Challenges and Solutions: Total Knee Replacement in Patients with Chronic Lymphatic Filariasis: A Case Report.

CASE: A 59-year-old woman with a history of left knee pain exacerbated by lymphatic filariasis underwent successful total knee replacement (TKR) for advanced osteoarthritis. Postoperatively, diligent adherence to compression bandaging, physiotherapy, and lymphatic flow promotion resulted in no lymphedema progression. During the 5-year follow-up, the patient showed improved Knee injury and Osteoarthritis Outcome Score and stable implant. CONCLUSIONS: Currently, there are no established protocols or formulated guidelines for TKR in patients with chronic filariasis. The preoperative lymphedema prevention must be tailor-made for each patient in the context of advanced osteoarthritis based on the functional lymphatic vessel status.

Implementation and Outcomes of a Pilot Collaborative Surgical Hydrocele Training in Côte d'Ivoire.

Lymphatic filariasis (LF) is a neglected tropical disease that can cause hydrocele and its associated stigma, loss of economic productivity, and depression. Hydrocele surgery is an essential part of LF morbidity management but can be difficult for national programs to implement. To improve access to hydrocele surgeries in Côte d'Ivoire, we provided a WHO-certified surgical training for six surgical teams from five health districts in Côte d'Ivoire. We then evaluated the surgical outcomes and assessed the impact of hydrocele surgery on quality of life of hydrocelectomy patients. Preoperative and operative records were reviewed to describe baseline hydrocele characteristics and operative details. Postoperative interviews were conducted 4 to 6 months after surgical correction using a standardized questionnaire. Seventeen men underwent surgery during the training and were available for an interview at the 6-month visit. At the time of 6-month follow-up, 11/17 (64.7%) reported improvement in activities of daily living and reduction in difficulties with work, 8/17 (47.1%) reported an improved economic situation, 15/17 (88.2%) reported improved social interactions, and 15/16 (93.8%) reported improved sex life after surgical correction. Three patients (17.6%) had minor postoperative complications, but none required hospitalization. All 17 patients who were available for an interview were satisfied with their surgery. Surgical hydrocelectomy training in Côte d'Ivoire was well received and provided life-altering health improvements for participating patients across multiple domains of life. Support to scale up surgical capacity for this neglected problem is needed.

The implementation and impact of a pilot hydrocele surgery camp for LF-endemic communities in Ethiopia.

BACKGROUND: Ethiopia aims to eliminate lymphatic filariasis by 2020, through a dual approach of mass drug administration to interrupt transmission and morbidity control which includes making hydrocele surgery available in all endemic areas. Locating patients requiring surgery, providing high quality surgeries, and following up patients are all formidable challenges for many resource-challenged or difficult-to-reach communities. To date, hydrocele surgery in Ethiopia has only occurred when a patient has the knowledge, time and resources to travel to regional hospitals. Ethiopia tested the novel approach of using a surgical camp, defined as mobilizing, transporting, providing surgery at a static site, and following up of a large cohort of hydrocele patients within a hospital's catchment area, to address delays in seeking and receiving care. METHODOLOGY AND RESULTS: Health extension workers mobilized 252 patients with scrotal swelling from a list of 385 suspected hydrocele cases from seven endemic districts in the region of Beneshangul-Gumuz. Clinical health workers and surgeons confirmed 119 as eligible for surgery. Of 70 additional patients who self-referred, 56 were eligible for surgery. Over a two-week period at a regional hospital, 175 hydrocele excision surgeries were conducted. After discharge three days after surgery, trained clinical health workers followed up with the patients on Day 5, Day 8, Day 14 and 1st-month benchmarks with a randomized follow-up of a selection of patients conducted at 9-12 months. There were no post-operative complications upon discharge at Day 3 and 22, while minor complications occurred (12.6%) between Day 3 and one month. The 9-12 month follow-up found patients self-reported an improvement in quality of life, health and economic status. CONCLUSION: A hydrocele surgery camp was effective at providing a large number of quality surgeries in a short time. Using peripheral health workers to mobilize and follow up patients helped address delays in seeking and receiving quality care. Mainstreaming patient mobilization and follow-up into a community health system could be effective in other countries. The camp's results also influenced two regions in Ethiopia to change their policies in order to offer free hydrocele surgery (including patient transport, consultation, surgery, diagnostic tests and necessary medications).

[Physiopathology of vulvar elephantiasis of filarial origin. A case report]. / Fisiopatología de la elefantiasis vulvar de origen filarial. A propósito de un caso.

