Swelling of the legs in cancer patients
Search for effective methods of prevention and treatmentLymphatic edema of the limbs remains at present one of the important problems of practical health care. According to domestic and foreign authors [Kupchenko LG. 1980; Moffat E, Scnofsky G. Davis K. et al. 1992], in 33.3-84.3% of patients after treatment of malignant neoplasms, which involves surgical interventions or radiotherapy on a regional lymphatic apparatus, irrespective of the time elapsed after treatment, on the side of intervention (surgery, radiotherapy) there is lymphatic edema. The latter can lead already healed from a tumor to a deep disability, which is observed in 40% of cases [Gerasimenko VN. Grushina TI 1990; Zelisovski A. Manoach M. 1982; Foldi M. 1985; Knobf M. 1996]. If we consider that the lymphatic edema of the limbs are found mainly in young people of the most able-bodied age, then the problem of rehabilitation of these patients, the specific gravity of which reaches 22.5-60% [Grushina Т.V. 1990; Abalmasov K.G. 1992; Vishnevsky A.A. et al. 1998; Kinmonth J. 1982], acquires not only important medical, but also social significance. Lymphatic outflow disturbances in patients after radical treatment of breast cancer are often combined with venous insufficiency (16%), plexitis (10%), gross trophic and cicatricial changes of skin and soft tissues (14%) [Milanov IO. 1984].
Most of the currently usedknown methods of treatment of lymphatic edema of extremities - conservative therapy by traditional methods [Kupchenko LG. 1980; Milanov N.O. 1981; Levin A.O. et al., 1987; Mogilevsky I.L. 1988; Foldi M. et al. 1985], lymphovenous shunting [Abalmasov K.G. 1982; Vasilyev V.V. 1988; Zolotarevsky V.Ya. et al. 1990; Ragnarsson R. 1990] - are effective only in the initial stages of the disease and do not prevent the further development of the disease. The results of radical operations (partial or radical dermolipofasciectomy) with lymphedema and its extreme degree - elephantiasis, unfortunately, remain unsatisfactory. The reasons for this are the duration of the postoperative period, the early (hematoma, necrosis of the skin graft, etc.) and the late (development of coarse keloid scars, lymphorrhea, papillomatosis, hyperkeratosis up to the cancerous degeneration of the skin in the ulcer zone) postoperative complications [
Gilevsky IL 1988; Egorov Yu.S. 1996; Williams A. 1993]
There is no consensus on the importance of diagnosticmethods for lymphedem, and the advisability of using some of them, for example, X-ray lymphography, is even questioned [Tsyb AF. 1981; Rab-kin I.Kh. et al. 1984; Zerbino D.D. et al. 1990; Chepelenko G.V. Frolkov Yu.A. 1997]. The lack of clear indications for choosing a method and the timing of surgical treatment explains to a certain extent great differences in the results obtained. Until now, there is no well-developed system for the treatment of lymphatic edema of the limbs using a complex method (a combination of conservative measures and surgical interventions), which undoubtedly significantly reduces the effectiveness of treatment for this severe group of patients and limits the possibilities of preventing lymphedema.
A new direction in the treatment of this complexthe category of patients was the development of reconstructive and reconstructive operations aimed at improving the drainage of lymph from the limb by using tissues rich in lymphatic structures and, above all, a large omentum. However, despite the possibility of using a large omentum in the treatment of lymphatic edema of the extremities, the clinical experience of its application is small and based on individual observations [Kirikuta I. 1980; GoldsmithH.S. 1989; Abalmasov K.G. 1992; EgorovY.S. 1992]. Information on the results of transposition of the epiploon on the stem is inconsistent. The clinical experience in the treatment of edema with the help of autotransplantation and transposition of a large omentum in combination with the use of aspiration lipectomy is not known in the literature.
At the present time, newpharmacological preparations and physiotherapy techniques, allowing to solve the problem of treatment of lymphatic edema of limbs on a completely different level. One of the new promising drugs offered for the treatment of venolymphatic insufficiency is a cyclo-3-fort-angiotropic drug with a wide spectrum of action [Demarez J.P. Laurent D. 1988; Monteil-Seurin J. 1988; Le Devehat C, 1994].
Thus, a large number of patients withpostmastectomy edemas of the extremities, unsatisfactory results of traditional methods of treatment of this severe category of patients, their high disability, lack of a clearly developed system of complex treatment of this complex pathology, indicate the urgency of the problem, which was
cause of this study. The practical importance of studying this problem is also relevant because patients with lymphatic edema of the limbs have not received the necessary assistance so far due to the absence of specialized centers for their rehabilitation in the system of practical health care of our republic.
The thesis is fulfilled according to the plan of scientific research works of SRIOncology and Medical Radiology. N.N. Alexandrova "To develop a method for the complex treatment of secondary limfedem extremities with the use of reconstructive-reconstructive operations and liposuction in cancer patients" (1998-2000, State Registration No. 19983345) and is part of the Republican scientific and technical program "Oncology" ("Develop and implement effective methods of diagnosis, treatment and rehabilitation of cancer patients. "
Purpose of the study: develop and implement effectiveetiopathogenetically directed method of complex treatment of patients with postmastectomy edema of limbs, developed after radical treatment of breast cancer.
