Brazil's
position in relation to the universal consensus on lymphology
(Portuguese
PDF version)
Rubens Carlos Mayall1
1.
Additional data contributed by Dr. Cleusa Belczak.
Correspondence:
Hospital da Gamboa
Caixa Postal: 1822
CEP 20001-970 - Rio de Janeiro - RJ
Brazil
J Vasc
Br 2004;3(1):57-9
Lymphology
is one of the newest of specializations and, within the constellation
of cardiovascular diseases, has always been considered one of the least
important for reasons that are very easily understood.
The study of lymph vessels has always been considered difficult, despite
Embryology having discussed the vessels that conduct the white blood
in his writings and despite the lymph vessels themselves having been
known by anatomists since 1627 when they were described by Asellius,
almost at the same time that Harvey was describing the blood vessels
in 1628.
Radiology, and the correlation between the etiopathogenesis of the most
common diseases and lymphatic system function, had not been properly
equated until recently with progress in immunology, oncology and surgical
and, most importantly, microsurgical technique. These, allied with the
rapid technological development of radiology and of the pharmaceuticals
industry, have made it possible for the then-nascent specialization
become fully mature and incorporate the whole of the lymphology family,
which is represented by more than 600 of the International Lymphology
Society.
Here in Brazil, this new knowledge was obviously assimilated and some
parts were even met with greater interest and enthusiasm, generating
practical applications. The first publication in the western world on
in-vivo visualizations of lymph vessels was thanks to Souza Pereira
and two other anatomists, Carvalho and Rodrigues, from Porto, Portugal,
in 1931.
Since lymphedema incidence has always been more serious in the Northeast
of the country, it is natural that pioneering work originated there.
As early as 1943, JJ Almeida Seabra presented his lymphographic thesis,
at the same time that Servelle, in France, was creating excellent images
of the lymphatics of the leg.
From 1940 onwards in Recife, Prof Romero Marques together with Manuel
Caetano de Barros and their followers gave great impetus to the study
of lymphatic anatomy (Dr.Edvaldo Silva Telles) and of lymphedema. They
created beautiful lymphographs of lymphocele in filiariasis sufferers,
which, when exhibited at the 1954 SBACV Congress (Brazilian Society
of Angiology and Vascular Surgery - Brazilian Society of Angiology
and Vascular Surgery) in Belo Horizonte (Minas Gerais), impressed Dr.
Haimovici to the extent that, on observing the size of the vessels in
contrast from the thigh to the foot he believed he was viewing phlebographs.
In around 1951, Dr. Kinmonth began to employ a technique using dissected
lymphatics viewed by the Mc. Master method using patent blue violet
stains. A little later, this method was used here in Brazil, from 1955
routinely and it is from this point that a great deal of interest in
lymphology dates. This applies not just to the study of the lymphatics
in lymphedema, but also to severe post-phlebitic syndromes and post-trauma
edema. Our work began to be used in one-year courses to teach students
in places as far away as Japan.
Worldwide reactions were first manifest when we released our first reports
on post-operative, lower-member edemas, in particular with respect of
varicose veins. It is enough to remember the presentations made in 1963
by Natali, Marmasse and Salleras, during a plenary session, at the World
Congress of the International Cardiovascular Society in Rome to more
than 700 delegates stating that the post-operative edema presented in
6% of a sample of more than 72,000 saphenectomies must have been produced
by the lymphatic lesions that had been clearly demonstrated at previous
congresses by Dr. Mayall from Rio de Janeiro. Truly, this work, and
also the discussion of lymphatic lesions in post-phlebitic syndrome,
had far reaching repercussions for worldwide practices. However, it
is undeniable that Prof Mario Degni was the person who contributed most
to the diffusion of research into the lymph vessels of the lower members.
His new phleboextractor in the shape of an inverted Aztec pyramid is
already well-known worldwide.
Engeset, Shanbron, Zheutlin and Wallace used liposoluble contrasts from
1947 and 1950 onwards and the importance of this lymphographic method
overtook the interest that had hitherto been partially limited to the
lower limbs and chylous reflux and came to be considered an excellent
resource which is still used today for differential tumor diagnosis
and for lymphoma and neoplastic metastasis mapping; including occult
febrile states which have brought many of our oncologists to the forefront.
In 1965, with the creation of the International Lymphology Society Foundation,
there was, undeniably, a great stimulus to research thanks to the new
findings demonstrated and published there.
Soon after, a small, but highly enthusiastic group in Brazil stuck to
their work, until, in 1975, they were successful in their bid to host
the 5th World Lymphology Congress in Rio de Janeiro, with the complete
support of the SBACV which, since 1956, had been reserving certain sessions
for work on lymphatic diseases and the problems of diagnosing them.