Genital filariasis is an uncommon infectious entity in the western world. It has characteristic clinical features and a well-recognized endemic area that causes typical histological alterations. We report a case of a 32-year-old woman, a native of Mozambique, who presented with vulvar elephantiasis as a pendulous tumor with a maximum diameter of 15cm. A large part of the genital mass was resected. Microscopically, hyperkeratosis with irregular acanthosis, a notable thickening of dermis with dense fibrosis and inflammatory clusters of patchy distribution, mostly made up of plasma cells, was seen. Since the parasite was not observed, an exclusion diagnosis was made, as frequently happens with this lesion.

Exploring determinants of hydrocele surgery coverage related to Lymphatic Filariasis in Nepal: An implementation research study.

BACKGROUND: Hydrocele is a chronic condition in males in which there is an excessive collection of straw-colored fluid, which leads to enlargement of the scrotum. It is a common manifestation of lymphatic filariasis (LF) affecting nearly 25 million men worldwide. Surgery is the recommended treatment for hydrocele and is available free of cost in all government hospitals in Nepal. This research explored patient, provider, and community factors related to accessing hydrocele surgery services by the patients. METHODS: This study employed a qualitative method. The research was conducted in two LF endemic districts, namely Kanchanpur and Dhading, which are reported to have the highest number of hydrocele cases during morbidity mapping conducted in 2016. In addition to five key informant interviews with the LF focal persons (one national and 4 district-level), nine in-depth interviews were conducted with hydrocele patients (5 of whom had undergone surgery and 4 who had not undergone surgery) and with 3 family members, and two focus group discussions with the female community health volunteers. RESULTS: Most of the respondents did not have knowledge of hydrocele as one of the clinical manifestations of LF nor that it is transmitted through a mosquito bite. Although perceived as treatable with surgery, most of the patients interviewed believed in as well as practiced home remedies. Meanwhile, fear of surgery, embarrassment, lack of money, along with no knowledge of the free hydrocele surgery acted as barriers for accessing the surgery. On the other hand, financial support, flexible guidelines enabling the hospital to conduct surgery, decentralization and scaling up of morbidity mapping along with free hydrocele surgery camps in any remaining endemic districts were identified as enablers for accessing surgery. CONCLUSION: Hydrocele surgery coverage could be improved if the program further addresses community awareness. There is a need for more focus on information dissemination about hydrocele and hydrocele surgery.

Case Report: Periorbital Filariasis Caused by Brugia malayi.

Brugia malayi is a lymphatic nematode that accounts for approximately 10% of lymphatic filariasis cases worldwide. It is endemic in several countries in South and Southeast Asia. In Thailand, B. malayi is endemic in the southern region. The extralymphatic presentation of B. malayi is rare. Here, we report the case of a woman residing in the central region of Thailand who presented with an erythematous periorbital nodule at the left medial canthal area caused by lymphatic filaria. A viable sexually mature filarial adult was removed from the lesion. The nematode species was identified as B. malayi by histology staining and DNA sequencing of the partial mitochondrial 12S ribosomal RNA (rRNA) gene. As far as we know, this is the first case report of B. malayi presenting with a periorbital nodule that has occurred in a disease non-endemic area of Thailand with possibly a zoonotic origin.

Surgical Treatment of Advanced Lymphatic Filariasis of Lower Extremity Combining Vascularized Lymph Node Transfer and Excisional Procedures.

Background: Lymphatic filariasis (LF) in advanced stage is a clinically challenging disability resulting in poor quality of life. In advanced stage of filariasis, medical management is seldom effective and few surgical procedures are beneficial. In this study, we assessed clinical efficacy of a surgical technique combining vascularized lymph node transfer (VLNT) and serial excision for patients affected by advanced LF. Patients and Methods: A total of 17 patients with grades 2 and 3 lower limb lymphedema after three consecutive humanitarian missions in India between 2014 and 2018 underwent excision of excessive soft tissue of leg and supraclavicular lymph node flap transferred to dorsum of foot. Recipient vessels were prepared and microanastomosis was performed. Lymphedema was assessed by measuring leg circumferences at different levels, episodes of infectious lymphangitis, and lymphoscintigraphy. Results: A significant decrease of lower limb circumference measurements at all levels was noted postoperatively. Postoperative lymphoscintigraphy revealed reduced lymph stasis. One patient suffered of a seroma on donor site. Six patients had partial loss of skin graft over the flap at recipient site and it was managed by regrafting. Data analysis observed statistically significant reduction in feeling of heaviness (p < 0.005) and episodes of acute lymphangitis after surgery. Conclusion: Advanced LF of leg is difficult to manage using traditional medical treatment. The combination of VLNT and surgical excision provided a safe and reliable approach to treat this debilitating disease.

