积极应对乳腺癌术后淋巴水肿

淋巴水肿至今仍被普遍认为是不可治愈, 甚至是无法治疗的。通常,完善的体格检查和排除性的诊断技术可以明确诊断乳腺癌术后淋巴水肿而并不需要专业的诊断技术。从淋巴水肿综合保守治疗,到以核素淋巴显像、MRI为代表的诊断技术,到以淋巴管静脉吻合术、吸脂术、淋巴结移植术为代表的外科手术的开展,淋巴水肿的诊断与治疗已有较大进步。针对淋巴回流梗阻,淋巴管功能损害,组织间淋巴液淤滞、脂肪增生、纤维化的病生理改变,分期手术治疗,包括一期肢体减容整形手术,二期肱动脉旁深淋巴管静脉吻合术,绝大部分病例可明显缓解。当前淋巴水肿诊断治疗理念变化显著,积极应对乳腺癌术后淋巴水肿,将成为该领域的发展趋势。     

乳腺癌术后上肢淋巴水肿因素分析与外科治疗进展

上肢淋巴水肿是乳腺癌术后的常见并发症,乳腺癌根治术后早期常有上肢不同程度的肿胀,在数月甚或20年后可出现淋巴水肿,但75%发生在术后第1年内,1个月以内发生率为28%[1]。淋巴水肿可导致上肢功能障碍和患者精神紧张,轻者随着侧支循环的建立而缓解,严重者可影响术后生活质量,甚至导致无法正常生活和工作[2]。临床处理较为棘手,其治疗方法可分为保守治疗和外科治疗,目的均是改善淋巴液生成与回流之间平衡,减小上肢周径。本文就乳腺癌术后上肢淋巴水肿产生的因素进行分析,探讨其预防措施和外科治疗。1乳腺癌术后上肢淋巴水肿形成的机制1.1腋窝淋巴结清扫手术腋窝淋巴结清扫是大部分乳腺癌手术的必要步骤,淋巴结被彻底清扫干净,可有效预防术后复发和转移。乳腺癌术后上肢淋巴水肿主要由淋巴回流障碍引起,其可能形成的机制为:由于腋窝淋巴的清扫切断了上肢的淋巴回流通路,使上肢的淋巴不能充分引流,导致上肢淋巴液中的蛋白浓度增高,滤过压增加,由于血浆蛋白减少,使液体渗透压降低,同时,毛细血管渗透压增加,所以可出现程度不等的上肢水肿,随后上肢组织出现纤维化及炎症的淋巴水肿[3]。Pain等[4]认为乳腺癌腋窝淋巴清扫改变腋静脉血流动力学,使之易发生...     

间质MR淋巴造影术

淋巴水肿是由于先天性淋巴管发育不全或后天原因,致使淋巴液回流受阻、返流所引起的肢体浅层软组织内体液积聚、继发纤维组织增生、脂肪硬化、筋膜增厚及整个患肢变粗的病理状态。因淋巴管细小,尤其是肢体的淋巴管更为明显,而且淋巴液无色透明,肉眼观察只能看到较粗大的集合淋巴     

显微淋巴外科在胶体慢性淋巴水肿中的应用

肢体淋巴水肿是一种进行性疾病,属于高蛋白水肿,是由于淋巴液回流障碍所致。当淋巴管负荷正常而对淋巴液的转运能力和组织蛋白质的溶解能力低于正常时,则形成淋巴水肿。主要表现为肢体浅层有过多的蛋白质和液体积聚,过量的蛋白质和液体超过     

促淋巴管生成因子的研究进展

淋巴水肿的临床治疗比较困难,淋巴管再生为治疗淋巴水肿提供了新的思路.多种因素可以促进淋巴管内皮细胞再生,从而改善淋巴水肿.目前研究表明,多种促淋巴管生成因子与淋巴管再生关系密切,现就促淋巴管生成因子的研究进展进行综述.     

