超声造影在继发性上肢淋巴水肿术前规划中的应用价值研究

Application value of contrast-enhanced ultrasound lymphography in preoperative planning for lymphaticovenous anastomosis in secondary upper extremity lymphedema

目的探讨超声造影作为淋巴管静脉吻合(LVA)术前规划手段,对提高继发性上肢淋巴水肿患者LVA手术质量和改善术后短期疗效的价值。方法回顾性分析2021年8月至2023年8月在浙江省人民医院乳腺外科接受LVA手术治疗的乳腺癌相关上肢淋巴水肿患者的临床资料。根据是否进行术前超声淋巴管造影,将患者分为超声造影组和对照组。超声造影组通过术前超声淋巴管造影联合高频超声彩色多普勒成像来定位淋巴管和受体静脉,并规划LVA手术靶标;对照组则根据术前吲哚菁绿淋巴管造影结果来引导LVA手术探查。2组患者LVA单肢手术探查切口数量、单肢成功吻合数量采用Mann-Whitney U检验;吻合成功率(成功吻合总数/手术探查切口总数)采用卡方检验;单次吻合手术时长、平均臂围、术前和术后臂围差用独立样本t检验。通过术后3个月随访,采用配对t检验对比2组患者手术侧肢体的平均臂围改善情况。P<0.05为差异有统计学意义。结果共纳入47例女性患者,其中超声造影组27例,年龄(57.1±9.0)岁,中位水肿病程2年;对照组20例,年龄(58.1±9.6)岁,中位水肿病程2年。超声造影组与对照组相比,单肢手术探查数[6.0(4.0,7.0)例vs.5.0(3.0,6.0)例]、单肢成功吻合数[5.0(3.0,6.0)例vs.3.0(2.0,3.0)例]、总体吻合成功率[82.8%(125/151)vs.61.4%(54/88)]以及术前术后平均臂围差均显著增加[(6.2±3.3)cm vs.(3.9±1.9)cm],单次吻合时长显著缩短[(57.4±16.0)min vs.(92.8±18.5)min],差异均有统计学意义(P均<0.05)。超声造影组、对照组的术前、后平均臂围分别比较[(31.4±4.6)cm vs.(25.3±4.7)cm]、[(31.3±4.3)cm vs.(27.5±3.8)cm],差异均有统计学意义(P均<0.01)。结论超声淋巴管造影作为LVA术前规划手段,能显著提高继发性上肢淋巴水肿患者LVA手术吻合数量和吻合成功率,缩短单次吻合时长,并改善LVA术后短期内肢体减容效果。

Objective To investigate the value of contrast-enhanced ultrasound(CEUS)as a preoperative planning strategy for lymphaticovenous anastomosis(LVA)in improving the quality of LVA and the outcome of short-term limb volume reduction in patients with secondary upper limb lymphedema.Methods Patients with breast cancer-related upper extremity lymphedema who underwent LVA at the Department of General Surgery Cancer Center Division of Breast Surgery of Zhejiang Provincial People’s Hospital from August 2021 to August 2023 were enrolled retrospectively.According to whether preoperative ultrasound lymphography was performed,the patients were divided into CEUS assisted group and control group.In the CEUS assisted group,preoperative CEUS lymphography combined with high-frequency ultrasound color Doppler imaging was utilized for precise localization of lymphatic vessels and recipient veins,as well as surgical target planning for LVA.In the control group,preoperative indocyanine green lymphography was employed to guide surgical exploration.Mann-Whitney U test was used to compare the number of LVA surgical exploration incisions per limb and the number of successful anastomoses per limb between the two groups.The success rate of anastomosis(total number of successful anastomoses/total number of surgical exploration incisions)was compared by the chi-square test.The duration of single anastomosis,mean arm circumference,and the difference between preoperative and postoperative mean arm circumference were compared by independent sample t-test.Paired-sample t-test was used to compare the improvement of the mean arm circumference of the operated limb of the two groups after 3 months of follow-up.P<0.05 was considered statistically significant.Results A total of 47 female patients were enrolled,including 27 patients in the CEUS assisted group,with an average age of(57.1±9.0)years and a median edema course of 2 years.There were 20 cases in the control group,with an average age of(58.1±9.6)years and a median duration of edema of 2 years.The CEUS group,compared with the control group,exhibited a higher number of surgical exploration incisions per limb[6.0(4.0,7.0)cases vs.5.0(3.0,6.0)cases],a greater number of successful anastomoses per limb[5.0(3.0,6v0)cases vs.3.0(2.0,3.0)cases],and a significantly increased overall success rate of anastomosis[82.8%(125/151)vs.61.4%(54/88)].Additionally,there was a significant increase in the preoperative and postoperative mean arm circumference difference[(6.2±3.3)cm vs.(3.9±1.9)cm].The duration of single anastomosis was significantly shortened[(57.4±16.0)min vs.(92.8±18.5)min],with statistically significant differences observed in all comparisons(all P<0.05).The preoperative and postoperative mean arm circumference were compared between the CEUS group[(31.4±4.6)cm vs.(25.3±4.7)cm]and the control group[(31.3±4.3)cm vs.(27.5±3.8)cm],respectively,with statistically significant differences observed in both groups(both P<0.01).Conclusion CEUS lymphography,as a preoperative planning strategy for LVA,can significantly increase the number and success rate of LVA anastomosis in patients with secondary upper limb lymphedema,shorten the duration of single anastomosis,and improve the short-term effect of limb volume reduction after LVA.