Elefantiasis escrotal. Presentación de un caso en Gambia / Elefantíase escrotal. Apresentação de caso na Gâmbia / Scrotal elephantiasis. Case presentation in the Gambia

Se presentó un paciente masculino con 25 años de edad, procedencia rural. Refirió en la cara lateral del hemiescroto derecho secreciones de color amarillo. En los genitales externos presentó una masa de 38 cm de largo y 35 cm de ancho, bordes irregulares, piel circundante edematosa, seca, acartonada, ulcera de 10 x 5 cm, no dolorosa y secreciones blanquecinas y serohemática escasa, pérdida de la anatomía del pene y disuria. Se confirmó el diagnóstico de elefantiasis escrotal secundaria a filariasis. Se aplicó tratamiento con dietilcarbamazina y quirúrgico. El tratamiento posibilitó la curación y la reincorpación social y sexual del paciente(AU)

A 25-year-old male patient was presented, of rural origin to the Urology office of the Royal Victoria National Hospital in the Republic of Gambia. He reported on the lateral side of the right hemiescrot yellow secretions. In the external genitalia it presented a mass of 38 cm long and 35 cm wide, irregular edges, surrounding edematous, dry, cracked skin, ulcer of 10x5 cm, non-painful and whitish secretions and serohematic scarce, loss of penile anatomy and dysuria The diagnosis of scrotal elephantiasis secondary to filariasis was confirmed. Diethylcarbamazine treatment and surgical intervention were applied. The treatment allowed the healing and social and sexual reincorpation of the patient(AU)

Um paciente do sexo masculino, 25 anos, foi apresentado, de origem rural, ao consultório de Urologia do Royal Victoria National Hospital, na República da Gâmbia. Ele relatou no lado lateral das secreções amarelas hemiescrot à direita. Na genitália externa, apresentava massa de 38 cm de comprimento e 35 cm de largura, bordas irregulares, circundando pele edematosa, seca e quebradiça, úlcera de 10x5 cm, secreções não dolorosas e esbranquiçadas e escassez seroemática, perda de anatomia peniana e disúria O diagnóstico de elefantíase escrotal secundária à filariose foi confirmado. Tratamento com dietilcarbamazina e intervenção cirúrgica foram aplicados. O tratamento permitiu a cura e a reincorpação social e sexual do paciente(AU)

Case Report: Filaria or Megasperm? A Cause of an Ultrasonographic "Filarial Dance Sign".

Bancroftian filariasis can cause genital abnormalities related to chronic inflammation and obstruction of the afferent lymphatic vessels, and may demonstrate a "filarial dance sign" on scrotal ultrasound with mobile echogenic particles observed. We present a patient with a positive "filarial dance sign," travel within Latin America, and negative filarial serology.

Filarial breast lump.

Lymphatic filariasis is one of the most debilitating and disfiguring scourges among all diseases. This report presents a case of a woman with recurrent breast nodularity after being previously operated for a suspected breast neoplasm. We would like to highlight the issue of similar clinical presentation of a filarial breast lump and other breast lesions leading to inappropriate therapy.

Investment Success in Public Health: An Analysis of the Cost-Effectiveness and Cost-Benefit of the Global Programme to Eliminate Lymphatic Filariasis.

Background: It has been estimated that $154 million per year will be required during 2015-2020 to continue the Global Programme to Eliminate Lymphatic Filariasis (GPELF). In light of this, it is important to understand the program's current value. Here, we evaluate the cost-effectiveness and cost-benefit of the preventive chemotherapy that was provided under the GPELF between 2000 and 2014. In addition, we also investigate the potential cost-effectiveness of hydrocele surgery. Methods: Our economic evaluation of preventive chemotherapy was based on previously published health and economic impact estimates (between 2000 and 2014). The delivery costs of treatment were estimated using a model developed by the World Health Organization. We also developed a model to investigate the number of disability-adjusted life years (DALYs) averted by a hydrocelectomy and identified the cost threshold under which it would be considered cost-effective. Results: The projected cost-effectiveness and cost-benefit of preventive chemotherapy were very promising, and this was robust over a wide range of costs and assumptions. When the economic value of the donated drugs was not included, the GPELF would be classed as highly cost-effective. We projected that a typical hydrocelectomy would be classed as highly cost-effective if the surgery cost less than $66 and cost-effective if less than $398 (based on the World Bank's cost-effectiveness thresholds for low income countries). Conclusions: Both the preventive chemotherapy and hydrocele surgeries provided under the GPELF are incredibly cost-effective and offer a very good investment in public health.

