Diseases ofDiseases ofLymphatic systemLymphatic systemDR. NADIR MEHMOODDR. NADIR MEHMOODASSISTANT PROFESSORASSISTANT PROFESSOROF SURGERYOF SURGERYDHQ HOSPITAL,DHQ HOSPITAL,RAWALPINDIRAWALPINDI
ReferenceReferenceBAILEY AND LOVE’S SHORT PRACTICEBAILEY AND LOVE’S SHORT PRACTICEOF SURGERY, PAGE 944-958OF SURGERY, PAGE 944-958
LEARNIG OBJECTIVESLEARNIG OBJECTIVES DESCRIBE FUNCTIONS OF LYMPHATICDESCRIBE FUNCTIONS OF LYMPHATICSYSTEMSYSTEM DEFINE AND CLASSIFY LYMPHEDEMADEFINE AND CLASSIFY LYMPHEDEMA ENUMERATE THE SIGN AND SYMPTOMSENUMERATE THE SIGN AND SYMPTOMSOF LYMPHATIC DISEASESOF LYMPHATIC DISEASES ENUMERATE THE FACTORS LEADING TOENUMERATE THE FACTORS LEADING TOLYMPHEDEMALYMPHEDEMA DESCRIBE THE SEC L EDEMA IN CADESCRIBE THE SEC L EDEMA IN CABREASTBREAST DESCRIBE DIAGNOSTICDESCRIBE DIAGNOSTICINVESTIGATIONS IN A CASE OFINVESTIGATIONS IN A CASE OFLYMPHATIC OBSTRUCTIONLYMPHATIC OBSTRUCTION ENLIST TREATMENT OPTIONS FORENLIST TREATMENT OPTIONS FOR
ANOTOMY OF THEANOTOMY OF THELYMPHATICSLYMPHATICSLymphatic system consist of:-Lymphatic system consist of:-1)1) Peripheral lymph vessels ( consist of single layer ofPeripheral lymph vessels ( consist of single layer ofattenuated endothelial cells, no basementattenuated endothelial cells, no basementmembrane)membrane)2)2) Lymph nodesLymph nodes3)3) Major lymphatic trunksMajor lymphatic trunksFUNCTIONFUNCTION:- primary function is to transport extracellular fluid:- primary function is to transport extracellular fluidfrom the interstitial space back to blood stream, act asfrom the interstitial space back to blood stream, act asprotective filter against foreign body invasionprotective filter against foreign body invasionTotal lymph return to the venous circulation in 24 hours aboutTotal lymph return to the venous circulation in 24 hours about2-4 liters.2-4 liters.
Superficial and deep lymphaticsSuperficial and deep lymphatics Thoracic ductThoracic duct Cisterna chyliCisterna chyli Right lymphatic ductRight lymphatic ductMajor lymph-collecting vesselsMajor lymph-collecting vessels
Other Lymphoid OrgansOther Lymphoid Organs Several otherSeveral otherorgans contributeorgans contributeto lymphaticto lymphaticfunction:function: SpleenSpleen ThymusThymus TonsilsTonsils Peyer’s patchesPeyer’s patches
21-21-99Mechanisms of Lymph FlowMechanisms of Lymph Flow Lymph flows at low pressure and speedLymph flows at low pressure and speed Moves along by rhythmic contractions of lymphaticMoves along by rhythmic contractions of lymphaticvesselsvessels stretching of vessels stimulates contractionstretching of vessels stimulates contraction Flow aided by skeletal muscle pumpFlow aided by skeletal muscle pump Thoracic pump aids flow from abdominal to thoracicThoracic pump aids flow from abdominal to thoraciccavitycavity Valves prevent backward flowValves prevent backward flow Rapidly flowing blood in subclavian veins, drawsRapidly flowing blood in subclavian veins, drawslymph into itlymph into it Exercise significantly increases lymphatic returnExercise significantly increases lymphatic return
LymphedemaLymphedema Excessive and persistent accumulation ofExcessive and persistent accumulation ofextravascular and extracellular fluid and proteinsextravascular and extracellular fluid and proteinsin tissue spacesin tissue spaces Caused by a disturbance of the water andCaused by a disturbance of the water andprotein balance across the capillary membraneprotein balance across the capillary membrane Increased concentration of proteins drawsIncreased concentration of proteins drawsgreater amount of water into interstitial spacesgreater amount of water into interstitial spaces Exceeds transport capacity of the lymphaticExceeds transport capacity of the lymphaticsystem, leading to lymphedemasystem, leading to lymphedema
