الجامعة السورية الدولية الخاصة للعلوم و التكنولوجيا

1. الجامعة السورية الدولية الخاصة للعلوم و التكنولوجيا كلية الطب البشري قسم الجـراحـة الدكتور عاصم قبطان MD - FRCS M.A.Kubtan

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3. LEARNING OBJECTIVES To understand: • The main functions of the lymphatic system • The development of the lymphatic system • The various causes of limb swelling • The aetiology, clinical features, investigations • Treatment of lymphoedema M.A.Kubtan

4. Anatomy of the Lymphatic System In the human embryo lymph sacs develop at 6–7 weeks’ gestation as four cystic spaces, one on either side of the neck and one in each groin These cisterns enlarge and develop communications that permit lymph from the lower limbs and abdomen to drain via the cisternachyli into the thoracic duct, which in turn drains into the left internal jugular vein M.A.Kubtan

5. Continue The lymphatic system comprises : • lymphatic channels • lymphoid organs : (lymph nodes, spleen, Peyer’s patches, thymus,tonsils) • circulating elements (lymphocytes and other mononuclear immune cells) M.A.Kubtan

6. Microanatomy and physiology Lymphatics originate within the interstitial fluids space from specialised or non-endothelialised channels such as the spaces of Disse in the liver endothelialised capillaries • They are blind-ended; • They are much larger (50 mm); • They allow the entry of molecules of up to 1000 kDa in size • because the basement membrane is fenestrated, tenuous or • even absent and the endothelium itself possesses intra- and intercellular pores; • They are anchored to interstitial matrix by filaments. In the resting state, initial lymphatics are collapsed. When ISF volume and pressure increases, initial lymphatics and their pores are held open by these filaments to facilitate increased drainage. M.A.Kubtan

7. Terminal lymphatics • Initial lymphatics drain into terminal (collecting) lymphatics that • possess bicuspid valves and endothelial cells rich in the contractile protein actin. • Larger collecting lymphatics are surrounded by smooth muscle. Valves partition the lymphatics into segments (lymphangions) that contract sequentially to propel lymph into the lymph trunks. M.A.Kubtan

8. Lymph trunks • Terminal lymphatics lead to lymph trunks . • Have a structure similar to that of veins . a single layer of endothelial cells, lying on a basement membrane overlying a media comprising smooth muscle cells . • They are innervated with sympathetic, parasympathetic and sensory nerve endings. • About 10% of lymph arising from a limb is transported in deep lymphatic trunks that accompany the main neurovascular bundles. M.A.Kubtan

9. Continue • About 10% of lymph arising from a limb is transported in deep lymphatic trunks that accompany the main neurovascular bundles. • The majority, however, is conducted against venous flow from deep to superficial in epifascial lymph trunks. • Superficial trunks form lymph bundles of various sizes, which are located within strips of adipose tissue, and tend to follow the course of the major superficial veins. M.A.Kubtan

10. Starling’s forces The Starling equation is an equation that illustrates the role of hydrostaticand oncotic forces (the so-called Starling forces) in the movement of fluid across capillary membranes and lymphtics. Capillary fluid movement may occur as a result of three processes: • diffusion • filtration • pinocytosis M.A.Kubtan

11. Mechanisms of lymph transport • Transient increases in interstitial pressure secondary to • Muscular contraction and external compression; • The sequential contraction and relaxation of lymphangions; • The prevention of reflux because of valves. M.A.Kubtan

12. Lymphoedema Definition : an abnormal limb swelling caused by the accumulation of increased of high protein interstital fluids secondary to defective lymphatic drainage in the presence of near normal net capillary filtration . M.A.Kubtan

13. Symptoms frequently experienced by patients with lymphoedema • Constant dull ache, even severe pain • Burning and bursting sensations • General tiredness and debility • Sensitivity to heat • Pins and needles’ • Cramp • Skin problems including flakiness, weeping, excoriation and breakdown • Immobility, leading to obesity and muscle wasting • Backache and joint problems • Athlete’s foot • Acute infective episodes M.A.Kubtan

