaussettesPieds fermésSur-mesureSuperposition MI

×