带淋巴结游离皮瓣移植治疗乳腺癌术后淋巴水肿的围术期护理

目的 总结带淋巴结腹股沟游离皮瓣移植治疗乳腺癌术后上肢淋巴水肿的围术期护理方法.方法 对10例带淋巴结腹股沟游离皮瓣移植术治疗乳腺癌术后上肢淋巴水肿患者,进行术前心理护理、手术区皮肤准备,术后实施淋巴排水按摩、严密细致观察皮瓣血运、控制疼痛、禁烟、体位护理等.结果 10例带淋巴结的腹股沟游离皮瓣移植全部成活,上肢淋巴水肿逐渐消退.结论 带淋巴结腹股沟游离皮瓣移植能有效治疗乳腺癌术后上肢淋巴水肿,术后密切观察移植区皮肤色泽、温度,促进局部血液循环,做好健康教育能促进皮瓣成活,保证治疗效果.     

背阔肌淋巴结皮瓣游离移植治疗淋巴水肿围手术期的护理经验

目的总结背阔肌淋巴结皮瓣游离移植治疗淋巴水肿的围手术期的护理方法。方法 2020年5月至2022年5月, 中山大学附属第一医院显微创伤手外科应用背阔肌淋巴结皮瓣游离移植治疗下肢淋巴水肿患者15例, 病程4个月～15年, 平均6.13年, 淋巴水肿分期为Ⅱ～Ⅲ期;在围手术期构建和实施标准化护理干预, 包括术前肢体肿胀监测、淋巴引流手法按摩和使用弹力袜, 术后常见并发症的观察和护理、改良淋巴引流手法按摩、制定淋巴水肿患者康复手册、开展淋巴水肿患者延续性护理和"互联网+"护理模式等标准化护理措施, 采用门诊及微信随访, 比较术后移植皮瓣成活例数、肿胀肢体周径及是否出现淋巴管炎。结果 15例患者移植皮瓣均成活。随访6～12个月, 临床症状均有改善, 淋巴管炎发作频率较术前减少, 水肿肢体手术前、后的下肢周径分别为(42.85±6.96)cm、(40.24±8.61)cm, 在髌骨下缘远侧5.0 cm平面, 术后患侧周径较术前改善1.0～9.1 cm, 手术后患侧与健侧的周径差值较术前明显减小(P=0.04)。结论背阔肌淋巴结皮瓣游离移植结合围手术期的标准化护理干预措施能有效促进移植皮瓣成活和肿...     

薄层血管化腹股沟淋巴结皮瓣移植联合反向淋巴显影在继发性上肢淋巴水肿手术中的应用

目的 探讨薄层血管化腹股沟淋巴结皮瓣移植联合反向淋巴显影在继发性上肢淋巴水肿手术中的应用效果。方法 2019年7月至2020年9月,应用吲哚菁绿、美蓝双染法引导的反向淋巴显影术,制备薄层游离血管化腹股沟淋巴结皮瓣,切取后移植于患侧上肢,治疗乳腺癌术后继发性淋巴水肿患者5例。皮瓣约10 cm×5 cm大小,平均厚度约0.7 cm,切取供区淋巴结约2～3枚,术后随访7～15个月。结果 5例皮瓣存活良好,淋巴结均存活。术后随访显示,患肢臂围均于1.5个月后出现明显缩小,供区无并发症。结论 联合反向淋巴显影技术完成的薄层血管化淋巴结游离皮瓣移植治疗继发性上肢淋巴水肿疗效优良,明显改善患肢臃肿外形。     

