Surgical debulking of podoconiosis nodules and its impact on quality of life in Ethiopia

Background In Ethiopia, severe lymphedema and acute dermato-lymphangio-adenitis (ADLA) of the legs as a consequence of podoconiosis affects approximately 1.5 million people. In some this condition may lead to woody-hard fibrotic nodules, which are resistant to conventional treatment. We present a series of patients who underwent surgical nodulectomy in a resourcelimited setting and their outcome. Methods In two teaching hospitals, we offered surgical nodulectomies under local anaesthesia to patients with persisting significant fibrotic nodules due to podoconiosis. Excisions after nodulectomy were left to heal by secondary intention with compression bandaging. As outcome, we recorded time to re-epithelialization after surgery, change in number of ADLA episodes, change in quality of life measured with the Dermatology Quality of Live Index (DQLI) questionnaire, and recurrence rate one year after surgery. Results 37nodulectomy operations were performed on 21 patients. All wounds re-reepithelialised within 21 days (range 17-42). 4 patients developed clinically relevant wound infections. The DLQI values were significantly better six months after surgery than before surgery (P<0.0001). Also the number of ADLA episodes per three months was significantly lower six months after surgery than before surgery (P<0.0001). Conclusion Nodulectomy in podoconiosis patients leads to a significant improvement in the quality of life with no serious complications, and we recommend this to be a standard procedure in resource-poor settings. Podoconiosis is a disease that causes swelling of the lower legs and tissue lumps (nodules) of the feet. The condition is physically disabling with significant psycho-social impact. It is caused by the destruction of the lymphatic system, that is critical in the transportation of body fluids. The disease is said to be caused by long term barefooted exposure to red-clay soil. Podoconiosis affects more than four million subsistent farmers in the tropics. Ethiopia is one of the endemic countries with more than 1.5 million affected people. Early-stage podoconiosis morbidity management consists of foot hygiene, regular inspection and care for traumatic abrasions, use of moisturizer, daily exercise, compression with elastic bandages, and last but not least shoe wearing. In the late disease stage, irreversible swelling and woody-hard fibrous nodules arise. As a result, patients can no longer wear shoes and suffer from disabling bacterial infection. Both complications aggravate lymphatic destruction. Moreover, late-stage podoconiosis is unresponsive to the aforementioned therapy options. Surgical intervention removing the nodules (nodulectomy) can potentially alleviate late-stage disease. Here, we describe the clinical outcome of nodulectomy and its effect on the quality of life in 21 late stage podoconiosis patients, in a before to 12 months after the procedure comparison. We demonstrate that nodulectomy is safe, allows patients to wear shoes again, reduces the number of bacterial infections, and significantly improves their quality of life. Nodulectomy is a safe and effective procedure for podoconiosis patients. We recommend nodulectomy as the preferred therapy option for late-stage podoconiosis complicated by nodules.