Disorders of the Lymphatic SystemDisorders of the Lymphatic SystemLeading to Lymphatic InsufficiencyLeading to Lymphatic Insufficiency Primary (Congenital) MalformationPrimary (Congenital) Malformation Infection and InflammationInfection and Inflammation Obstruction or FibrosisObstruction or FibrosisTrauma, Surgery, NeoplasmsTrauma, Surgery, NeoplasmsRadiation TherapyRadiation Therapy Surgical Dissection of Lymph NodesSurgical Dissection of Lymph Nodes Chronic Venous InsufficiencyChronic Venous Insufficiency
COMMON CAUSES OF LYMPHOEDEMACOMMON CAUSES OF LYMPHOEDEMA1)1) Bacterial infection.Bacterial infection.2)2) Parasitic infestation (Filariasis).Parasitic infestation (Filariasis).3)3) Fungal infection (tinea pedis).Fungal infection (tinea pedis).4)4) Exposure to foreign body material (SilicaExposure to foreign body material (SilicaParticles).Particles).5)5) Primary lymphatic malignancy.Primary lymphatic malignancy.6)6) Metastatic spread to lymph nodes.Metastatic spread to lymph nodes.7)7) Surgical excision of lymph nodes.Surgical excision of lymph nodes.8)8) Trauma (Particularly degloving injuries).Trauma (Particularly degloving injuries).9)9) Superficial thrombophlebetis (acute Cellulites).Superficial thrombophlebetis (acute Cellulites).10)10) Deep venous thrombosis.Deep venous thrombosis.11)11) Factitious lymphoedema- tourniquet or hystericalFactitious lymphoedema- tourniquet or hystericalmisuse.misuse.
PATHOPHYSIOLOGYPATHOPHYSIOLOGYDue to any causeDue to any cause out flow due toout flow due tosclerosis or obliterations of lymphsclerosis or obliterations of lymphchannel, lymphatic hypertensionchannel, lymphatic hypertensionDecrease in contractility valvularDecrease in contractility valvularimpairment lymph stasis accumulation ofimpairment lymph stasis accumulation offluid, proteins, and other active peptidesfluid, proteins, and other active peptidesfibroblasts and accumulation offibroblasts and accumulation ofinflammatory cells and activation ofinflammatory cells and activation ofkeratinocytes.keratinocytes. Proteins rich oedema,Proteins rich oedema,Sub dermal fibrosis, dermal thickening andSub dermal fibrosis, dermal thickening andproliferations.proliferations.
Clinical Signs and Symptoms ofClinical Signs and Symptoms ofLymphedemaLymphedema Edema of the dorsum of the foot orEdema of the dorsum of the foot orhand (Lymphedema)hand (Lymphedema) Increased girth and weight of the limbIncreased girth and weight of the limb Decreased range of motion, flexibilityDecreased range of motion, flexibilityand functionand function Usually unilateralUsually unilateral Worse after prolonged dependencyWorse after prolonged dependency No discomfort or a dull, heavyNo discomfort or a dull, heavysensation; sense of fullnesssensation; sense of fullness
Lymphedema- swelling in tissues- due to infection, tumor pressure,parasites, or surgeryBlockage of lymphdrainage
Severity of LymphedemaSeverity of Lymphedema Mild lymphedema: One to two cm increase inMild lymphedema: One to two cm increase ingirth measurements between the involved andgirth measurements between the involved andnon-involved limbnon-involved limb Moderate lymphedema: Two to five cm increaseModerate lymphedema: Two to five cm increasein girth measurementin girth measurement Severe lymphedema: Greater than five cmSevere lymphedema: Greater than five cmincreaseincrease
Clinical grades (Brunners) ofClinical grades (Brunners) oflymphedemalymphedema Subclinical/ latentSubclinical/ latent I. Edema pits on pressure and swellingI. Edema pits on pressure and swellingdisappears on rest and elevationdisappears on rest and elevation II. Edema does not pit nor reduce onII. Edema does not pit nor reduce onelevationelevation III. Edema with irreversible skin changes-III. Edema with irreversible skin changes-fibrosis and papillaefibrosis and papillae
