2. Diseases ofDiseases of
Lymphatic systemLymphatic system
DR. NADIR MEHMOODDR. NADIR MEHMOOD
ASSISTANT PROFESSORASSISTANT PROFESSOR
OF SURGERYOF SURGERY
DHQ HOSPITAL,DHQ HOSPITAL,
RAWALPINDIRAWALPINDI

3. ReferenceReference
BAILEY AND LOVE’S SHORT PRACTICEBAILEY AND LOVE’S SHORT PRACTICE
OF SURGERY, PAGE 944-958OF SURGERY, PAGE 944-958

4. LEARNIG OBJECTIVESLEARNIG OBJECTIVES
 DESCRIBE FUNCTIONS OF LYMPHATICDESCRIBE FUNCTIONS OF LYMPHATIC
SYSTEMSYSTEM
 DEFINE AND CLASSIFY LYMPHEDEMADEFINE AND CLASSIFY LYMPHEDEMA
 ENUMERATE THE SIGN AND SYMPTOMSENUMERATE THE SIGN AND SYMPTOMS
OF LYMPHATIC DISEASESOF LYMPHATIC DISEASES
 ENUMERATE THE FACTORS LEADING TOENUMERATE THE FACTORS LEADING TO
LYMPHEDEMALYMPHEDEMA
 DESCRIBE THE SEC L EDEMA IN CADESCRIBE THE SEC L EDEMA IN CA
BREASTBREAST
 DESCRIBE DIAGNOSTICDESCRIBE DIAGNOSTIC
INVESTIGATIONS IN A CASE OFINVESTIGATIONS IN A CASE OF
LYMPHATIC OBSTRUCTIONLYMPHATIC OBSTRUCTION
 ENLIST TREATMENT OPTIONS FORENLIST TREATMENT OPTIONS FOR

5. ANOTOMY OF THEANOTOMY OF THE
LYMPHATICSLYMPHATICS
Lymphatic system consist of:-Lymphatic system consist of:-
1)1) Peripheral lymph vessels ( consist of single layer ofPeripheral lymph vessels ( consist of single layer of
attenuated endothelial cells, no basementattenuated endothelial cells, no basement
membrane)membrane)
2)2) Lymph nodesLymph nodes
3)3) Major lymphatic trunksMajor lymphatic trunks
FUNCTIONFUNCTION:- primary function is to transport extracellular fluid:- primary function is to transport extracellular fluid
from the interstitial space back to blood stream, act asfrom the interstitial space back to blood stream, act as
protective filter against foreign body invasionprotective filter against foreign body invasion
Total lymph return to the venous circulation in 24 hours aboutTotal lymph return to the venous circulation in 24 hours about
2-4 liters.2-4 liters.

6.  Superficial and deep lymphaticsSuperficial and deep lymphatics
 Thoracic ductThoracic duct
 Cisterna chyliCisterna chyli
 Right lymphatic ductRight lymphatic duct
Major lymph-collecting vesselsMajor lymph-collecting vessels

7. Lymph NodesLymph Nodes

8. Other Lymphoid OrgansOther Lymphoid Organs
 Several otherSeveral other
organs contributeorgans contribute
to lymphaticto lymphatic
function:function:
 SpleenSpleen
 ThymusThymus
 TonsilsTonsils
 Peyer’s patchesPeyer’s patches

9. 21-21-99
Mechanisms 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 lymphatic
vesselsvessels
 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 thoracic
cavitycavity
 Valves prevent backward flowValves prevent backward flow
 Rapidly flowing blood in subclavian veins, drawsRapidly flowing blood in subclavian veins, draws
lymph into itlymph into it
 Exercise significantly increases lymphatic returnExercise significantly increases lymphatic return

