Edema in the upper part of the leg

... is an integral part of the so-called postmastectomy syndrome.

Postmortemectomy of the upper limb(MIP) is an edema that occurs after all radical operations on the mammary gland, which are performed with (!) Mandatory axillary lymphodissection, in which the collection of lymphatic vessels, which carry out lymphatic drainage from the upper limb, inevitably cross.

According to various statistical data, regardless of the selected treatment methods, MIP develops in 10-80% of patients with breast cancer after a course of therapy.

The reasons for the development of MIP are the followingetiopathogenetic factors: (1) disturbance of vascular microcirculation, as a result of removal of subclavian, axillary and subscapular lymphatic collectors, as well as due to a disorder of the innervation of the blood vessels of the hand as a result of trauma (crossing) of numerous small nerves in mastectomy and as a result of prolonged vasospasm followed by thrombosis, thrombophlebitis and lymphangitis ; (2) purulent-necrotic complications in the area of ​​the operating wound, as well as erysipelatous inflammation of the upper limb on the affected side; (3) also a possible cause of MI development is a prolonged course of teletherapy.

Predictors of MIP development: (1) large tumor size; (2) clinical manifestations of axillary lymph node involvement; (3) the presence of metastases; (4) a surgical operation, including an insufficient one; (5) insufficiency or absence of postoperative chemotherapy; (6) postoperative radiotherapy; (7) relapse of the disease.

An additional factor. contributing to the development of MIP and increasing its frequency is an individual variant of the lymph of the upper limb in the form of the absence of anatomical compensatory mechanisms that allow sufficient lymphatic drainage from the limb after crossing the collection of lymphatic vessels.

Clinical manifestations of MIP can be (invarious combinations): swelling, numbness, paresthesia, pain syndrome of varying severity (from minor soreness to sudden burning or prolonged blunt pain with diverse irradiation); feeling of heaviness; cramps and spasms; loss or significant limitation of mobility; increase in local temperature; dry skin. This symptomatology can appear, either directly or in the near future after a mastectomy, and also in more distant terms: the average time of appearance of MIP, indicated in the work of A.R. Pecking (1995), were 17 ± 7.6 months. Among psychiatric pathologies, patients with MIP are the most common anxiety, anxiety, mental exhaustion, severe depression.

Complications of MIP: damage to m. supraspinatus, chronic bursitis, contracture or limitation of the amplitude of the movements of the shoulder joint, plexitis and neuropathy, cellulitis, scalenus syndrome, the development of lymphangiosarcoma in a series of observations against the background of the long-existing lymphostasis of the upper limb is Stewart-Trivs syndrome. The presence of MIPs usually adversely affects the professional skills of women (sometimes resulting in loss of ability to work), significantly complicating interpersonal and family relationships in patients with breast cancer, (!) So they have a decrease in self-esteem, as well as self-esteem.

Classification. There is no unified classification of MIP. Classification based on the timing of the emergence of MIP (VA Udyak (1972): (1) early MIP - develops up to 3 months after radical treatment, (2) late PMS-develops 3 months after the radical treatment. O. Levin et al. (1987) distinguish the following forms (considering them as stages): MIP (1) transient, (2) soft, (2) dense, and (3) deforming D. Efremov (1963) subdivides MIP into three degrees: (I) pronounced lymphostasis, when the shoulder circumference exceeds 6 cm (in comparison with a healthy limb), (ii) moderately you Agen lymphostasis with a difference in circumferential shoulder 3 to 6 cm, (III) with a slight difference lymphostasis arm circumferential length of 1.5 to 3 cm.