携带淋巴结的组织瓣移植治疗下肢淋巴水肿

目的 探讨携带淋巴结的组织瓣移植治疗下肢淋巴水肿的疗效。方法 2019年6月至2021年6月,采用携带淋巴结的组织瓣移植治疗Ⅱ～Ⅲ期下肢淋巴水肿5例,皮瓣大小（10～30） cm×（4～9） cm,受区选择患肢小腿区,受区血管为胫前动脉及伴行静脉,术后定期随访。结果 1例皮瓣术后部分坏死,予以换药对症治疗后,创面瘢痕愈合,其余4例移植皮瓣顺利成活。术后随访0.5～2年,患肢周径于术后1个月及6个月平均减少0.84 cm及2.29 cm,术后未出现淋巴管炎,供区未出现淋巴漏及淋巴水肿。结论 应用淋巴结皮瓣移植治疗肢体淋巴水肿近期疗效较好,供区无并发症,是早中期下肢淋巴水肿可选择的治疗方法之一。     

带血运淋巴结移植治疗肢体淋巴水肿的研究进展

目的综述带血运淋巴结移植治疗肢体淋巴水肿的动物及临床研究进展。方法广泛查阅近年来国内外有关带血运淋巴结移植治疗肢体淋巴水肿的相关研究文献,进行分析总结。结果动物实验提示,与无血管吻合的淋巴结移植相比,带血运淋巴结移植可提高淋巴结成活率,有效减轻肢体淋巴水肿。虹吸假说和淋巴结泵假说是淋巴结移植治疗淋巴水肿两种主要可能机制,但目前均缺少确切的证据证实。临床研究提示,带血运淋巴结移植可显著降低患肢水肿程度,但研究随访时间较短,因远期存在淋巴水肿复发风险,所以该术式疗效有待长期、大规模临床研究进一步验证。结论带血运淋巴结移植可以有效缓解淋巴水肿症状,但其有效性及机制仍需要进一步研究。     

血管化淋巴结皮瓣移植治疗下肢淋巴水肿的研究进展

下肢淋巴水肿的治疗是临床研究中的难点和重点。严重的下肢淋巴水肿对患者的生存质量影响极大。近年来,血管化淋巴结皮瓣移植作为一种新兴的手术方式,对重度下肢淋巴水肿具有较好的治疗效果。本文对血管化淋巴结皮瓣移植的作用机制、手术方式、辅助手段、常见并发症等方面的研究进展进行综述。     

人工血管复合皮瓣移植修复濒临截肢肢体

目的：报道急诊人工血管复合皮瓣移植修复濒临截肢肢体的临床效果。方法：采用Ｇｏｒｅ－Ｔｅｘ膨体泡沫聚四氯乙烯（ｅＰＴＦＥ）人工血管复合游离脐旁皮瓣、游离或带血管蒂的背阔肌皮瓣移植，修复上肢皮肤、软组织及肌肉缺损，同时重建前臂血管。结果：修复严重创伤上肢５例，游离脐旁皮瓣移植２例，游离背阔肌皮瓣移植２例，带血管蒂背阔肌皮瓣移植１例及采用直径５ｍｍｅＰＴＥＥ５条重建桡或尺动脉，皮瓣全部成活，肢体血运良好。经５～２０个月随访，所有经复合人工血管及皮瓣修肢体均得到保留及恢复基本功能。结论：采用人工血管复合皮瓣移植修复濒临截肢肢体，通过显微外科技术，可重建其活力及功能。     

皮肤与骨骼复合缺损的修复

目的 探讨显微外科修复肢体骨与皮肤复合缺损的技术和效果。方法 39例肢体骨与皮肤复合缺损患者接受显微外科手术修复:游离移植背阔肌肌皮瓣,而后髂骨植骨4例,移植髂骨皮瓣7例,移植腓骨皮瓣6例,组合移植背阔肌肌皮瓣与游离腓骨20例,组合移植双侧背阔肌肌皮瓣与游离腓骨2例。结果 移植组织完全成活30例,9例移植的(肌)皮瓣远端皮肤发生局部浅表坏死,经换药后愈合。移植骨术后12～18周与宿主骨牢固连接。平均随访3年6个月,修复肢体均恢复有用功能。14例12岁以下儿童,修复后下肢生长正常,未发生肢体不等长现象。结论 严格手术指征,准确操作,酌情选择不同皮瓣与骨复合组织移植的显微外科修复是治疗骨与皮肤缺损的有效手段。     