信息动态

乳腺癌手术后,上肢淋巴水肿的发病率为8％～65％[1],与多种因素有关,如手术方式、病期、术后的放、化疗等因素有关;从患者个体生理角度说,与患者的年龄、体重指数、是否优势手臂等有关,但也有文献持不同观点[2].此种术后并发症给患者带来极大痛苦,国内外有很多针对此种并发症的研究.上肢淋巴水肿是一慢性过程,可分为淋巴液蓄积、脂肪组织增生、纤维化3个阶段.基本原因是由于手术、放疗导致淋巴管阻塞,造成皮肤、皮下组织及肌肉间隙压力增高.大分子如蛋白质堆积在小间隙中而液体被周围血管带走,加重了淋巴的堆积,使组织间隙压力增大,淋巴管与毛细血管逐渐阻塞.单纯的物理机械治疗、药物(地奥司明片)以及手术治疗等多个方面均有研究,也都取得了一定的阶段性的疗效.目前尚没有公认的治疗方式,但是,不同的治疗方法均取得了较好的效果.本文就近几年有关治疗进展作一介绍.     

淋巴水肿的手术处理

内科或外科治疗淋巴水肿仍属一难题。目前尚无治愈的方法。尽管 Herophilos 和 Aristotle 早在第三和第四世纪已对淋巴管进行了观察,淋巴解剖学仍未完全阐明。虽有大量的近代研究,淋巴水肿的确切发病机理尚不清楚。一般而言,淋巴水肿是由于淋巴管先天性发育异常或继发性梗阻所引起的间质淋巴液的异常积聚。多数的轻、中度淋巴水肿可用保守方法改善。手术治疗则用于非手术疗法无效的严重病例。对淋巴功能的基础科学和新手术技术的进一步研究,提示此领域大有发展。此外,根治性淋巴结大块切除近代有减少趋势(如在乳癌和黑色瘤的治疗中),将来继发性淋巴水肿的发病率或将下降。精确的局部放射操作对这方面也将起作用。分类淋巴水肿可分为原发的(特发的)和继发的。原发     

胃十二指肠手术后淋巴漏及其营养支持治疗

胃十二指肠术后淋巴漏主要是由于手术或其他创伤因素导致胸导管或腹腔淋巴管破裂使淋巴液进入胸、腹腔所致。一旦发生高流量淋巴漏时,经常导致脂肪、蛋白质、水及电解质的丢失,病人出现营养不良而衰竭;另外淋巴液中含有大量的淋巴细胞,随着淋巴液丢失可引起体内淋巴细胞功能低下而继发感染,不仅延缓康复时间,严重者可造成病人死亡。淋巴漏后积极行营养支持治疗可帮助病人顺利康复。本文主要从淋巴漏发生的原因、临床表现、诊断和治疗这几个方面对术后淋巴漏进行阐述分析。     

改良静脉淋巴管吻合技术在乳腺癌术后上肢淋巴水肿中的临床价值

探讨改良静脉淋巴管吻合技术在治疗乳腺癌术后上肢淋巴水肿中的临床价值。取2013年1月—2015年1月乳腺癌术后上肢淋巴水肿患者80例作为研究对象,按照随机数字化原则,将其分为观察组和对照组,对照组采用创痛静脉淋巴管吻合术进行治疗,观察组采用改良静脉淋巴管吻合术进行治疗。治疗周期结束后,比较各时期上臂、前臂周径及两组患者2年内上肢情况及生活质量。治疗前两组患者的上臂、前臂周径无明显差异(P0.05);治疗后3个月、24个月时观察组上臂、前臂周径分别为(30.9±3.4)cm、(30.8±3.4)cm,对照组上臂、前臂周径分别为(32.6±3.7)cm、(32.5±3.6)cm,观察组上臂、前臂周径明显小于对照组(P0.05)。经过治疗,观察组上肢及前臂疼痛、肿胀均减轻,无丹毒发作,生活质量评分增加,治疗效果明显优于对照组(P0.05)。改良静脉淋巴管吻合术能有效促进淋巴液进入静脉循环,通过多切口吻合,促进淋巴液回流,改善上肢水肿,提高患者生活质量,减轻疼痛、肿胀,手术操作简单,安全性较高,临床效果显著,对治疗乳腺癌术后上肢淋巴水肿具有可靠的临床价值。     