10. LymphedemaLymphedema
 Excessive and persistent accumulation ofExcessive and persistent accumulation of
extravascular and extracellular fluid and proteinsextravascular and extracellular fluid and proteins
in tissue spacesin tissue spaces
 Caused by a disturbance of the water andCaused by a disturbance of the water and
protein balance across the capillary membraneprotein balance across the capillary membrane
 Increased concentration of proteins drawsIncreased concentration of proteins draws
greater amount of water into interstitial spacesgreater amount of water into interstitial spaces
 Exceeds transport capacity of the lymphaticExceeds transport capacity of the lymphatic
system, leading to lymphedemasystem, leading to lymphedema

11. Disorders of the Lymphatic SystemDisorders of the Lymphatic System
Leading to Lymphatic InsufficiencyLeading to Lymphatic Insufficiency
 Primary (Congenital) MalformationPrimary (Congenital) Malformation
 Infection and InflammationInfection and Inflammation
 Obstruction or FibrosisObstruction or Fibrosis
Trauma, Surgery, NeoplasmsTrauma, Surgery, Neoplasms
Radiation TherapyRadiation Therapy
 Surgical Dissection of Lymph NodesSurgical Dissection of Lymph Nodes
 Chronic Venous InsufficiencyChronic Venous Insufficiency

12. COMMON CAUSES OF LYMPHOEDEMACOMMON CAUSES OF LYMPHOEDEMA
1)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 (Silica
Particles).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 hysterical
misuse.misuse.

13. PATHOPHYSIOLOGYPATHOPHYSIOLOGY
Due to any causeDue to any cause  out flow due toout flow due to
sclerosis or obliterations of lymphsclerosis or obliterations of lymph
channel, lymphatic hypertensionchannel, lymphatic hypertension
Decrease in contractility valvularDecrease in contractility valvular
impairment lymph stasis accumulation ofimpairment lymph stasis accumulation of
fluid, proteins, and other active peptidesfluid, proteins, and other active peptides
fibroblasts and accumulation offibroblasts and accumulation of
inflammatory cells and activation ofinflammatory cells and activation of
keratinocytes.keratinocytes.  Proteins rich oedema,Proteins rich oedema,
Sub dermal fibrosis, dermal thickening andSub dermal fibrosis, dermal thickening and
proliferations.proliferations.

14. Clinical Signs and Symptoms ofClinical Signs and Symptoms of
LymphedemaLymphedema
 Edema of the dorsum of the foot orEdema of the dorsum of the foot or
hand (Lymphedema)hand (Lymphedema)
 Increased girth and weight of the limbIncreased girth and weight of the limb
 Decreased range of motion, flexibilityDecreased range of motion, flexibility
and functionand function
 Usually unilateralUsually unilateral
 Worse after prolonged dependencyWorse after prolonged dependency
 No discomfort or a dull, heavyNo discomfort or a dull, heavy
sensation; sense of fullnesssensation; sense of fullness

15. Lymphedema
- swelling in tissues
- due to infection, tumor pressure,
parasites, or surgery
Blockage of lymph
drainage

17. Elephantiasis
– blockage by
parasitic worms

18. Secondary Lymph oedemaSecondary Lymph oedema
after radical mastectomyafter radical mastectomy

19. Role of Lymph Vessels in Metastasis

20. Severity of LymphedemaSeverity of Lymphedema
 Mild lymphedema: One to two cm increase inMild lymphedema: One to two cm increase in
girth measurements between the involved andgirth measurements between the involved and
non-involved limbnon-involved limb
 Moderate lymphedema: Two to five cm increaseModerate lymphedema: Two to five cm increase
in girth measurementin girth measurement
 Severe lymphedema: Greater than five cmSevere lymphedema: Greater than five cm
increaseincrease

21. Clinical grades (Brunners) ofClinical grades (Brunners) of
lymphedemalymphedema
 Subclinical/ latentSubclinical/ latent
 I. Edema pits on pressure and swellingI. Edema pits on pressure and swelling
disappears on rest and elevationdisappears on rest and elevation
 II. Edema does not pit nor reduce onII. Edema does not pit nor reduce on
elevationelevation
 III. Edema with irreversible skin changes-III. Edema with irreversible skin changes-
fibrosis and papillaefibrosis and papillae

