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1. Overview of lymphedema lymphedema refers to subcutaneous fibrous connective tissue hyperplasia and liposclerosis caused by repeated infection of soft tissue fluid on the body surface due to the obstruction of lymphatic reflux in some parts of the body. If it is a limb, it will thicken, and the skin will be as thick, rough and tough as elephant skin in the later stage, which is also commonly known as "elephant skin swelling".
2. The diagnosis is 1. Have a history of recurrent filariasis infection or erysipelas, or a history of axillary and inguinal lymph node dissection and radiotherapy.
3, 2. Lifting can reduce the early swelling of the affected limb.
4. In the late stage, the affected limb is obviously swollen, with rough surface keratinization and rubbery swelling.
A few may have skin cracks, ulcers or warty vegetation.
6.3. Microfilariasis can be found in the blood around filariasis patients.
7. Lymphangiography can determine the development or obstruction of lymphatic vessels.
8, treatment measures lymphedema according to the course of disease sooner or later, the treatment principle is different.
9. In the early stage, the purpose is to eliminate stagnant lymph and prevent the regeneration of hydrolymph. In the later stage, the purpose is to surgically remove irrecoverable diseased tissue or treat localized lymphatic obstruction through shunt.
10, (1) acute lymphedema, mainly treated by non-operation.
1 1, 1. Postural drainage of lower limb droop aggravated lymphatic retention in interstitial space. Lifting the affected limb by 30 ~ 40 cm can promote lymphatic reflux and reduce edema caused by gravity.
12, this is not simple and effective, but the effect is not lasting, and the edema of the affected limb is aggravated.
13, 2. On the basis of postural drainage, elastic socks or elastic bandages were used to compress the tissue space to assist lymphatic reflux.
14, elastic bandage tightness should be appropriate.
15. Intermittent compression pump can also be used for many times and for a long time, which has a certain effect on improving edema.
16, literature report: lymha-press is an advanced and effective inflator abroad at present. The inflatable device is divided into 9 ~ 12 pieces, each piece can be inflated independently, and the pressure is gradually increased from the distal end to the proximal end of the limb, and the cycle does not exceed 25 weeks.
17. Compared with other simple compressors, this kind of lymphatic compressor greatly shortens the inflation and compression time (the cycle period of the simple compressor is about 100 seconds), and at the same time, it can generate higher pressure15.6 ~ 20.8 kPa (120 ~10).
18, but its use is complicated, and it cannot reduce the protein component in the gap. It is only suitable for short-term treatment such as acute phase and preoperative preparation.
19, 3. Limit sodium intake and use diuretics to limit sodium chloride intake in acute phase, generally 1 ~ 2g/d, so as to reduce tissue sodium and water retention.
20. At the same time, use appropriate diuretics to speed up the discharge of water and sodium.
2 1, dichlorothiazide 25mg each time, three times a day, and appropriate potassium supplementation, and stop taking medicine after the condition is stable.
22, 4. Preventing infection, choosing antifungal ointment and powder and keeping toes dry are the most effective methods to prevent fungal infection; Bacterial infections under toenail beds are also more common. Qin Ying cut toenails to remove dirt and reduce the way of bacterial invasion.
23, when streptococcal infection with systemic symptoms, should choose penicillin and other drugs, with bed rest, actively control the infection.
24. Late lymphedema complicated with chapped skin can be protected and lubricated by topical ointment.
25. In addition, injection of various vaccines, milk and foreign proteins is a long-standing anti-infection therapy.
26. Various defense mechanisms of the human body have been improved.
27. Foreign scholars have proved that when typhoid triple vaccine is injected, the number of lymphocytes in the export lymphatic vessels increases, and gamma globulin in the blood also increases, which can prevent the occurrence of permanent lymphatic obstruction.
28. Some authors speculate that foreign proteins may act through pituitary gland and adrenal gland.
29. (2) Chronic lymphedema includes drying and stretching treatment and non-surgical treatment of various surgical treatments.
30, 1. Baking stretching therapy is a therapeutic method to explore the medical heritage of the motherland.
3 1, its treatment principle is to use continuous radiant heat to dilate the skin blood vessels of the affected limb, sweat a lot, and the liquid in the local tissue space returns to the blood to improve lymphatic circulation.
