SURGERY A LAST RESORT FOR LYMPHEDEMA
What do you recommend for someone who has lymphedema in the leg that doesn't respond to wraps or compression? At what point is surgery an option?
The mainstay of treatment for lymphedema is conservative therapy that doesn't involve surgery. Lymphedema treatment usually starts with wraps and compression. If that doesn't work, other nonsurgical options are available. If there's no improvement after thorough use of conservative treatment, then it may be necessary to consider surgery.
Lymphedema affects your lymphatic system, part of your body's immune system. Your lymphatic system circulates lymph fluid throughout your body, collecting bacteria, viruses and waste products. It carries this fluid and these substances through your lymph vessels and into the lymph nodes. The wastes then are filtered out by infection-fighting cells in the lymph nodes.
Lymphedema happens when your lymph vessels cannot adequately drain lymph fluid. That usually happens because of damage to or removal of lymph nodes from an infection, trauma, cancer treatment or surgery. When lymph fluid doesn't drain normally, the excess fluid builds up and causes swelling, most often in an arm or leg. If it's not promptly and properly treated, the accumulation of lymph fluid eventually can lead to solid deposits of fat and fiber in the areas affected by lymphedema. That can make the condition more difficult to treat effectively and therefore more likely to require surgery.
Compression therapy usually is the first line of treatment for lymphedema. It involves wrapping the entire arm or leg in a snug bandage or compression garment to reduce swelling and encourage the flow of lymph fluid.
If wrapping alone isn't enough, complete decongestive therapy may be useful. That approach includes wrapping and other techniques, such as massage, exercise and skin care, to ease swelling. Your doctor also may recommend a device that puts pressure on your limb to move lymph fluid. These compression devices usually consist of a sleeve worn over the arm or leg connected to a pump that intermittently inflates to provide pressure.
If you don't see improvement with decongestive therapy, then surgery would likely be the next step. Some of the surgical techniques used for lymphedema must be performed when the condition is still in the fluid phase, before solids are deposited in the affected area. A delay in treatment that allows solids to accumulate may require more complex surgical approaches and can make lymphedema more difficult to treat over time.
Three surgical techniques that can be used to treat lymphedema while it's still in the fluid stage are vascularized lymph node transfer, lymphaticovenous anastomosis and lymphaticolymphatic bypass.
The first, vascularized lymph node transfer, releases scar tissue that's blocking the lymph fluid. It also transfers a soft tissue flap from a donor into the affected area. This flap contains lymph system components. The second surgical technique, lymphaticovenous anastomosis, connects existing lymphatic vessels to tiny veins located nearby, allowing the extra lymph fluid to drain directly into the veins. The third approach, lymphaticolymphatic bypass, connects normal functioning lymphatic vessels from a donor directly to the lymphatic vessels of the affected limb.
When lymphedema progresses to the point that solids start to accumulate in the limb, other surgical procedures must be used to remove that material. Those techniques don't address the underlying cause of lymphedema, though, so you still need compression or other therapy after surgery. In some cases, surgery to remove the solids can be combined with one of the other surgical techniques mentioned earlier.
The right surgical procedure for lymphedema varies by individual. With proper diagnosis and evaluation, however, surgical techniques can be used to treat lymphedema safely and effectively in many people when combined with integrated lymphedema therapy.
Kevin Cohoon, D.O., Cardiovascular Diseases, Mayo Clinic, Rochester, Minn.
IODIZED SALT ISN'T SOLE IODINE SOURCE
I rarely use table salt anymore when cooking. Instead, I like to use sea salt. But I've noticed that a lot of sea salts don't contain iodine. Do I need iodized salt, or are there other sources that give me all the iodine I need?
For most people, iodized salt is probably the easiest way to maintain sufficient iodine intake. Iodine is an important nutrient that your thyroid needs to produce certain hormones. Not getting enough iodine can lead to problems such as an enlarged thyroid gland (goiter) and an abnormally low level of thyroid hormones (hypothyroidism).
Iodine is a trace element present in the earth. Distributed variably around the world due to the effects of the ice age, iodine has accumulated primarily in coastal areas. The most common dietary sources of iodine are seaweed, fish and dairy products. Inland areas have fewer natural sources of iodine. Areas where iodine deficiency was common in the early 1900s —the Great Lakes, Appalachians and Northwest — were known as the "goiter belt." Researchers from these areas encouraged the United States to adopt table salt iodization as an inexpensive way of providing iodine supplementation. Although salt iodization wasn't made mandatory, estimates are that more than 90 percent of U.S. households today have access to iodized salt.
Other sources of dietary iodine include eggs, enriched grain products and plant foods grown in iodine-rich soils. Unfortified sea salt contains a small amount of iodine.
It's hard to determine precisely how much iodized salt contributes to an individual's iodine levels. Iodized salt in the United States contains 45 micrograms of iodine per gram of salt. The recommended daily intake for adults is 150 micrograms, which can be obtained from about one-half to three-quarters of a teaspoon of table salt. Testing indicates that most Americans consume sufficient levels of iodine through their diets. Pregnant women and nursing mothers are the only groups that are advised to take a daily iodine supplement.
Depending on where you live and how much seafood you eat, you may not want to substitute all of your table salt with sea salt. However, that shouldn't stop you from using sea salt when you want that flavor. Be cautious with the amount, however, as all salt is high in sodium.
Katherine Zeratsky, R.D.N., L.D., Endocrinology/Nutrition, Mayo Clinic, Rochester, Minn. (adapted from the Mayo Clinic Health Letter)
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