Classification of MIP (most significant), proposed by TA. Pantyushenko, M. Beltran (1990):
• Stage I (stage of preclinical manifestations of MIP): the volume of the hand on the side of the lesion is increased to 150 ml as compared to the opposite upper limb; noticeable changes in the circumference of the shoulder can not be detected.
• Stage II (onset of clinical manifestations of MIP): the arm volume exceeds the opposite limb by 150-300 ml, the circumference of the shoulder is 1-2 cm; while the edema of the entire arm or its individual segments is visually noted; The meal appears in the evening and disappears by morning; patients feel heaviness in the hand, sometimes they experience painful sensations; the skin gradually loses the color inherent in a healthy limb, is taken in a coarser fold.
• The third degree (moderately expressed MIP): increase the volume of the hand by 300-500 ml or shoulder circumference by 2-4 cm; The swelling of the arm acquires a constant character, does not disappear by morning; the skin becomes cyanotic, pale, hardly folds.
• IV degree (expressed by MIP): exceeding the volume of the hand by 500-700 ml or the circumference of the shoulder by 4-6 cm; there is a constant swelling of the hand with the transition to fibredema. The limb is deformed, partially losing its function.
• V degree (burdened by MIP): increase the volume of the hand by 700 ml or more or the circumference of the shoulder over 6 cm; the limb completely loses its function; there are pronounced trophic disorders. Patients are forced to keep their hands in suspense.

Diagnosis of MIP begins with a clinicalexamination of patients in the form of determining the degree of increase in the volume of the limb, as well as the degree of tension and hydrophilicity of the soft tissues of the limb ("preclinical", "transient", "soft", "dense" and "deforming" edema stage), presence or absence of stenosis of the subclavian vein and venous hypertension. Clinical examination is supplemented by special research methods, the most important of which are: (1) dynamic lymphoscintigraphy (which allows to get lifetime contrast of functionally full lymph vessels and nodes), (2) phlebotonometry (measurement of intravenous pressure in the superficial veins of the limb), and (3) phlebography , (4) ultrasound examination of the soft tissues of the limb and in some cases (5) computed tomography.

Treatment. All methods of treatment of patients with MPS can be divided into 3 groups: physical and physiotherapeutic; medicamentous; surgical. The most effective physical and physiotherapeutic methods of treatment of MIP are currently: (1) pneumatic compression with sequential compression of the upper limb from the distal to the proximal, (2) mechanical lymphatic and manual lymphatic drainage. Drug therapy is an obligatory part of the conservative therapy of MIP and includes several groups of drugs. The main ones are medicines that stimulate limfodrenazhnuyu limb function and act simultaneously on venous tone, improving lymphatic drainage (eg, diosmin). In addition, according to indications, antibiotics, desensitizing drugs, immunomodulators are used.

Surgical methods of treatment of MIP. Surgeons perform the removal of fibro-altered tissues with subsequent autodermoplasty, plastic surgery with the musculoskeletal flap, the formation of lymphovenous anastomoses, phlebolysis of the axillary and subclavian veins, liposuction, a combination of liposuction and transplantation of the musculoskeletal flap. latissimus dorsi. Since such treatment methods are multi-stage, traumatic, require the development of special microsurgical techniques and do not always give positive cosmetic and functional results, preference should still be given to conservative methods.

Preventive actions. IN AND. Drizhak et al. (1998) to prevent MIP include the use of a transverse section of the skin, a careful separation of its flaps, the preference for intensive irradiation before the prolonged course of radiation therapy. They recommend patients in the absence of complications starting from 6-7 days after the operation to perform active dosage for the shoulder and elbow joints, gradually increasing the load. After 2 weeks in the complex of exercises include massage of the upper limb belt - various types of stroking and rubbing, later - kneading muscles in different directions. Control of the effectiveness of restorative treatment was carried out by determining the circumference of the shoulder, the strength of the muscles of the hand and the forearm (dynamometry), the amplitude of movements in the shoulder joint in dynamics.

V.S. Erickson et al. (2001) distinguish four main categories of preventive measures: (1) avoidance of excessive intraoperative trauma; (2) prevention of infection; (3) avoiding any squeezing of the hand; (4) functional load and exercise therapy. This includes the following precautions: gloves when working at home or in the garden / in the country; avoid venepunctures, injections and pressure measurements on the "edematous" upper limb; to provide first aid for any hand injuries, even the most minor ones; avoid sources of heat and prolonged exposure to the sun; avoid any tight clothes for the "edematous" upper limb; adhere to moderate functional activity of the upper limb; do not carry weights; avoid sudden movements.

Posted by Laesus De Liro on 05 October 2010, 22:10:05 · 0 Comments · 4757 Reads ·


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