32. For severe limb skin hyperplasia without lymphedema, baking and stretching therapy can be selected.
There are two methods: electric radiation hyperthermia and oven heating.
34. The temperature is controlled at 80 ~ 100℃, 1 time every day, 1 hour every time, and 20 times is a course of treatment.
35. The interval of each course of treatment is 1 ~ 2 weeks.
36, after each treatment, should add elastic bandage.
37. According to clinical observation, after 1 ~ 2 courses of treatment, it can be seen that the affected limb tissue becomes soft and the limb gradually shrinks, especially the number of erysipelas attacks is greatly reduced or stopped.
38, 2. The surgical treatment of most lymphedema does not require surgery.
39. About 15% of primary lymphedema eventually needs lower limb plastic surgery.
40. The existing surgical methods except amputation can not cure lymphedema, but can obviously improve the symptoms.
4 1, (1) Surgical indications: (1) Limb function damage: due to heavy limbs, fatigue and limited joint activity.
42, ② Excessive swelling with pain.
43 cases. ③ Recurrent cellulitis and lymphangitis were ineffective after medical treatment.
44.④ Lymphangiosarcoma: the fatal cause of long-term lymphedema malignancy.
45.⑤ Beauty: Most patients with primary lymphedema are young women. For those with obvious swelling and cosmetic requirements, surgery can be considered, but the function should be improved mainly, supplemented by beauty, otherwise the curative effect may not be ideal.
46. Preoperative preparation and postoperative treatment: (2) Preoperative preparation plays an important role in the surgical effect.
47, they include: ① Bed rest to raise the affected limb: reduce limb edema to a minimum.
48, there are methods such as lower limb padding, lower limb suspension and bone traction, and the lower limb is raised by 60? Suitable.
49.② Control infection: For recurrent acute cellulitis and acute lymphangitis, sensitive drugs should be injected intravenously or intramuscularly before and during operation to reduce the chance of skin flap infection after operation.
50.③ Clean skin: to achieve the purpose of ulcer healing or control local infection.
5 1, ④ keep postoperative drainage unobstructed; The separated rough surface may have continuous capillary exudate.
52. Negative pressure drainage must be placed to keep no hematocele and effusion under the flap, reduce the factors affecting the blood supply of the flap, prevent necrosis and infection of the flap, and reduce the failure rate of the operation.
53.⑤ Continue to raise the affected limb after operation to reduce the edema of the affected limb, which is beneficial to venous and lymphatic reflux.
54.(3) Classification of operations: lymphedema operations can be divided into two categories: ① extensive resection of diseased tissues.
55.② Lymphatic reflux reconstruction.
56. According to experimental and clinical evidence, some or most of the good effects of the latter were actually achieved on the basis of extensive resection of diseased tissues.
57, simple reconstruction of lymphatic reflux, the operation is very fine, but the effect is minimal.
58. Because the lymphatic system near and far from the lymphatic obstruction point of secondary lymphedema is in good function, surgical reconstruction of regional lymphatic reflux should achieve good results. On the contrary, most primary lymphedema's proximal and distal lymphodysplasia cannot be expected to improve symptoms.
59. Etiology There are many causes of lymphedema, which are mainly divided into primary and secondary categories.
60. Primary lymphedema is mostly caused by congenital dysplasia, such as lymphatic dilatation and valve insufficiency or loss.
6 1. According to lymphangiography, primary lymphedema can be divided into: ① hypoplasia of lymph with hypodermic lymphocytes; ② Lymphatic dysplasia with small lymph nodes and lymphatic vessels; ③ Lymphatic hyperplasia, with large and numerous lymph nodes and lymphatic vessels, sometimes twisted and varicose.
62. Lymphatic hypoplasia is very rare and common in congenital lymphedema.
63. Underdevelopment is the most common type.
64. Both simple and reactive lymphedema are congenital.
65. Early onset lymphedema is more common in adolescent women or young women, and the menstrual symptoms are aggravated. Therefore, it is speculated that the cause may be related to endocrine disorders, accounting for 85 ~ 90% of primary lymphedema.
Delayed lymphedema occurs after the age of 66 or 35.
67. Secondary lymphedema is mostly caused by lymphatic obstruction.
68. Filariasis lymphedema and streptococcal lymphedema are the most common in China.
69. Lymphedema of upper limbs after radical mastectomy is not uncommon.
70. Although Herophilos and Aristotle observed the lymphatic system as early as the third and fourth centuries and did a lot of experimental research in modern times, the exact pathogenesis of lymphedema is still unclear.