14. What every patient with lymphoedema should receive • An explanation of why the limb is swollen and the underlying cause • Guidance on skin hygiene and care and the avoidance of acute infective episodes • Anti-fungal prophylactic therapy to prevent athlete’s foot • Rapid access to antibiotic therapy if necessary, hospital admission for acute infective episodes M.A.Kubtan

15. Continue • Appropriate instructions regarding exercise therapy • Manual lymphatic drainage (MLD) • Multilayer lymphoedema bandaging (MLLB) • Compression garments and, if appropriate, specialised footwear • Weight loss • Access to support services and networks M.A.Kubtan

16. Classification of lymphoedema Two main types of lymphoedema are recognised: • primary lymphoedema, in which the cause is unknown (or at least uncertain and unproven); it is thought to be caused by‘congenital lymphatic dysplasia’; • secondary or acquired lymphoedema, in which there is a clear underlying cause. M.A.Kubtan

17. Causes of lymphatic oedema • Aplasia . • Hypoplasia . • Dysmotility (reduced contractility with or without valvular insufficiency) . • obliteration by inflammatory, infective or neoplastic processes . M.A.Kubtan

18. Pre disposing factors leading to lymphatic oedema • Trauma (particularly degloving injuries) • Secondary Parasitic infection (filariasis) • Surgical excision of lymph nodes ( Breast ) • Fungal infection (tinea pedis) • Exposure to foreign body material (silica particles) • Primary lymphatic malignancy • Metastatic spread to lymph nodes • Radiotherapy to lymph nodes • Sperficialthrombophlebitis • Deep venous thrombosis M.A.Kubtan

19. Symptoms frequently experienced by patients with lymphoedema • Constant dull ache , even sever pain . • Burning and bursting sensations. • General tiredness and debility . • Sensitivity to heat. • Pins and needles . • Cramp . • Skin problems including flakiness , weeping ,excoriation, and breakdown . • Immobility , leading to obesity and muscle wasting. • Backache and joint problems . • Athletes foot . • Acute infective episodes . M.A.Kubtan

20. Upper limb/trunk lymphoedema • Surgery with axillary lymph node dissection, particularly if extensive breast or lymph node surgery . • Radiotherapy to the breast or to the axillary, internal mammary or subclavicular lymph nodes or subclavicular lymph nodes . • Seroma formation , Advanced cancer . • Congenital predisposition . • Trauma in an ‘at-risk’ arm (venepuncture, blood pressure measurement, injection) M.A.Kubtan

21. Lower limb lymphoedema • Surgery with inguinal lymph node dissection . • Postoperative pelvic radiotherapy . • Recurrent soft tissue infection at the same site . • Obesity . • Varicose vein stripping and vein harvesting . • Genetic predisposition/family history of chronic oedema . • Intrapelvic or intra-abdominal tumours that involve or directly compress lymphatic vessels . • Living in or visiting an area for endemic lymphatic filariasis . M.A.Kubtan

22. The severity of unilateral limb lymphoedema can be classified as: • mild: < 20% excess limb volume; • moderate: 20–40% excess limb volume; • severe: > 40% excess limb volume. M.A.Kubtan

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25. Lymphatic filariasbancrofti M.A.Kubtan

26. Pressure garment M.A.Kubtan

27. ACUTE INFLAMMATION OF THELYMPHATICS Acute lymphangitis is an infection caused by: • Streptococcus Pyogenes. • Staphlococcusaureus . • Infection spreads to draining lymphatic channels and lymph nodes ( lymphangitis and lympadenitis ). • It may progress to bactaeremia , or septicaemia . M.A.Kubtan

28. The normal signs of lymphangitis • (Rubor, calor, dolor) . • Red streak is seen in the skin along the line of the inflamed lymphatic . • Same signs may applied to lymph nodes . M.A.Kubtan

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30. Management of subcutaneous lymphangitis • The limb should be rested . • Intravenous antibiotics . • Failure to improve within 48 hours me be caused by pus formation , and necessitate drainage of abscess and changing antibiotic . • There may be an underlying systemic disorder ( malignancy , immunodeficiency ) • The lymphatic damage by acute lymphangitis may lead to recurrent attacks of lymphangitis and lymphoedema . M.A.Kubtan