异体复合组织移植皮肤淋巴引流隔绝动物模型的建立

目的:通过SD大鼠下腹部游离皮瓣及皮管的移植,建立大鼠异体复合组织移植皮肤淋巴引流隔绝模型。方法:7～8周龄雄性SD大鼠切取下腹部皮瓣并游离行同种异体移植,皮肤隔离组(A组):将供体皮瓣边缘对合、缝合成管状,底边留血管蒂出口用隔离器隔离皮肤,显微外科吻合血管,皮管缝合于隔离器,隔离器固定于受体;皮肤未隔离组(B组):将供体游离皮瓣卷制成管状,显微外科吻合血管并将供受体皮肤对位缝合;空白对照组(C组):行下腹部游离皮瓣异体移植。大体观察每组皮瓣或皮管存活时间,于术后3、5、7、14、28、35d取移植物皮肤组织行HE染色,观察病理学变化。结果:A组:皮管存活时间为32(34,32)天;B组:皮管存活时间为15(16,15)天;C组:皮瓣存活时间为6(7,6)天。A组与C组、B组与C组、A组与B组存活率差异均有统计学意义(P<0.05)。结论:本实验成功建立了大鼠的异体复合组织移植淋巴引流隔绝模型,并证实了隔绝皮肤淋巴引流能有效延长移植物的存活时间。     

皮肤与骨骼复合缺损的修复

目的：探讨显微外科修复肢体骨与皮肤复合缺损的技术和效果。方法：39例肢体骨与皮肤复合缺损患接受显微外科手术：游离移植背阔肌肌皮瓣，而后髂骨植骨4例，移植髂骨皮瓣7例，移植腓骨皮瓣6例，组合移植背阔肌肌皮瓣与游离腓骨20例，组合移植双侧背阔肌肌皮瓣与游离腓骨2例。结果：移植组织完全成活30例，9例移植的（肌）皮瓣远端皮肤发生局部浅表坏死，经换药后愈合。移植骨术后12－18周与宿主骨牢固连接。平均随访3年6个月，修复肢体均恢复有用功能。14例12岁以下儿童，修复后下肢生长正常，未发生肢体不等长现象。结论：严格手术指征，准确操作、酌情选择不同皮瓣与骨复合组织移植的显微外科修复是治疗骨与皮肤缺损的有效手段。     

Vascularized axillary lymph node transfer: A novel model in the rat

Vascularized lymph node transfer (VLNT) is a promising microvascular free flap technique for the surgical treatment of lymphedema. To date, few experimental animal models for VLNT have been described and the viability of lymph nodes after the transfer tested. We aimed to evaluate the feasibility of axillary VLNT in the rat. Lymph node containing flaps were harvested from the axillary region in 10 Lewis rats based on the axillary vessels. Flaps were transferred to the ipsilateral groin and end‐to‐side microanastomosis was performed to the femoral vessels using 10‐0 sutures. Indocyanine green (ICG) angiography was used to confirm flap perfusion. On postoperative day 7, flaps were elevated to assess their structure and vessel patency. Hematoxylin and eosin staining was used to confirm the presence and survival of lymph nodes. All animals tolerated the procedure well. Immediate post‐procedure ICG angiography confirmed flap perfusion. No signs of ischemia or necrosis were observed in donor extremities. At postoperative day 7, all flaps remained viable with patent vascular pedicles. Gross examination and histology confirmed the presence of 3.6 ± 0.5 lymph nodes in each flap without any signs of necrosis. This study showed that the transfer of axillary lymph nodes based on the axillary vessels is feasible. The flap can be used without the need for donor animals and it contains a consistent number of lymph nodes. This reliable VLNT can be further utilized in studies involving lymphedema, transplantation, and induction of immunologic tolerance. © 2015 Wiley Periodicals, Inc. Microsurgery 35:662–667, 2015.     