Determine the selection criteria for patients with postmastectomy edema of the extremities for reconstructive-reconstructive operations.
To develop a technique for microsurgical autotransplantation and transposition of a large omentum to a swollen limb, taking into account the mechanism of postmastectomy edema development and indications to them.
3. To determine the optimal scheme of complex treatment of patients with postmastectomy edema of limbs with the use of reconstructive-restoration operations, physiotherapeutic and medicamental influences.
4. To study the results of complex treatment of patients with postmastectomy edema and on their basis to develop recommendations for public health.
Scientific novelty of the results
A new method of complex etiopathogenetic treatment of patients was developed and introduced into clinical practice from Postmastectomy edema of the limbs, developed after radical treatment of breast cancer. Received a positive decision to grant a patent for an invention on the application N 961161 "Method of treatment of secondary limipedema of the extremities".
Indications and contraindications tosurgical treatment, which takes into account the degree of lymphedema, the nature of the course of the disease, the presence of local and general changes in the body. Developed indications for the implementation of combined operations with postmastectomy edema of the extremities. It has been established that in patients with postmastectomy edema of the extremities with the use of microsurgical autotransplantation and transposition of the large omentum, the gland flap must be fixed not only along the course of the neurovascular bundle on the shoulder, but also in the armpit, enveloping the vessels and nerves, which prevents subsequent their scarring after phlebolysis and neurology.
It has been established that a good result can beIt was received only under condition of carrying out of complex treatment which should include both surgical interventions and application of medicamental, physiotherapeutic means.
Practical significance of the results
The results of the study areclinical evidence of the advisability of using surgical interventions (microsurgical autotransplantation or transposition of a large omentum on a fixed vascular pedicle to the edematous limb, phlebolysis of the main veins, aspiration lapectomy and their combinations), medications (use of the cyclo-3-fort preparation), physiotherapeutic effects (pneumomassage edematous limb automatic pneumocompressor) in the treatment complex of patients with postmastectomy edema of extremities in oncology of patients.
The developed system of indications andcontraindications to the choice of the method of surgical treatment of postmastectomy edema of the limbs allows in each specific case to choose the optimal treatment plan, which expands its capabilities and improves results in an earlier unpromising group of patients.
The main theses of the dissertation, put on defense
1. The method of complex zhtopatogenetic treatment of patients with postmastectomy edema of the extremities was developed and introduced into clinical practice, including a gradual phased correction of existing disorders with the use of surgical interventions, physiotherapeutic effects, drug therapy.
Given the high vascularizing ability,good transport and drainage functions of the large omentum, the main component of the complex treatment of patients with postmastectomy edema of the extremities is transposition or microsurgical autotransplantation of the gland flap to the edematous limb.
A good result of treatment of patients withPostmastectomy edema of the extremities can be obtained only if the complex system of treatment measures is applied, which should include not only surgical interventions, but also courses of maintenance therapy and preventive measures.
The author was a doctor in all patients,included in the study. Performed surgical interventions, in the amount determined for the surgeon and assistant of one of the surgical teams and, thus, took part in the surgical and complex treatment of all patients included in the study. Patient control, statistical processing and analysis of the results of treatment, as well as the design of the dissertation are carried out personally.
The results of studies included inthesis is reported at the Republican scientific conference "Medical and professional rehabilitation of patients and invalids, prevention of disability" (Minsk, 1993); International Conference "Medical, social, professional rehabilitation of patients and invalids" (Minsk, 1996); Republican scientific-practical conference of oncologists "Actual problems of diagnostics, treatment and rehabilitation of patients with breast cancer" (Mogilev, 1996); interregional symposium "Organ-saving and reconstructive-plastic surgery in oncology" (Chelyabinsk, 1997), at the meeting of the Scientific Council of the Scientific Research Institute of Oncology and Medical Radiology. N.N. Alexandrov 19.06.1999 years.
The materials of the thesis published 9 papers, inincluding articles in scientific journals-1, in collections of scientific papers-4, theses of reports-4, positive decisions on granting patents for inventions-1. Total number of pages of published materials-37.
Introduction of research results into practice
The main theses of the dissertation are introduced inDepartment of General Oncology and Plastic Surgery of the Scientific Research Institute of Oncology and Medical Radiology. N.N. Alexandrov, the Department of Vascular Surgery and Microsurgery of the Minsk Regional Clinical Hospital, the Department of Microsurgery and Rehabilitation of the Gomel Oncology Dispensary. The results of the studies are included in the lecture courses of the Department of Oncology and Medical Radiology of the Belarusian State Institute for Advanced Training of Physicians.
Structure and scope of the dissertation
The thesis is written in Russian, consists ofintroduction, general characteristics of the work, 4 chapters (analytical review of the literature, description of the material and research methods, own results, discussion of the results), conclusions, practical recommendations, conclusions, list of literature including 300 sources.
The work is presented in 106 pages, 85 pages of text. The thesis contains 15 tables and 31 figures.