下肢慢性淋巴水肿的MRI表现与淋巴闪烁造影的比较

目的 探讨下肢慢性淋巴水肿的ＭＲＩ表现和诊断价值。方法 对１２例慢性淋巴水肿下肢作ＭＲＩ检查,并与淋巴闪烁显像（Ｌｙｍｐｈａｎｇｉｏｓｃｉｎｍｔｉｇｒａｐｈｙ ＬＡＳ）相比较。结果 ＭＲＩ图像的特征是皮下组织层明显增厚伴广泛水肿;真皮下扩张的淋巴管以及淋巴液潴留在间形成“裂隙”使皮下组织层呈的网络状或蜂窝状结构。结论ＭＲＩ清晰地显示增生扩张的集合淋巴管和淋巴干及乳糜池,以及组织中乳糜返流的程度和范     

Update on Post‐mastectomy Lymphedema Management

Lymphedema is a chronic, progressive condition caused by an imbalance of lymphatic flow. Upper extremity lymphedema has been reported in 16–40% of breast cancer patients following axillary lymph node dissection. Furthermore, lymphedema following sentinel lymph node biopsy alone has been reported in 3.5% of patients. While the disease process is not new, there has been significant progress in the surgical care of lymphedema that can offer alternatives and improvements in management. The purpose of this review is to provide a comprehensive update and overview of the current advances and surgical treatment options for upper extremity lymphedema.     

Post‐traumatic lymphedema treatment with superficial circumflex iliac artery perforator lymphatic free flap: A case report

Post‐traumatic lymphedema is poorly understood. It is rarely considered in limb reconstruction decision‐making approach. We report a case of a 41‐year‐old female who presented with right upper extremity lymphedema after degloving injury and split thickness skin graft, successfully treated with a superficial circumflex iliac artery perforator (SCIP) free flap restoring the lymphatic drainage. Right upper extremity had an excess of 258.7 mL or an excess volume of 27.86% compared to the healthy contralateral limb. A SCIP free flap including lymphatic vessels (SCIP‐L) was performed to replace the skin graft in order to restore the lymphatic flow. Flap size was 19 × 8 cm and pedicle length was 4 cm. No lymph nodes were included and no lymphatic or lymphovenous anastomoses were performed. The surgery was uneventful, and there were no postoperative complications. Fourteen days after free tissue transfer, lymphedema showed clear improvement. At a 4‐month follow‐up, 55.6% reduction of excess volume was obtained. Indocyanine green lymphography performed at that time showed a restitution of lymph flow through the flap. Lymphedema improvements persisted at a 6‐month follow‐up. A successful treatment of post‐traumatic lymphedema can be performed by using the SCIP‐L free flap for soft tissue reconstruction of critical lymphatic drainage areas.     

血管化淋巴结移植动物模型的研究进展

淋巴水肿是因各种原因引起的淋巴管输送功能障碍、淋巴回流受阻而引发的组织间隙病理性蛋白聚集,严重影响患者的生存质量。血管化淋巴结移植(Vascularized lymph node transfer,VLNT)可显著缓解淋巴水肿、降低蜂窝组织炎发生率,具有较高的安全性和有效性,已成为目前治疗淋巴水肿的优选方案,但其治疗机制尚不完全清楚。本文对VLNT动物模型的研究进展进行综述,为深入研究VLNT的治疗机制及术式更新提供动物模型参考。     

Lymphedema of the upper extremity following circumferential burns

Lymphedema is characterized by edema of the extremity due to the inability of the lymphatic system to remove lymph into the circulation. This condition can result from destruction of the superficial lymphatics from burn injury and recurrent infection of the extremity. Due to its rare occurrence, two cases of upper extremity lymphedema following burns are reported.     

Antegrade and retrograde lymphatico‐venous anastomosis for cancer‐related lymphedema with lymphatic valve dysfuction and lymphatic varix

In healthy people, no retrograde lymph flow occurs because of valves in collecting lymph vessels. However, in secondary lymphedema after lymph node dissection, lymph retention and lymphatic hypertension occurs and valvular dysfunction induces retrograde lymph flow. In this case reported, we focused on retrograde lymph flow and performed retrograde lymphatico‐venous anastomosis (LVA) simultaneously with antegrade LVA. A 67‐year‐old Japanese woman had worsening edema in her right thigh and hip area for 3 years. She had previously undergone extended hysterectomy with lymph node dissection for endometrial cancer 8 years before. Indocyanine green test showed antegrade and retrograde lymph flow. Four LVAs were made in the right medial thigh and right lower abdominal area under local anesthesia. Lymphedema showed rapid improvement within 12 months and compression therapy was not required at 24 months after LVA. Retrograde LVA has a possibility of a more efficacy for secondary lymphedema. © 2012 Wiley Periodicals, Inc. Microsurgery, 2012.     