Classification: (1) Primary lymphedema 1. Congenital: Milroy's disease) 2. Early onset (2) secondary lymphedema 1. Infectious: parasites, bacteria, fungi, etc. 2. Harmful: surgery, radiotherapy, burns, etc. 3. Malignant tumor.
72. Lymphatic circulation is also the physiological and functional physical circulation of human body.
73. Congenital dysplasia of lymphatic system or occlusion or destruction for some reason belongs to distal lymphatic reflux disorder, and interstitial lymph is abnormally increased.
74. If it occurs in a limb, the uniformity of the affected limb becomes thicker. At first, the skin was still smooth and soft, and the edema of the affected limb could be obviously alleviated by raising it.
75. Because the accumulated lymph is rich in protein, which can be as high as 5.8g/dl, [normal 0.72g/dl] long-term stimulation causes abnormal proliferation of connective tissue, and adipose tissue is replaced by a large number of fibrous tissues.
76. The skin and subcutaneous tissue are extremely thickened, the skin surface is keratinized and rough, there is no indentation after finger pressing, and warty growth appears, forming a typical "elephantiasis".
77. Infection increases inflammatory exudate, stimulates a lot of connective tissue proliferation, destroys more lymphatic vessels, increases lymphatic retention, increases the chance of secondary infection, forms a vicious circle, and leads to aggravated lymphedema.
78. Clinical manifestations According to the classification of the above causes, their respective clinical characteristics are described as follows: (1) Congenital lymphedema is divided into two categories: 1. Simple onset has no family or genetic factors.
79. The incidence of primary lymphedema was 65438 02%.
80. There is localized or diffuse swelling of one limb after birth, which is painless, ulcer-free, and rarely complicated with infection. Generally in good condition, more common in lower limbs.
8 1, 2. Hereditary, also known as Milroy's disease, is rare.
82. Many people in the same family get sick, that is, they get sick after birth, and most of them involve one lower limb.
83.(2) Early-onset lymphedema is more common in women, with the male-female ratio of 65,438+0 ∶ 3. The onset age is 9-35 years old, and 70% of them are unilateral.
84. Generally, there is slight swelling of the ankle, and there is no obvious inducement, which is aggravated when standing, moving, menstruating and the climate is warm.
85, refers to the high limb edema can be temporarily reduced.
86. The lesion gradually aggravates and spreads to the lower leg, but generally does not exceed the knee joint.
87. In the later stage, it may be a typical "elephant skin leg", but it is rarely complicated with ulcer and secondary infection.
88.(3) Infectious lymphedema includes infections such as bacteria, fungi and filariasis.
89. Cracks or blisters on toe skin are the most common route of pathogen invasion, followed by local injuries or infections such as varicose veins of lower limbs complicated with ulcer secondary infection.
90. In addition, it has also been reported that pelvic lymphadenitis caused by female pelvic inflammatory disease can hinder the lymphatic reflux of lower limbs, resulting in swollen lymph of affected limbs.
9 1, Streptococcus is the most common pathogen of secondary infection.
92. The clinical manifestations are recurrent acute cellulitis and acute lymphangitis, with serious systemic symptoms, including chills, high fever with nausea and vomiting, and local lymphadenopathy with tenderness.
93. After anti-inflammatory symptomatic treatment, the systemic symptoms subsided quickly, but the local lesions eased slowly and easily.
94. After each attack, the swelling of the lower limbs is aggravated, and finally the skin is rough and warty, and a few can be secondary to chronic ulcers.
95. Athlete's foot itself or secondary infection can also cause lymphedema, which is generally limited to the foot and instep. Severe fungal infection is usually a precursor to acute cellulitis and acute lymphangitis.
96. Controlling fungal infection is one of the effective measures to prevent lymphedema.
97. Filariasis is a common cause of lymphedema of lower limbs in the southeast coastal areas of China.
98. The incidence rate is 4-7%, which is more common in men.
99. At the initial stage of filariasis infection, there are different degrees of fever and local swelling and pain.
100, repeated filariasis infection made the local lymphatic vessels of lower limbs narrow, blocked and destroyed, and the lymphatic reflux of distal skin and subcutaneous tissue was blocked, resulting in lymphedema.