Surgical Treatment of Genital Manifestations of Lymphatic Filariasis: A Systematic Review.

Genital manifestations of lymphatic filariasis (genital LF) are a significant cause of disfigurement and disability in the developing world. Surgery is the standard treatment; however, definitive publications are lacking and best practice remains unclear. An exhaustive search strategy using keyword and subject headings was applied to Medline, EMBASE, Web of Science, CINAHL, and Scopus. Additionally citation lists, Google and Google Scholar, archives of relevant journals and websites were searched systematically. Studies with data on one or more human patient(s) who underwent surgery for genital LF were included. Articles were screened and data extracted by the first author with data verification by the second author. Fifty-seven studies were included: 18 series of ablative surgery, four series of non-ablative surgery and 35 case reports. Poor study quality, heterogeneous case definitions, lack of severity grading and limited follow-up precluded meta-analysis. Two series of simple hydrocelectomies performed in resource-limited settings reported early complication rates of 3.0-3.5 % using eversion and 5-7 % using excision, with recurrence of 7 % and 3-5 %, respectively. Complications were minimal for single-surgeon series and greater (12-18 %) when scrotal reconstruction was performed. There is little useful evidence for lymphatic bypass procedures in genital LF. Under-recognition of atypical manifestation of genital LF leads to potentially unnecessary surgeries. Surgery for genital LF is safe in resource-limited settings; however, more well-designed studies with better follow-up are needed. Research priorities include validation of case definitions and severity grading systems, and solutions to improve post-operative follow-up in resource-limited settings.

Exploring hydrocoele surgery accessibility and impact in a lymphatic filariasis endemic area of southern Malawi.

BACKGROUND: Hydrocoele surgery is the recommended treatment for the common clinical manifestation of lymphatic filariasis in men. This study determined the geographical differences in surgery accessibility, and improvements in the quality of life of patients in Chikwawa district, Malawi. METHODS: Surgery records from Chikwawa District Hospital (CDH), between 2008 and 2013, were used to map surgery rates by village, spatial dependence by census enumeration area and relationship of distance (kilometres) to CDH. A subset of patients were selected to quantify and compare their physical and socio-economic well-being and level of disability pre- and post-surgery using a standardised questionnaire. RESULTS: A total of 476 hydrocoele surgical cases were identified with 260 cases geo-referenced and mapped. A significant negative relationship between village-level surgery rates and distance to CDH (r=-0.137; 95% CI: -0.47 to -0.26) was found, and clusters of enumeration areas with high surgery rates identified around the CDH. Significant improvements in patients' ability to walk and work were found and the overall level of disability was reduced post-surgery. CONCLUSIONS: Hydrocoele surgery positively impacted on patients, improving their physical and socio-economic output. Surgical services need to scale-up and expand to reach cases that have less access to the best treatment currently available.

Retroperitoneoscopic single-site renal pedicle lymphatic disconnection for the treatment of serious filarial chyluria.

INTRODUCTION: To report our preliminary techniques and experience with retroperitoneoscopic single-site renal pedicle lymphatic disconnection (RPSS-RPLD) in five patients with serious filarial chyluria. MATERIALS AND METHODS: Between May 2010 and July 2011, five patients with serious filarial chyluria underwent RPSS-RPLD. In the patients, a 3 cm single incision was made between the 12th subcostal margin and posterior axillary line, and a homemade single multichannel port using a surgical glove and three conventional trocars was placed into retroperitoneal space. The lymphatic disconnection was similar to traditional open surgery. RESULTS: All the operations were successfully completed without conversion to open surgery. The mean operative time was 116 (102-145) minutes. The mean blood loss was estimated to be 98 (60-190) mL. Chyluria disappeared in all patients after surgery and did not recur during the follow up period (3-14, mean 7.6 months). CONCLUSION: RPSS-RPLD is safe and feasible, with favorable short term outcomes and aesthetic effect.

Learning curve for retroperitoneoscopic renal pedicle lymphatic disconnection for intractable chyluria: a single surgeon's experience.