All went well until 1960, although therapeutic gains did not keep pace
with the marvelous advances in diagnosis. At this point these advances
already included studies of lymph composition performed in the Northeast
of Brazil, by followers of Romero Marques, especially Laudenor Pereira,
in Recife, and, in greater detail, Edmundo Vasconcelos de Carvalho,
from Paraíba, who spread them further, not just in Brazil, but
also in New York, Paris, Bogota and Acapulco. Nevertheless, the results
of operations to excise large areas of lymphedema performed at the Hospital
da Gamboa by Josias de Freitas' excellent surgical team and also in
the rest of the world, were rarely successful over the long term, and,
in the majority of cases were disastrous. It was during this era that
we postulated certain concepts, nowadays accepted in many different
countries, showing that there was a need to study the problems that
cause edema of the genitalia in much greater depth. It was not sufficient
to simply find superficial lymphatic lesions and operate, something
else was needed. To our great satisfaction it is now routine practice
to study lymph nodes and deep lymphatics using Romero Marques and Pereira's
techniques, allied to a perfect evaluation of the superficial and deep
venous systems up to the inferior vena cava, investigating anatomical
variations in arterial-capillary circulation, which create hyperostomy
syndromes. Pratesi described them in the thigh and Malan in the foot
and it was us that rediscovered their importance in the lower limbs,
particularly the calves. These arterial, venous and lymphatic imaging
studies have now become compulsory before operating on lymphedema, which
has resulted in a radical transformation in terms of outcome between
the periods before and after 1960. Many cases still remained to be studied,
however.
Simultaneously, and driven by the same concerns in the face of unsatisfactory
aesthetic results, the first few operations with a more physiological
approach were performed. lymph node-venous anastomosis were performed
in Poland by Nielubowicz and Olzewski, and lymphatic-venous shunts in
Argentina by Carcacia. It was for these lymphovenous anastomosis that
the Brazilian surgeons A.K. Cordeiro in 1969 and Mario Degni 1971, thanks
to their ingenuity, simplified the instrumentation necessary to the
surgical act. By means of multiple technical variations to the technique
and by repeatedly demonstrating the practices at the most important
lymphology centers around the world they made possible, not just excellent
results from carefully-selected cases, but, more importantly, results
that are now more than ten years old, which, when analyzed by pre and
post operative diapositives are so good that no comments are necessary.
However, whenever good results are achieved we begin to look for even
more serious cases.
It is for these reasons that, thanks to the minutely detailed work of
Doctors Cordeiro and Fuad Al Assal from São Paulo, attempts are
already being made, some successfully, to construct, by means of microsurgery,
lymphatic-lymphatic anastomosis, and even longer segments of lymph vessels
are being transplanted, as is already routine for veins and arteries.
Furthermore, in cases where we would previously have abandoned imaging
studies because no dissectible conduits were apparent, we have already
managed, with our current team, on a number of different occasions and
with relative ease, perform lymphography by means of direct cutaneous
puncture, making spectacular cures possible operating in cases that
were once destined to almost total abandonment.
Notwithstanding, all of this effort would not have been sufficient to
improve the universal consensus on Brazil. It was necessary and indispensable
that, without taking any account of effort, economic problems or sheer
distance to be overcome, hundreds of papers were published by Brazilian
lymphopathologists in the most important languages worldwide such as
German, English, French Italian, Spanish and Japanese. Texts were even
published within textbooks from European universities, such as our chapter
on lymphographs in the Angiology Methods textbook from 1980 published
by the University of Lowvein in Belgium, by invitation from Prof. M.
Verstraette.
Theses have been defended on lymphology at Brazilian Universities, including
those of Dr. Mariano da Rocha Neto, in Santa Maria, Dr. Moacyr Santos
Silva at the Academia Nacional de Medicina, Dr. José Cantano
in Belo Horizonte, Dr. Waldemy Silva in Recife , Dr Mauro de Andrade
in São Paulo (USP) and that of Dr. Henrique Jorge Guedes Neto
(The Medical Faculty at the Santa Casa in São Paulo), and also
masters dissertations by Dr. Solange Gomes in Recife (UFPE), Dr. José
Luiz Cataldo in Campinas (UNICAMP), Dr. Claudia Stein Gomes in Curitiba
(Faculdade de Medicina Evangélica), and many others that did
not pass my way. Numerous courses have been given by Brazilian lymphologists
in a number of different Latin American cities and in Europe and at
conferences on the specialization all over the world.
Yet to be mentioned within the current domestic scene is the work by
Dr. Esther Azoubel in Recife with lymphographs and books dedicated entirely
to the subject such as the classic Linfologia by Cordeiro and
Bacarat, the recently re-edited Linfangites e Erisipelas by Dr
Merisa Garrido and our dearly-missed Dr. Amélio Pinto Ribeiro,
Linfologia Básica by Dr. Daniel Wogelfang, and the work
by Dr. José Maria Pereira de Godoy on a new Manual lymph drainage
approach. In recent years young, Brazilian vascular surgeons have had
placements in Genoa at Prof. Campisi's unit, such as Dr. Claudia Stein
Gomes from Curitiba and Dr. Eneida Couto de Melo from Belo Horizonte,
and Dr. Walter Azevedo from Salvador and Dr. Anderson Gariglio also
from Minas Gerais, bring back innovative lymphatic microsurgery techniques
and building a good reputation abroad.
Finally, we would add that, in 2003 on the occasion of the First Latin
American Lymphedema Consensus, debated in Argentina, Brazil was represented
by five delegates, among whom Dr. Anacleto de Carvalho from Pernambuco
stood out for his presentation on Filariasis in Brazil.
Another highly important detail, in my view, is the visits made by Brazilian
specialists to the largest centers dedicated to Lymphology, on personal
exchange schemes with service heads and assistants in order to become
familiarized with the materials used. Only thus has it been possible
to improve our image, and, thanks at least to lymphatics, we have managed
to reach proportions that are to be envied by many highly developed
countries, so improving the image of Brazil.
