腋窝周围组织瓣在乳腺癌腋窝淋巴结清扫术中的应用

Clinical application of axillary adjacent tissue flap in axillary lymph node dissection of breast cancer

目的探讨乳腺癌腋窝淋巴结清扫术中应用腋窝周围组织瓣即刻修复处理的临床应用价值。方法本前瞻性研究纳入2014年3月至2015年3月湖北省荆门市第一人民医院甲状腺乳腺外科诊断为乳腺浸润性导管癌并行腋窝淋巴结清扫的患者86例,其中应用腋窝周围组织瓣即刻修复处理者41例作为研究组,其余45例未即刻行修复处理者作为对照组。术后记录所有病例的引流时间、引流量,上肢功能障碍程度与腋窝外形满意度及舒适度情况,并应用多频生物电阻抗分析技术分别测定患者健肢与患肢细胞内外液差值的比值(ECW_d/ICW_d)来评估术后1年上肢淋巴水肿情况。2组年龄、体质指数、淋巴结清扫数目及阳性数目、引流量与引流时间、上肢功能障碍程度、腋窝外形满意度及腋窝舒适度、ECW_d/ICW_d比较采用t检验,淋巴瘘例数比较采用χ~2检验,病理分期比较采用秩和检验。结果2组在年龄、体质指数、淋巴结清扫数目、淋巴结阳性数目、病理分期方面差异无统计学意义(t=-0.216、0.625、-0.504、-0.796,Z=-0.459;P=0.830、0.534、0.615、0.428、0.647)。研究组的引流量及引流时间低于对照组[(408.95±49.18)ml比(458.60±53.88)ml,t=-4.448,P<0.001;(6.49±1.16)d比(7.11±1.15)d,t=-2.493,P=0.015]。研究组淋巴瘘发生率为9.76%(4/41),低于对照组的28.9%(13/45)(χ~2=4.952,P=0.026)。研究组上肢功能障碍程度低于对照组[(3.37±0.69)%比(3.71±0.81)%,t=-2.099,P=0.039]。研究组在腋窝外形满意度、腋窝舒适度及上肢淋巴水肿情况(ECW_d/ICW_d)方面优于对照组[(7.88±0.90)分比(7.20±0.96)分,t=3.355,P=0.001;(6.98±0.82)分比(6.18±0.80)分,t=4.544,P<0.001;1.83±0.21比1.94±0.22,t=-2.257,P=0.027]。结论乳腺癌腋窝淋巴结清扫术中应用腋窝周围组织瓣即刻修复处理能有效避免淋巴瘘,改善上肢功能与腋窝外形及舒适度,预防上肢淋巴水肿。

Objective To investigate the clinical application of axillary peripheral tissue flap during axillary lymph node dissection for breast cancer patients. Methods This prospective study involved the clinical data of totally 86 patients with invasive ductal breast cancer who underwent axillary lymph node dissection in Department of Thyroid and Breast Surgery, First People＇s Hospital of Jingmen City, Hubei Province from March 2014 to March 2015. Forty-one patients were surgically treated with axillary peripheral tissue flap as study group and the remaining 45 patients received no immediate surgical repair as control group. The drainage time, drainage volume, the extent of upper limb dysfunction and patients＇ satisfaction with axillary appearance and comfort degree were recorded in two groups. Multiple-frequency bioelectrical impedance analysis system wasused to determine the ratio of extracellular water to intracellular water in healthy and affected limbs （ECWa/ICWd ） so as to reflect the incidence of upper limb lymphedema in postoperative 1 year. The parameters including age, body mass index, number of dissected lymph nodes, number of positive lymph nodes, drainage volume and drainage time, upper limb dysfunction, patients＇ satisfaction with axillary appearance and comfort degree, and ECWJICWo between two groups were compared using t test. The number of lymphatic fistula patients was compared between two groups using X2 test. Postoperative pathological stage was compared between two groups using rank sum test. Results There were no significant differences in age, body mass index, number of dissected lymph nodes, number of positive lymph nodes and postoperative pathological stage between 2 groups （t =-0. 216, 0. 625, -0. 504, -0. 796, Z=-0. 459; P=O. 830, 0. 534, 0. 615, 0. 428, 0. 647）. The drainage volume and drainage time in study group were significantly lower than those in control group [ （408.95±49. 18） ml vs （458.60±53.88） ml, t= -4. 448 ,P〈O. 001 ; （6.49±1.16） d vs （7. 11 ± 1.15 ） d, t =-2. 493, P= 0. 015 ]. The incidence of lymphatic fistula was 9. 76% （4/41） in study group, significantly lower than that in control group （28.9%, 13/45） （X2 =4. 952, P=O. 026）. The extent of upper limb dysfunction in study group was significantly lower than that in control group [ （3.37 ±0.69 ）% vs （3.71±0. 81 ）%, t =-2. 099, P = 0. 039 ]. The patients＇ satisfaction with axillary appearance and comfort degree, and ECWo/ICWd in study group were superior to those in control group （7. 88±0. 90 vs 7. 20±0. 96 ,t= 3. 355, P=0. 001 ; 6. 98±0. 82 vs 6. 18±0. 80,t =4. 544, P〈0. 001 ; 1.83±0. 21 vs 1.94±0. 22,t= -2. 257, P=0. 027）. Conclusion The immediate surgical repair using axillary peripheral tissue flap during axillary lymph node dissection can effectively avoid lymphatic fistula, ameliorate upper limb function, improve axillary appearance and eotnfort and prevent upper limb lymphedema.