Novel lymphography using indocyanine green dye for near-infrared fluorescence labeling

Lymphedema is known to be caused by many pathologic conditions; however, its diagnostic and therapeutic strategies remain to be unestablished. In this study, we investigated the usefulness of a novel lymphographic method based on fluorometric sensing using indocyanine green (ICG) dye for imaging lymphatic vessels using rat models. The real-time imaging system enabled visualization of superficial lymphatic vessels with a diameter of 0.1 mm in 33 frames/second. In addition, morphologic changes in lymphatic vessels in a radiation-induced lymphedema model were detected even at the latent stage. These results suggest that this imaging technique is acceptable as an evaluation method for the lymphatic system.     

淋巴水肿治疗的研究进展

淋巴水肿是淋巴系统的一种慢性疾病。随着我国恶性肿瘤发病人数和发病率的增加,癌症治疗后的淋巴水肿已经成为继发性淋巴水肿的主要病因。正确、合理的治疗对淋巴水肿预后十分重要。近年来,淋巴领域的治疗进展给患者带来了新的希望。本文就淋巴水肿治疗的研究进展进行综述。     

MR淋巴造影在四肢淋巴水肿中的应用进展

淋巴水肿是慢性进行性疾病,及时合理诊治对改善患者预后十分重要。MR淋巴造影(MRL)空间及时间分辨率高、且无辐射,可用于早期诊断淋巴系统疾病。本文对MRL在四肢淋巴水肿中的应用进展进行综述。     

Current operative management and therapeutic algorithm of lymphedema in the lower extremities

Lymphedema is defined as the abnormal accumulation of interstitial fluid in subcutaneous tissues resulting from cancer, cancer treatment (surgery and/or radiotherapy), infection, inflammatory disorders, obesity, and hereditary syndromes. Surgical management of lymphedema can be broadly classified into two categories, reductive surgical techniques such as direct excision, suction assisted protein lipectomy (SAPL) or radical reduction with perforator preservation (RRPP); and physiological surgical procedures such as lymphaticovenous anastomosis (LVA) and vascularised lymph node transfer (VLNT). These techniques and their various combinations were evaluated. The results revealed patients with reversible lymphedema (ISL stage I, mild severity) benefit most from physiological procedures (LVA or VLNT) which can reduce the chance of disease progression to the chronic, solid phase. Reductive techniques such as SAPL, RPPP, or direct excision procedures should be reserved for patients with advanced – severe lymphedema (ISL stages II and especially stage III) as the surgical treatment of choice. In this study, current literature on the surgical treatment of lower extremity lymphedema is reviewed and discussed in conjunction with authors’ clinical experiences. An algorithm is presented, based on clinical evidence and experience which aims to provide a structured approach to managing lower limb lymphedema.     

Modified lambda‐shaped lymphaticovenular anastomosis with supermicrosurgical lymphoplasty technique for a cancer‐related lymphedema patient

Supermicrosurgical lymphaticovenular anastomosis (LVA) has become a useful option for the treatment of compression‐refractory lymphedema with its effectiveness and less invasiveness. It is important to make as many bypasses as possible for better treatment results of LVA operation. We report a secondary lymphedema case successfully treated using a modified lambda‐shaped LVA. A 62‐year‐old female with secondary lower extremity lymphedema (LEL) refractory to conservative treatments underwent LVA operation. A modified lambda‐shaped LVA was performed at the left groin. In modified lambda‐shaped LVA, two lymphatic vessels were transected, and both ends of the proximal and distal sides were converged respectively for an end‐to‐side and end‐to‐end anastomoses to one vein. Using modified lambda‐shaped LVA, four lymph flows of two lymphatic vessels could be bypassed into a vein. Six months after the LVA surgery, her left LEL index decreased from 261 to 247, indicating edematous volume reduction. Modified lambda‐shaped LVA effectively bypasses all lymph flows from two lymphatic vessels, when only one large vein can be found in the surgical field. © 2013 Wiley Periodicals, Inc. Microsurgery 34:308–310, 2014.