1. Filariasisunusual complication Surgery unit I Prof & HOD-Dr. N. K. Ray Asst Prof – Dr. R. N. Singh Presenter: Dr. SkSabir Ahmed

2. History 32yrs old Rajanna was suffering from elephantiasis of his right leg for 16yrs. He was treated in Victoria hospital for the same He has undergone plastic surgery procedure for the swollen limb, which failed & 14 yrs back above knee amputation was done. He was asymptomatic for 6yrs. 8 yrs back he has noticed one swelling in his Rt inguinal region which was gradually progressing. 2 yrs the swelling progressed rapidly to present size. dragging type of pain in the swelling, also heaviness in limb the since last 2months.

3. No H/O fever with chills & rigors. No H/O cough, No H/O any other swelling, No H/O difficulty in passing urine. No H/O passage of milky urine. No H/O –DM - HTN - TB Family history: not significant Personal history: diet- mixed bowel & bladder- normal sleep- disturbed due to pain habits: alcoholic since 3 yrs( 1 quarter/day) smoker, chew betel nut occasionally

4. General physical examination Patient is Rt sided above knee amputee & moderately nourished, conscious & cooperative. Vitals – stable pallor - present, No- icterus, cyanosis, clubbing. No generalized lymphadenopathy.

5. Local examination Single irregular swelling, 20x 15x15cm in size situated over right groin extending from right anterior superior iliac spine(ASIS) to pubic symphysis & root of the right scrotum to 10 cm below the ASIS. Surface of the swelling bosselated. Hypo pigmented patch over the swelling. On palpation tenderness present, no local rise of temperature, consistency firm to hard , restricted mobility in all the direction. Skin adherent throughout except the periphery. Penis & scrotum is deviated to opposite side.

6. Systemic examination: CVS : RS: NAD PA: CNS:

7. Investigation Hb - 10gm TC - 8,600 Platelets - 2.5Lakhs RBS - 147mg% BU -12mg% Sr Cr -0.7mg% BT - 2.5min CT -3min HIV/HBsAg-negative Bldgrp -o+ve FNAC: microfilaria against an edematous & inflammatory background.

8. Plain X ray- calcified lesion in Rt groin.

9. CT scan: multiple calcified lesion in the Right inguinal & thigh region.

10. Provisional diagnosis: Filarial lymphadenopathy. Pre-op preparation was done : 1 pint blood given to improve anemia.

11. Under GA an elliptical incision was made below the summit of the swelling

12. flaps were raised laterally over the swelling up to the muscle plane.

17. Femoral vessels, the right spermatic cord & root of the penis were protected.

18. swelling was ultimately dissected off the femoral triangle.

19. Perfect hemostasis secured during the whole surgery.

20. Specimen sent for histopathology.

21. Histopathology report: soft tissue mass with extensive fibrosis, calcification & ossification.

22. Post operative patient had lymphorrhea for about 15 days. Lymphorrhea subsided & patient was discharged 1 month after operation

24. Discussion Lymphedema of leg: Accumulation of the lymph in the subcutaneous tissue results in enlargement of the limb. Fluid collects in the extracellular, extravascular compartment.

25. Causes of lymphadenitis Primary: Lymphatic aplasia: number of lymphatic channels & nodes are grossly reduced Lymphatic hypoplasia: lymphatic channels are small in caliber. Secondary : Filarial elephantiasis Following lymph node block dissection Following radiotherapy Advanced malignancy

26. filariasis This is the most common cause of lymphoedema worldwide, affecting up to 100 million individuals. It is particularly prevalent in Africa, India & south America where 5-10% of population may be affected. filarial elephantiasis is caused by wuchereriabancrofti, transmitted by the mosquito(Culexfatigans). The disease is caused by adult worms which have the affinity towards lymphatic vessels & lymph nodes.

28. Pathophysiology of lymphoedema Lymphatic obstruction Lymphatic hypertension & distention Accumulation of ISF, proteins, GF & other active peptide moieties, GAG & particulate matter including bacteria. Increased collagen production by fibroblast Accumulation of inflammatory cells Activation of keratinocytes End result is protein rich edema fluid, increased deposition of ground substance, subdermal fibrosis & dermal thickening & proliferation.

29. Pathogenesis Initially it causes lymphangitis which clinically presents with high grade fever with chills & rigors, red streaks in the limbs.

30. Pathogenesis (cond…) The lymph nodes are swollen & tender.

31. Pathogenesis (cond…) Due to such repeated infections, fibrosis occurs resulting in lymphatic obstructions. This later gives rise to lymphatic dilatation. Lower limb lymphatics are dilated & tortuous(lymphangiectasis).

32. Pathogenesis (cond…) To start with lymphoedema is pitting in nature & after some time becomes nonpitting in nature. After repeated infections, the skin over the limb becomes dry thickened, thrown in to folds and even nodules which break open and results in ulcer, hence called elephant leg.

33. Reaction to adult worms in the Lymphatic vessels lead to elephantiasis hydrocele chyluria Acute filarial Lymphangitis abscess tropical pulmonary eosinophilia lymphadenopathy

34. Special investigation Lymphangiography : in this technique the lymphatic of the lower limb are delineated with radio opaque dye. Isotope lymphoscintigraphy: radioactive technetium labeled protein or collied particles are injected into an interdigital web space & specifically taken up by lymphatics & serial radiograph are taken with gamma camera. CT scan: MRI: USG:

36. Elastic crape bandage.

37. Diuretics.

39. Bypass procedure Omental pedicle graft: Physiologic operations- attempt to link subcutaneous tissue with deep lymphatics or to attach lymphatic bearing pedicles such as omentum or small bowel to the root of the affected limb.

41. Nodo venous shunt(Neibulowitz): dilated, enlarged lymph node in the inguinal region is anatomized to a vein near by, eg., long saphaenous vein or femoral vein etc.

42. Reduction procedure Sistrunk operation : A wedge of skin & subcutaneous tissue is excised & wound closed primarily.

43. Reduction procedure Sistrunk operation : A wedge of skin & subcutaneous tissue is excised & wound closed primarily.

44. Homans operation: First skin flaps are elevated, Subcutaneous tissue are excised Flaps are trimmed to accommodate the reduced girth of the limb & closed primarily.

45. Homans operation: First skin flaps are elevated, Subcutaneous tissue are excised Flaps are trimmed to accommodate the reduced girth of the limb & closed primarily.

46. Swiss roll operation (Thompson’s): in this a skin flap is raised containing dermis and is buried in to deep tissues (close to vascular bundle). This is a dermal flap prepared by denuding epidermis.

47. Swiss roll operation (Thompson’s): in this a skin flap is raised containing dermis and is buried in to deep tissues (close to vascular bundle). This is a dermal flap prepared by denuding epidermis.

48. Clarke’s excision operation: in this operation , diseased skin and subcutaneous tissue are excised till the healthy underlying structures are seen f/b split skin grafting.

49. Aim of presentation This case is a rare complication of filariasis. The weight of the swelling was 4.5kg, which was relieved after the surgery. This is the first case of filariasis operated in our hospital.

50. Thank you