Modified lymph vessel flap transplantation for the treatment of refractory lymphedema: A case report

Lymph vessel flap transplantation (LFT), lymphaticovenous anastomosis (LVA), or lymph node flap transfer are sometimes used to treat lymphedema that is resistant to conservative treatment. LFT harvested from the contralateral limb has been reported for the treatment of lymphedema. Here we report the use of modified LFT from the abdominal wall for the treatment of refractory lymphedema. Our patient was a 57‐year‐old patient with secondary lower limb lymphedema was previously treated with conservative therapy and lymphaticovenous anastomosis. We first examined the lymphatic function of the lower abdominal region in the patient using indocyanine green (ICG) lymphography. After confirming the good lymphatic function in the right abdominal region, we harvested the pedicled abdominal adiposal flap containing multiple abdominal lymph vessels and transferred it to the left groin region. The flap (20 × 10 cm²) was based on the superficial circumflex iliac artery perforator. We anastomosed one lymph vessel in the flap to that in the recipient site. We also performed multiple fibrotripsy using a 3‐mm‐diameter stainless steel stick inserted into small incisions. The postoperative course was uneventful. The circumference measurement was decreased by 2.2–13.5 cm at 1 year after the operation. The lower abdominal region has many lymph vessel networks and is thought to be a less risky donor site in patients with lymphedema than the lower limbs. Thus, LFT may be an option for the treatment of chronic lymphedema. © 2015 Wiley Periodicals, Inc. Microsurgery 36:695–699, 2016.     

Treatment of various secondary lymphedemas by microsurgical lymph vessel transplantation

Chronic lymphedema is a debilitating complication of cancer diagnosis and therapy and poses many challenges for health care professionals. It remains a poorly understood condition that has the potential to occur after any intervention affecting lymph node drainage mechanism. Microsurgical lymph vessel transplantation is increasingly recognized as a promising method for bypassing the obstructed lymph pathways and promoting long-term reduction of edema in the affected limb. A detailed review of 14 patients with postoperative lymphedema treated with autologous lymph vessel transplantation between October 2005 and November 2009 was performed. In this report, the authors gave an account of their experience in utilizing this operative method to alleviate secondary lymphedema including upper limb, lower limb, genital, and facial edemas. Lymph vessel transplantation enhanced lymphatic drainage in patients with secondary lymphedema. In the upper and lower extremities, three patients had completed symptomatic recovery and another nine patients achieved reasonable reduction of lymphedema, four of these needed no further lymph drainage or compression garments and the remaining maintained their improvement with further decongestive therapy with or without compression garments. The patients with facial and genital edemas also experienced significant symptomatic improvement. The authors were able to establish long-term patency of the lymph vessel anastomosis by magnetic resonance lymphangiography.     

Proactive Approach to Lymphedema Risk Reduction: A Prospective Study

Background

Advances in cancer treatments continue to reduce the incidence of lymphedema. Yet, many breast cancer survivors still face long-term postoperative challenges as a result of developing lymphedema. The purpose of this study was to preliminarily evaluate The Optimal Lymph Flow program, a patient-centered education and behavioral program focusing on self-care strategies to enhance lymphedema risk reduction by promoting lymph flow and optimize body mass index (BMI).

Methods

A prospective, longitudinal, quasi-experimental design with repeated-measures was used. The study outcomes included lymph volume changes by infrared perometer, and BMI by a bioimpedance device at pre-surgery baseline, 2–4 weeks after surgery, 6-month and 12-month follow-up. A total of 140 patients were recruited and participated in The Optimal Lymph Flow program; 134 patients completed the study with 4 % attrition rate.

Results

Fifty-eight percent of patients had axillary node dissection and 42 % had sentinel lymph node biopsy (SLNB). The majority (97 %) of patients maintained and improved their preoperative limb volume (LV) and BMI at the study endpoint of 12 months following cancer surgery. Cumulatively, two patients with SLNB and two patients with axillary lymph node dissection had measurable lymphedema (>10 % LV change). At the 12-month follow-up, among the four patients with measurable lymphedema, two patients’ LV returned to preoperative level without compression therapy but by maintaining The Optimal Lymph Flow exercises to promote daily lymph flow.