Types of LymphedemaTypes of Lymphedema Pitting edemaPitting edemaShort duration edemaShort duration edemaFinger indentation of the skinFinger indentation of the skin Brawny edemaBrawny edemaTissue feels hard upon palpationTissue feels hard upon palpationIndicates fibrotic changesIndicates fibrotic changes WeepingWeepingFluid leaks, wound healing is impairedFluid leaks, wound healing is impairedOccurs mostly in the lower extremitiesOccurs mostly in the lower extremities
Examination and Evaluation ofExamination and Evaluation ofLymphatic FunctionLymphatic FunctionSpecial ConsiderationsSpecial Considerations History, systems reviewHistory, systems review Daily activities and position of limbDaily activities and position of limb Functional assessmentFunctional assessment Skin integritySkin integrity Girth measurementsGirth measurements Volume measurementsVolume measurements
INVESTIGATIONSINVESTIGATIONS Routine Tests:Routine Tests:Blood C/P, urinalysis, urea and electrolytesBlood C/P, urinalysis, urea and electrolytesLFT, CXR, midnight blood smear for microLFT, CXR, midnight blood smear for microfilaria.filaria. Contrast LymphangiographyContrast Lymphangiography(Now reserves for preoperative(Now reserves for preoperativeinvestigations for lymphvenous bypass)investigations for lymphvenous bypass)Isotope LymphoscintigraphyIsotope LymphoscintigraphyComputerized TomographyComputerized TomographyMRIMRIHistopathology (Suspected malignancy)Histopathology (Suspected malignancy)
MANAGEMENT OF LYMPHOEDEMAMANAGEMENT OF LYMPHOEDEMA ElevationElevation Manual lymphatic drainageManual lymphatic drainage CompressionCompression ExerciseExercise && Weight reductionWeight reduction Skin careSkin care Daily living precautionsDaily living precautions DrugsDrugsAntibioticsAntibiotics Penicillin’s / Erythrocin,Penicillin’s / Erythrocin,Cotrimazole/ GrisflovinCotrimazole/ Grisflovin SURGERYSURGERY
CompressionCompression No-stretch, non-elastic or low-stretchNo-stretch, non-elastic or low-stretchelastic bandages are usedelastic bandages are used Sports bandages are NOT recommendedSports bandages are NOT recommendedin the treatment of lymphedemain the treatment of lymphedema Compressive garments are availableCompressive garments are available Use of a sequential, pneumaticUse of a sequential, pneumaticcompression pump on a daily basis maycompression pump on a daily basis maybe recommendedbe recommended
SKIN CARESKIN CARE Lymphedema increases risk of skin breakdown,Lymphedema increases risk of skin breakdown,infection, and delayed wound healinginfection, and delayed wound healing PROTECT HANDSPROTECT HANDS AVOID BARE FOOT WALKAVOID BARE FOOT WALK USE ELECTRIC RAZOR TO DEPILATEUSE ELECTRIC RAZOR TO DEPILATE AVOID SKIN MACERATIONAVOID SKIN MACERATION ANTI MOSQUITO PRECAUTIONSANTI MOSQUITO PRECAUTIONS SEEK MED TREAT EARLY IN CASE OFSEEK MED TREAT EARLY IN CASE OFREDNESS, SWELLING, PAIN ETCREDNESS, SWELLING, PAIN ETC AVOID TAKING BLOOD SAMPLES FROMAVOID TAKING BLOOD SAMPLES FROMAFFECTED LIMBAFFECTED LIMB USE OF SUNBLOCK WHEN NEEDEDUSE OF SUNBLOCK WHEN NEEDED
SURGERYSURGERY BYPASSBYPASS Procedures.Procedures. LimbLimb REDUCTIONREDUCTION Procedures.Procedures. Sis trunk OperationSis trunk Operation(Skin + S/C)(Skin + S/C) PRIMARY ClosurePRIMARY Closure Homan OperationHoman OperationSkin flaps are elevated and subcutaneousSkin flaps are elevated and subcutaneoustissue is excised.tissue is excised. Thompson OperationThompson Operation: - buried dermal: - buried dermalflap.flap. Charles OperationCharles Operation: - all skin /S/C tissue is: - all skin /S/C tissue isexcised to deep fascia with coverage SSG.excised to deep fascia with coverage SSG.