10 1, tinea pedis and other local lesions or secondary erysipelas attack repeatedly, which makes lymphatic drainage blocked and infection mutually causal, forming a vicious circle and eventually becoming a typical "elephant leg".
102, its flash and scrotal lymphedema are not uncommon, and it can cause extremely swollen scrotum in the late stage.
103, which is also a major feature of filarial infectious lymphedema.
104, (4) Traumatic lymphedema is mainly divided into postoperative lymphedema and radiotherapy lymphedema.
105, 1. Postoperative lymphedema often occurs after lymph node dissection, especially after radical mastectomy.
106, after extensive lymph node dissection, the distal lymph was blocked, which stimulated tissue fibrosis and gradually aggravated swelling.
107, the postoperative lymphedema time is quite different. Generally, the proximal limb is slightly swollen when the limb starts to move after operation, but it can also appear weeks or even months after operation.
108, 2. The depth of lymphedema caused local tissue fibrosis after radiotherapy X-ray and radium ingot treatment, and lymphedema was caused by lymphatic occlusion.
109, (5) Malignant tumor lymphedema Both primary and secondary lymphoid malignant tumors can block lymphatic vessels and produce lymphedema.
1 10, the former is found in Hodgkin's disease, lymphosarcoma, Kaposi's multiple hemorrhagic sarcoma and lymphangiosarcoma.
Although11/lymphangiosarcoma is rare, it is the result of long-term malignant transformation of lymphedema, which mostly occurs in patients with lymphedema of limbs after radical mastectomy. It usually occurs 10 years after operation, and the skin appears red or purple spots, which are multiple, and then it is combined with ulcerative mass.
1 12, limb lymphedema is more serious after onset.
1 13, biopsy should be done in time.
1 14, amputation is required after definite diagnosis.
1 15. The secondary lymphatic system diseases are metastatic diseases of breast, cervix, labia, prostate, bladder, testis, skin and internal bones.
1 16, sometimes the primary focus is small and difficult to find, and the clinical manifestations are chronic recurrent, painless and progressive lymphedema.
1 17. Therefore, for lymphedema of unknown cause, we should be alert to the possibility of tumor and make a definite diagnosis by lymph node biopsy if necessary.
1 18. In addition, pregnancy and many systemic diseases such as pneumonia, influenza and typhoid fever can also lead to recurrent cellulitis and lymphangitis, and venous thrombosis and lymphatic obstruction can also cause lymphedema.
1 19, auxiliary examination (1) diagnostic puncture tissue fluid subcutaneous edema tissue fluid analysis is helpful for differential diagnosis of difficult cases.
The protein content of 120 and lymphedema fluid is usually very high, generally 1.0 ~ 5.5g/dl, while the protein content of edema tissue fluid with venous stasis, heart failure or hypoproteinemia is 0. 1 ~ 0.9g/dl.
12 1. Examination is usually used for limbs with chronic gross swelling, and can only be operated with syringes and fine needles. This method is simple and convenient.
122, but we can't understand the lesion site and function of lymphatic vessels.
123 is a rough diagnosis method.
124, (2) lymphangiography Lymphatic puncture injection of contrast agent, showing the morphology of lymphatic system in the photo, is a specific auxiliary examination of lymphedema.
125, 1. Indications (1) Differentiation between lymphedema and venous edema.
126, ⑵ Distinguish primary lymphedema from secondary lymphedema.
127, (3) those who intend to perform lymphatic-venous anastomosis.
128, 2. At present, most lymphangiography methods are direct lymphatic puncture injection angiography.
129. Evans blue was injected subcutaneously at the level of instep 1 ~ 4 metatarsal bone. After 3 ~ 5 minutes, you can see the thin blue superficial lymphatic vessels.
130, under local anesthesia, cut the skin to separate superficial lymphatic vessels, and bypass a filament at its proximal end and distal end respectively, temporarily sealing the proximal end to make the lymph stay. Puncture lymphatic vessels with 27 ~ 30 needle, and then inject a little 1% procaine to confirm that it is in the cavity and does not leak. Fix the needle and connect it with the syringe through a plastic pipe, with the ratio of 0. 1 ~.