Conclusions

This educational and behavioral program is effective in enhancing lymphedema risk reduction. The study provided initial evidence for emerging change in lymphedema care from treatment-focus to proactive risk reduction.     

Chimeric thoracodorsal lymph node flap with a perforator-based fasciocutaneous skin island for treatment of lower extremity lymphedema: A case report

Free vascularized lymph node transfer (VLNT) is applied more and more in the treatment of lymphedema. A random-pattern skin island with VLNT is of use but can have its limitations in flap inset. We describe an option for free VLNT in the treatment of lower extremity lymphedema. We present the case of a chimeric thoracodorsal lymph node flap (TAP-VLNT) with a thoracodorsal artery perforator (TAP) flap (5 × 9 cm) to the lower leg in a 22-year old female patient with stage 2 lower leg lymphedema caused by severe traumatic skin decollement and postoperative scarring after a car accident. TAP flap enabled tailored and tension-free wound closure at the recipient site after scar release and lymph node flap inset. The anastomosis was performed to the anterior tibial artery. The postoperative course was uneventful with no complications or secondary donor-site lymphedema. Follow-up at 6 months showed reasonable cosmetic and functional outcomes. The circumference reduction rate was up to 11% and the patient reported improved quality of life. The purpose of this report is to describe a case of a more flexible lymph node flap inset and tension-free wound closure by harvesting a thin thoracodorsal artery perforator (TAP) skin island together with a thoracodorsal VLNT as a chimeric flap (TAP-VLNT) for treatment of lower extremity lymphedema. Larger series with longer follow-up data are needed to justify its widespread use and demonstrate long-term results.     

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??Prevention strategies and treatment principles of upper limb lymphedema after breast cancer operation ZHANG Bao-ning. Cancer Hospital Chinese Academy of Medical Sciences, Beijing 100021, China
Abstract The incidence of upper limb lymphedema was 21.4% among breast cancer cases performed operation reported in prospective studies and the rate had a geographic variation worldwide. Surgeons should pay attention to the prevention of lymphedema for breast cancer patients. Preventive strategies include standardized operation, radiotherapy, functional exercise and life attentions. Treatment options include conservative treatment, drug and surgical therapies. Surgeries are to reduce lymphetic system load, such as excision of lesion and negative pressure suction technique; to promote lymphetic drainage, such as article fascia drainage, retinal drainage and pedicle flap drainage; and to reconstruct lymphetic channels, such as lymphetic venous anastomosis, lymphetic vessel grafting, vein replacing lymphetic vessel transplantation, and lymph node transplantation. However, the efficacy is unsustainable and hetergeneous. The therapy should focus on early stage, sustainability, integration and individualization.     

Ileocecal vascularized lymph node transfer for the treatment of extremity lymphedema: A case report

Vascularized lymph node (VLN) transfer has been of high interest in the past decade for the treatment of lymphedema, since it has been shown to be effective in reducing limb volumes, decreasing infectious episodes and improving quality of life. Multiple donor sites have been described in the quest for the optimal one. Herein, we describe a novel lymph node flap option based on the ileocolic artery and vein. The ileocecal vascularized lymph node (IC‐VLN) flap was used in the management of a 33‐year‐old male patient with lower extremity lymphedema secondary to left inguinal trauma. The patient had previously underwent a pedicled omentum flap transposition with minimal improvement in limb size and persistent episodes of infection. At 15 month follow‐up, the IC‐VLN flap improved the lymphatic drainage in the affected limb with a mean limb circumference reduction rate of 26.3%. No donor site complications or further episodes of infection were noted. According to our findings, the IC‐VLN flap may be another option for VLN transfer in very selected cases. Nevertheless, larger series with a longer follow‐up are required to analyze the efficacy and long‐term results of this flap.