Secondary Lymphoedema

Innumerous lymph collectors located within und directly underneath the skin tissue collect the interstitial fluid and transport it to the lymphatic vessels of the subcutaneous tissue. These lymphatic vessels form a well organised network with other superficial and deep lymphatic vessels.  Along with their tributaries the lymphatic vessels drain the collected lymph into the lymphatic nodes that are strategically placed in joint folds, viz., the elbows, arm pits, below and above the collar bones, behin the ears, in the neck etc.  All the lymph drain finally into the thoracic duct. The thoracic duct is the carrier of chyle, a mixture of lymphatic fluid and emulsified fats. The thoracic duct drains into systemic blood circulation at the confluence of the left subclavian vein and internal jugular vein.

Secondary lymphoedema occurs as a result of removal of all lymphnodes of a particular region. For example, women undergoing mastectomy and axillary lymphnode removal for breast cancer typically develop lymphoedema of the involved arm.

Wherever the axillary or inguinal lymph nodes have been completely removed, lymph drainage massage and bandages are neccessary thoughout life. Sometimes tertiary skin and soft tissue changes as well as peripheral nerve compression secondary to lymphoedema might occur, causing respective symptoms.

A selected cohort of patients usually within five years after total lymphnode removal, and/or intact lymph-pump function supported by adequate and disciplined physical therapy will benefit from the so called peripheral super-microsurgical lymphatic bypass surgery (or lymphovenous anastomoses). In this, the peripheral lymphatic vessels are connected to the superficial subcutaneous venules at several locations along the upper or lower extremity under maximum surgical microscopic magnification using microminiature suture material.  Thus the [removed] lymphnodes are bypassed at the peripheral level and the superficial venous network is used as the carrier of lymph.

A more complex, but less effective procedure is the autotransplantation of lymphnodes from some other part of the body, viz., part of the lymphnodes from the inguinal region of the healthy side may be transplanted as a free vascularised tissue flap into the axilla, where the lymph nodes have been removed. However, this surgical treatment is reserved for severe and highly selected cases of secondary lymphoedema.

Surgical treatment is usually followed and complemented by manual lymph drainage as well as device supported lymph drainage. In the latter, a multi-chamber cuff is applied to the affected arm and connected to the specially programmed pump. Lymph transport is assisted by serial and consequent pumping and release of the chambers of the cuff beginning from the periphery. Such devices offer precisely consistent regularity and uniformity of the compression that can not be provided by manual massages. Furthermore, the patients are able to apply this kind of therapy all by themselves several times a day.  Compression bandages play an equally important role in the treatment of chronic lymphoedema.