After the injection of 13 1.2ml, photos were taken in the ankle joint and pelvic cavity to determine whether the contrast agent was extravasated or not, and to exclude accidental injection into the vein.
132, after injection, the needle was pulled out, lymphatic vessels were ligated to prevent lymphatic leakage, and the skin was sutured.
133. Comparative photos include: anteroposterior position of calf, anteroposterior position of thigh, anteroposterior position from groin to the first lumbar vertebra, oblique position or lateral position.
134, 3. Abnormal manifestations of lymphangiography (1) Primary lymphedema: missing or incomplete lymphatic valve, tortuous lymphatic vessels.
135, (2) secondary lymphedema: the lymphatic vessels at the middle and distal ends are dilated and tortuous, and the number is increased and irregular.
136, metastatic lymph nodes can be seen, with filling defects in the lymph nodes and vermiform edges.
137, 4. Complications (1) Incision infection and horse leakage.
138, (2) systemic reaction: allergic to contrast media may cause fever, nausea, vomiting and peripheral circulation failure.
139, (3) local lymphoreactive inflammation aggravated lymphedema.
140, (4) pulmonary embolism: the pressure of contrast agent may increase and enter the vein through the anastomotic collateral, causing pulmonary embolism, the incidence rate is 2 ~ 10%, and there are reports of death due to pulmonary embolism in the literature.
14 1, (3) Isotopic lymphangiography Because X-ray lymphangiography can't provide quantitative dynamic data of lymphatic system function and simple information of lymphatic drainage in different limb parts, valuable static lymphangiography (radionuclide imaging) is currently performed, and 0.25ml(75MBq) of 99m sulfide gel is injected into the second toe of both feet.
142. The patient's lower abdomen and inguinal region were scanned with R camera at 1/2, 2 and 3 hours respectively, and then the isotope intake of ilioinguinal lymph nodes was calculated respectively.
143. Using isotope imaging to study the lymphatic function of chronic lymphedema, it is suggested that the reduction of lymphatic reflux of the affected limb is related to the severity of lymphedema.
144. In severe lymphedema, the isotope uptake rate is almost zero, but the absorption percentage of lymphatic reflux in venous edema increases significantly.
145, so it can be used to distinguish lymphedema from venous edema, and its sensitivity and specificity in diagnosing lymphedema are 97% and 100% respectively.
146, compared with lymphangiography, radionuclide imaging is simple and the diagnosis is clear.
147, but lymphatic vessels and lymph nodes could not be anatomically located.
148, lymphangiography is the best if lymphatic surgery is considered.
149 in addition, the newly developed non-invasive detection technology of blood vessels is also helpful to distinguish venous edema from lymphedema. As an outpatient screening method, it is simple and convenient.
150, differential diagnosis: 1 because of slight changes in early skin and subcutaneous tissue, it should be differentiated from other diseases. Venous edema is more common in deep venous thrombosis of lower limbs, and its clinical features are sudden swelling of one limb, obvious tenderness of gastrocnemius and femoral triangle area, and exposure of superficial veins, but edema of dorsum of foot is not obvious.
15 1, lymphedema, slow onset, especially swelling of instep and ankle.
152, 2. angioneurotic edema occurs under the stimulation of external allergic factors, which is characterized by rapid onset, rapid regression and intermittent attacks.
153, lymphedema aggravated.
154, 3. Systemic diseases such as hypoproteinemia, heart failure, kidney disease, liver cirrhosis and myxedema can all produce edema of lower limbs.
155, generally bilateral symmetry, accompanied by clinical manifestations of its own primary disease.
156, usually diagnosed by detailed medical history inquiry, careful physical examination and necessary laboratory examination.
157, 4. Congenital arteriovenous fistula Congenital arteriovenous fistula can be manifested as limb edema, but generally the length and circumference of the affected limb are longer than that of the healthy side, the skin temperature is increased, superficial varicose veins are seen, vascular murmurs can be heard in some areas, and the oxygen content of peripheral vein blood is close to that of artery.
158, the above is its uniqueness.
159, 5. Lipoma A small amount of lipoma or adipose tissue hyperplasia, with a wide range of lesions, can be confused with lymphedema.
160 However, lipomas mostly grow locally, with a slow course of disease and soft subcutaneous tissue without edema. If necessary, X-ray mammography of soft tissue is feasible to help diagnosis.