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The Non-Operative Teatment of Filarial Lymphedema
Hendro Sudjono Yuwono
Departement of Surgery, School of Medicine, Padjadjaran University, Bandung Indonesia
Abstract
Introduction: Filarial lymphedema sufferers are still often found in Indonesia. In Division of Vascular Surgery of Hasan Sadikin General Hospital, Diethylcarbamazine citrate (DEC) is not administrated to the patients. How the results of non-surgical treatment in filarial lymphedema ?
Methods: All patients should be in vegetarian diet at all of their life.
MPFF 1 tablet two time daily, Warfarin sodium 1 tablet 3 time daily, Hydroxyethyl-rutoside 1 capsule 3 time daily; and should wear elastic bandage of 4 inches wide. All patients are treated without DEC.
Results: All were 35 patients with FL, 20 females and 15 males. Averageimprovement of measuringchanges in diameter in lower extremity is significant (after 12 months p=0.000004, and after 24 months p=0.000135). in scrotal lymphedema and upper extremity the non-operative treatment also resulted a significant changes.
Conclusion: Non-operative treatment is an acceptable treatment of choice for the lymphedematous patients to to decrease their lymphrdema and to bring a better quality of their life.
Key words: Filarial lymphedema; benzopyrones; vegetarian; medium chain triglyceride.
Introduction
In Indonesia patients suffering from filarial lymphedema (FL) is not uncommon, although the numbe is quite a lot. Indonesia’s Health Ministry reported estimates of as 6233peoples with filarial lymphedema scattered in 26 provinces. FL is a mosquito-borne disease of the trofical and subtrofical lands that caused by filarial worms which blocage the lymphatic vessels in human body. The worms that cause FL in Indonesia mostly Wuchereria bancrofti, Brugia malayi, Brugia timori. Edema by filarial infection is a difficult medical problem that is not completely working on applying any surgery.
This clinical study conducted at one hospital which will reperted the results of conservative treatment.
Methods
Patients with FL have been collected in Hasan Sadikin General Hospital. The peripheral blood smear and rapid test of these patients have been undertaken to investigate microfilarial worms.
Diameter of edematous lmb was taken to meaure the edema as well as the contralateral limb. Oral benzopyrone-tablets administered to patient; MPFF (Micronized Purified Flavonoid Fraction) 1 tablet two times daily, Warfarin-Na with dose of 1 tablet 3 times daily, Hydroxyethyl-rutoside capsule with dose of 1 capsule 3 times daily.
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lymphedema. They are also to manage their edematous skin to prevent skin infection using mild oil. Patients should do their own massage after being taught. Exercise activity should be done daily.
All patients were given treatment that is Warfarin-Na tablet, MPFF, and Hydroxyethyl-rutoside. All tablets and capsules were used for 6-12 months, some cass had to be longer until 24 months.
Satistics (Statsoft® 1992,USA) were performed using t-test to calculate the diameter differences.
Results
All were 35 patients with FL, 20 females and 15 males, which cases collected in 21-year period 1990 until 2011.
Table 1 Lymphedema in female patients
Patient number
Sex F=female M=male
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Majority cases were female, but not found FL in the breast. All cases are WHO grade 2, exept 6 cases of grade 1.
Average improvement of measuring changes in diameter in lower extremity is significant (after 12 months p=0.000004, and after 24 months p=0.000135). in scrotal lymphedema and upper extremity are also a significant change.
Some patients were not coming for consultation without any prior notice.
The results of peripheral blood smear on 35 patients and Rapid test on 12 patients are remain negative after 2 times of repeated xaminations.
Decrease in diameter accompanied by reduction in symptoms of heaviness, healthier skin and subcutaneous tissue elasticity is significantly softer.
After 6-12 months of treatment, patients are become more confident an many began to dare to go out and start their work again with better quality of life.
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4 Discussion
All patients in this study are diagnosed as filarial lymphedema though not found any microfilaria in their blood as well as no other cause that is possible.
In the cases the reduction of edema can not be maximal, so that unable to return o the true normal diameter like the situation before suffering, but the most desired by all patients is thet they can eventually return to their activity.
Researcher from indonesia’s Health Ministry reported also found some cases of FL tn the breast, but it is believed that much fewer in number than other FL.
All patients in this study should be in a vegetarian life style all his life,because if it is not followed becomes dificult to control the sweling. This is presumbly become one of the causes why there is difference in edema reduction in each patient.
Medium Chain Triglycerides (MCT) inthe vegetarian diet that contained within the body does not get into chylomicron, so it can not cause an increase in fibrotic tissue formation .1,2,3Long Chain Triglycerides are derived from animal products in the body will enter into chylomicron in the lymph fluid.1,2,3
Lymphatic obstruction bymicrofilaria causing disturbances in the form of hypertensive lymphatic, vasodilatation and protein extravasation.2Protein molecules outside the lymphatic vessel stimulate inflammation and fibrosis.2
Some patients did not follow the doctor’s advice to swell again because back into the habit of eating diary products, but after realizing their mistake swelling decraese again.
