Download الجامعة السورية الدولية - موقع الدكتور عاصم قبطان

‫كلية الطب البشري‬
‫قسم الجـراحـة‬
‫الدكتور عاصم قبطان‬
‫‪MD - FRCS‬‬
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‫‪M.A.Kubtan‬‬
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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
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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
cisterna chyli into the thoracic duct, which in
turn drains into the left internal jugular vein
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The lymphatic system comprises :
 lymphatic channels
 lymphoid organs : (lymph nodes, spleen,
Peyer’s patches, thymus,tonsils)
 circulating elements (lymphocytes and other
mononuclear immune cells)
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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 intraand
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.
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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.
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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.
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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.
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The Starling equation is an equation that
illustrates the role of hydrostatic and 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
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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.
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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 .
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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
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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
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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
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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.
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Aplasia .
Hypoplasia .
Dysmotility (reduced contractility with or
without valvular insufficiency) .
obliteration by inflammatory, infective or
neoplastic processes .
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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
Sperficial thrombophlebitis
Deep venous thrombosis
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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 .
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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)
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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 .
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can be classified as:
 mild: < 20% excess limb volume;
 moderate: 20–40% excess limb volume;
 severe: > 40% excess limb volume.
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Pressure garment
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Acute lymphangitis is an infection caused by:
 Streptococcus Pyogenes.
 Staphlococcus aureus .
 Infection spreads to draining lymphatic
channels and lymph nodes ( lymphangitis and
lympadenitis ).
 It may progress to bactaeremia , or
septicaemia .
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(Rubor, calor, dolor) .
Red streak is seen in the skin along the line
of the inflamed lymphatic .
Same signs may applied to lymph nodes .
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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 .
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