PURPOSE: To evaluate the surgical experience and outcomes of retroperitoneoscopic renal pedicle lymphatic disconnection (RRPLD) and to define a learning curve for this minimally invasive technique to treat patients with intractable chyluria. MATERIALS AND METHODS: We collected the clinical records of 40 consecutive patients who were selected for RRPLD of 42 renoureteral units between 2007 and 2010 for chyluria by a single surgeon with no experience for this procedure. Patients' demographics and peri-operative parameters were recorded and compared. Operation time, blood loss, and other peri-operative parameters were analyzed to document the learning curve for the procedure. RESULTS: All the 40 patients, 14 women and 26 men, underwent RRPLD successfully, and no open conversions were needed. The median operation time was 77.5 minutes [interquartile ranges (IQR): 69.0 to 89.0] and the median blood loss was 46.5 mL (IQR: 35.0 to 67.0). A total of five complications occurred (11.9%). We divided the patient cohort to the first 20 (group 1) and the last 20 (group 2) patients since operation time reached a plateau after about 20 cases. There were significant differences in the operation time (P = .000) and the blood loss (P = .006) between the two groups. The two phases did not differ in terms of demographic data, peri-operative complications, gastrointestinal recovery time, extubation time, or hospitalization duration. CONCLUSION: Retroperitoneoscopic renal pedicle lymphatic disconnection is a well standardized and reproducible procedure. This study of the learning curve of a single surgeon suggests that competence at performing RRPLD is reached after approximately 20 cases.

Surgical management of morbidity due to lymphatic filariasis: the usefulness of a standardized international clinical classification of hydroceles.

The objective of this work is to evaluate the usefulness of a standardized clinical classification of hydroceles in lymphatic filariasis endemic countries to guide their surgical management. 64 patients with hydroceles were operated in 2009-2010, in Level II hospitals (WHO classification), during two visits to Fiji, by the same mobile surgical team. The number of hydroceles treated was 83. We developed and evaluated a much needed clinical classification of hydroceles based on four criteria: Type (uni/bilateral); Side (left/right); Stage of enlargement of the scrotum rated from I to VI; Grade of burial of the penis rated from 0 to 4. It lead to the conclusion that 1) A Stage I or II hydrocele, associated with Grade 0 or 1 penis burial could be considered a "Simple Hydrocele". The surgical treatment is simple with no anticipated early complication. WHO Level II of health care structure seems adapted. 2) A Stage III or IV hydrocele associated with Grade 2, 3 or 4 penis burial could be considered a "Complicated Hydrocele". The operation is longer, more complicated and the possibility of occurrence of complications seems greater. A level III health care facility would be more adapted under the normal functioning of the health system. We conclude that a standardized clinical classification of hydroceles based on the Stage of enlargement of the scrotum and the Grade of burial of the penis appears to be a useful tool to guide the decision about the level of care and the surgical technique required. We use the same classification for penoscrotal lymphoedema. A decision tree is presented for the management of hydroceles in lymphatic filariasis endemic countries which could usefully complement the "Algorithm for management of scrotal swelling" proposed by WHO in 2002. An international classification system of hydroceles would also allow standardization and facilitate study design and comparisons of their results.

Reconstructive surgery for penoscrotal filarial lymphedema: a decade of experience and follow-up.

OBJECTIVES: To present our experience of reconstructive surgery in patients with penoscrotal filarial lymphedema. METHODS: From January 2000 to December 2009, we treated 48 patients with penile and penoscrotal filarial lymphedema using reconstructive surgery. Isolated penile involvement was seen in 14 patients, and 34 patients had penoscrotal involvement. All the patients had taken multiple courses of antifilarial drug before surgery. For isolated penile involvement, the diseased penile skin was excised and covered with a split-thickness skin graft. In some patients, the inner prepucial skin was preserved and used to cover the penile shaft. For those with penoscrotal involvement, scrotoplasty was performed, after excising the diseased scrotal skin and underlying soft tissue, while sparing the testes and spermatic cords. RESULTS: The mean patient age was 38 years (range 25-52), and the median follow-up time was 48 months (range 10-120). All 48 patients reported a satisfactory cosmetic appearance after the procedure and noted improvement in their ability to void while standing. Also, all of them could ambulate better and resumed sexual activity. Local groin infection was present in 12 patients; all were cured after proper management. CONCLUSIONS: In filarial lymphedema of penis and/or scrotum, excision of the diseased tissue and covering with a split-thickness skin graft provided good results. If the inner prepucial skin is healthy, it should be used to cover the distal penile shaft. If the scrotum is involved, scrotoplasty with lateral and posterior mobilized flaps provides satisfactory results.