22. Types of LymphedemaTypes of Lymphedema
 Pitting edemaPitting edema
Short duration edemaShort duration edema
Finger indentation of the skinFinger indentation of the skin
 Brawny edemaBrawny edema
Tissue feels hard upon palpationTissue feels hard upon palpation
Indicates fibrotic changesIndicates fibrotic changes
 WeepingWeeping
Fluid leaks, wound healing is impairedFluid leaks, wound healing is impaired
Occurs mostly in the lower extremitiesOccurs mostly in the lower extremities

24. Examination and Evaluation ofExamination and Evaluation of
Lymphatic FunctionLymphatic Function
Special 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

25. INVESTIGATIONSINVESTIGATIONS
 Routine Tests:Routine Tests:
Blood C/P, urinalysis, urea and electrolytesBlood C/P, urinalysis, urea and electrolytes
LFT, CXR, midnight blood smear for microLFT, CXR, midnight blood smear for micro
filaria.filaria.
 Contrast LymphangiographyContrast Lymphangiography
(Now reserves for preoperative(Now reserves for preoperative
investigations for lymphvenous bypass)investigations for lymphvenous bypass)
Isotope LymphoscintigraphyIsotope Lymphoscintigraphy
Computerized TomographyComputerized Tomography
MRIMRI
Histopathology (Suspected malignancy)Histopathology (Suspected malignancy)

26. MANAGEMENT OF LYMPHOEDEMAMANAGEMENT OF LYMPHOEDEMA
 ElevationElevation
 Manual lymphatic drainageManual lymphatic drainage
 CompressionCompression
 ExerciseExercise && Weight reductionWeight reduction
 Skin careSkin care
 Daily living precautionsDaily living precautions
 DrugsDrugs
AntibioticsAntibiotics Penicillin’s / Erythrocin,Penicillin’s / Erythrocin,
Cotrimazole/ GrisflovinCotrimazole/ Grisflovin
 SURGERYSURGERY

27. Manual Lymphatic DrainageManual Lymphatic Drainage

28. Manual Lymphatic DrainageManual Lymphatic Drainage

29. CompressionCompression
 No-stretch, non-elastic or low-stretchNo-stretch, non-elastic or low-stretch
elastic bandages are usedelastic bandages are used
 Sports bandages are NOT recommendedSports bandages are NOT recommended
in the treatment of lymphedemain the treatment of lymphedema
 Compressive garments are availableCompressive garments are available
 Use of a sequential, pneumaticUse of a sequential, pneumatic
compression pump on a daily basis maycompression pump on a daily basis may
be recommendedbe recommended

30. BandagesBandages

31. Compressive BandagesCompressive Bandages

33. Compression GarmentsCompression Garments

34. Sequential, Pneumatic PumpsSequential, Pneumatic Pumps

35. 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 OF
REDNESS, SWELLING, PAIN ETCREDNESS, SWELLING, PAIN ETC
 AVOID TAKING BLOOD SAMPLES FROMAVOID TAKING BLOOD SAMPLES FROM
AFFECTED LIMBAFFECTED LIMB
 USE OF SUNBLOCK WHEN NEEDEDUSE OF SUNBLOCK WHEN NEEDED

36.  SURGERYSURGERY
 BYPASSBYPASS Procedures.Procedures.
 LimbLimb REDUCTIONREDUCTION Procedures.Procedures.
 Sis trunk OperationSis trunk Operation
(Skin + S/C)(Skin + S/C)  PRIMARY ClosurePRIMARY Closure
 Homan OperationHoman Operation
Skin flaps are elevated and subcutaneousSkin flaps are elevated and subcutaneous
tissue is excised.tissue is excised.
 Thompson OperationThompson Operation: - buried dermal: - buried dermal
flap.flap.
 Charles OperationCharles Operation: - all skin /S/C tissue is: - all skin /S/C tissue is
excised to deep fascia with coverage SSG.excised to deep fascia with coverage SSG.

37. Any Questions???Any Questions???
THANK YOU