lymphedema

2. By
DR. Sameh Attia Ali Basha
Senior Registrar Vascular Surgery
MBBCh, MSc, MRCS(A), EBVS, MD

4. APPLIED
ANATOMY

6. Components of the Lymphatic
Vessels
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• Lymphatic Vessels
– Lymphatic Capillaries
– Lymphatic Vessels
– Lymphatic Trunks
– Lymphatic Ducts

8. Lymphatic Capillaries
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Features of structure :
• Single layer of overlapping
endothelial cells
• More permeable than that of
blood capillary
• Absent from avascular
structures, brain, spinal cord
splenic pulp and bone
marrow

9. Lymphatic Capillaries –Lacteals
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• The small intestine contains special
types of lymphatic capillaries called
lacteals .
• Lacteals pick up not only interstitial
fluid, but also dietary lipids and lipid-
soluble vitamins .

10. Lymphatic Vessels
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Features of structure
Three layered wall but thinner than
vein
More numerous valves than in vein
Interposed by lymph nodes at
intervals
Arranged in superficial and deep sets

11. LYMPHATIC DUCTS
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Right lymphatic duct
 Formed by union of
right jugular,
subclavian, and
bronchomediastinal
trunks

12. Thoracic duct
• Begins in front of L1 as a dilated
sac, the cisterna chyli
• formed by left and right lumbar
trunks and intestinal trunk
• Enter thoracic cavity & ascends
upward, veering to the left at the
level of T5
LYMPHATIC
DUCTS

13. THORACIC DUCT …
..
• At the root of the neck, it turns
laterally
• arches forwards and descends
to enter the left venous angle
• before termination, it receives
the left jugular, Subclavian and
broncho-mediastinal trunk

14. DRAINAGE PATTERN
THORACIC DUCT - Drains lymph from lower
limbs, pelvic cavity, abdominal cavity, left side of
thorax, and left side of the head, neck and left
RIGHT LYMPHATIC DUCT -
Receives lymph from right
half of head, neck, thorax
and right upper limb, right
lung, right side of heart,
right surface of liver

16. DISEASES

17. LYMPHANGITIS
• Inflammation of the
lymph vessels
• Commonest cause
bacteria called
streptococcus
pyogenes(most
common(

18. The etiologic agents of acute lymphangitis are
different from those noted in patients with chronic
lymphangitis, in whom parasitic (usually filariasis) and
fungal infections predominate.
D.D
Thrombophlebitis
CCC by The presence of an indurated great
saphenous vein and absence of tender inguinal
lymph nodes .

23. Secondary lymphedema is much more common than
the primary form and can result from anything that
leads to the destruction of lymphatic vessels or nodes.
In the developed countries, most cases
are secondary to surgical interventions and radiation
treatment, usually related to cancer.
Worldwide,filariasis is the most common cause of
lymphedema

24. FILARIASIS

27. Stemmer sign is a classic
feature of
lymphedema and denotes the
inability to pinch the skin
on the dorsum of the second
digit of the foot

28. In extreme cases, particularly those produced by
tropical filariae, the limb may associated with massive
edema, fibrosis, and verrucous changes , This
appearance is commonly called elephantiasis.

30. The two reliable tests used to assess lymphatic
patency are lymphangiography and
lymphoscintigraphy. They provide both anatomic and
functional information.
Lymphangiography involves cannulation of a distal
lymphatic vessel via a surgical incision. Contrast dye
is injected into the cannulated vessel, and x-ray
images are obtained.
The study provides a detailed view of the lymph
vessels and nodes.

32. Lymphoscintigraphy involves the subcutaneous
injection of a radiolabeled colloid into the distal
extremity.The colloid travels through lymphatic
vessels and nodes, and its flow can be assessed using
traditional nuclear imaging cameras.
In normal subjects, transport to the abdominal level
occurs in 1 hour or less. When lymphatic obstruction
is present, the colloid never ascends the lymphatics
but instead becomes trapped in the interstitial
spaces of the distal limb.

36. D.D
In addition to venous diseases, there are other
conditions that can mimic lymphedema :
Myxedema associated with thyroid dysfunction
cardiac or renal failure
hypoproteinemia
chronic dependency can resemble lymphedema .
Obesity (including morbid obesity and lipedema) .

39. Conservative therapy is traditionally the
preferred initial approach.However, improving
microsurgical techniques may eventually lead to their
wider and earlier applicationThe use of pharmacologic
methods in lymphedema is limited.
Diuretics are generally not recommended
because of the risk of increased fibrosis and
worsening fluid accumulation

42. Stockings generally is generally recommended that
pressures be 30 to 40 mm Hg, also compression of 50
to 60 mm Hg (or more) may be necessary to
adequately control edema.

47. Lymphatic Tumors
A rare tumor which reveals the sequela of long-standing
peripheral lymphedema is the occurrence of
lymphangiosarcoma and/or angiosarcoma.
This aggressive vascular malignancy was once thought to
arise exclusively in the aftermath of radical mastectomy and
irradiation for the local control of breast cancer.
Lymphangiosarcoma, however, has now been documented in
other secondary lymphedemas and even in congenital or
primary lymphedema.

48. Lymphangiectasia
is a pathologic dilation of lymph vessels.When it
occurs rarely in humans, it causes a disease known as
"intestinal lymphangiectasia".This disease is
characterized by lymphatic
vessel dilation, chronic diarrhea and loss
of proteins such as serum albumin and globulin. It is
considered to be a chronic form of protein-losing
enteropathy.

49. Lymphangiomas
are malformations of the lymphatic system
characterized by lesions that are thin-walled cysts.
These malformations can occur at any age and may
involve any part of the body, but 90% occur in children
less than 2 years of age and involve the head and
neck.
There are three distinct types of lymphangioma, each
with their own symptoms. They are distinguished by
the depth and the size of abnormal lymph vessels :

50. Lymphangioma circumscriptum, a microcystic
lymphatic malformation, resembles clusters of small
blisters.
Cavernous lymphangiomas are generally present at
birth, but may appear later in the child's life.
Cystic hygroma shares many commonalities with
cavernous lymphangiomass. However, cystic
lymphangiomas usually have a softer consistency
than cavernous lymphangiomas
The direct cause of lymphangioma is a blockage of the
lymphatic system as a fetus develops.