多普勒超声造影在下肢淋巴管–静脉吻合术中选择最优功能淋巴管截断尺寸的应用

Application of Doppler Contrast-Enhanced Ultrasound in Selecting the Optimal Functional Lymphatic Vessel Ligation Size during Lower Limb Lymphaticovenular Anastomosis

摘要: 背景：淋巴水肿是由淋巴系统先天发育异常，或继发于肿瘤切除、淋巴结清扫、放疗、感染及外伤等导致的淋巴回流障碍，使富含蛋白的淋巴液在间质异常蓄积，引起慢性、进行性组织肿胀。该病好发于四肢，也可累及乳房、外阴、躯干及头颈部。病情进展后可出现皮下纤维化、脂肪沉积、皮肤增厚、反复蜂窝织炎及肢体功能受限，严重影响患者生活质量与预后。淋巴管–静脉吻合术(LVA)是外科治疗淋巴水肿的主要方法之一，通过在患肢将皮下浅淋巴管与小静脉多次吻合，绕过淋巴阻塞，使淋巴液转入静脉循环，具有微创、安全性高的优势。超声造影(CEUS)可实时动态显示淋巴管内造影剂流动，清晰显示淋巴管边界与管径。CEUS定位技术的应用，旨在满足淋巴水肿显微外科治疗向精准化、功能化发展的临床需求。目的：CEUS定位技术在LVA中的应用价值，评估其对最优淋巴管截断尺寸、手术效率及术后疗效的影响。方法：本研究为回顾性队列研究，纳入2024年9月至2026年9月在延安大学附属医院烧伤整形外科接受下肢LVA手术的患者共58例。其中研究组27例(2025年9月至2026年9月)，术前采用CEUS定位最优功能淋巴管；对照组31例(2024年9月至2025年8月)，术前使用吲哚菁绿红外显影(Indocyanine Green Lymphography, ICG-L)方式定位目标淋巴管。比较两组患者的单根淋巴管吻合时间、手术总时间、截断尺寸，以及术前、术后3个月、术后6个月的(Lower Extremity Lymphedema Index, LELI)。结果：两组总手术时间有统计学差异(研究组：214.23 ± 13.54 min，对照组：223.34 ± 23.64，t = 5.347，P = 0.002)，且研究组单根淋巴管吻合时间(29.89 ± 3.24 min)显著短于对照组(35.48 ± 9.66 min)，t = 3.873，P = 0.003，研究组术中吻合淋巴管的平均截断尺寸为(0.67 ± 0.06) mm，显著大于对照组的(0.39 ± 0.13) mm，差异具有统计学意义(P < 0.001)。通过治疗前、术后3个月、术后6个月LELI的随访观察，两组患者治疗前LELI无统计学差异具有可比性。术后3个月及术后6个月，研究组LELI均显著低于对照组。重复测量方差分析显示，对照组F_时间效应 = 85.334，P < 0.001；研究组F_时间效应 = 41.23，P < 0.001。F_组间效应 = 3.78，P = 0.001；F_交叉 = 5.446，P = 0.004。结果表明，两组患者的LELI均随时间显著下降，但研究组下降幅度大于对照组，CEUS定位技术能够显著增强LVA手术的水肿改善效果。结论：CEUS定位技术可显著提高LVA术中最优淋巴管截断尺寸，缩短单根淋巴管吻合时间，提高手术效率，改善患者术后下肢淋巴水肿程度及生活质量，具有重要的临床应用价值。

Abstract: Background: Lymphedema is a condition caused by impaired lymphatic drainage resulting from congenital malformations of the lymphatic system, or secondary to tumor resection, lymph node dissection, radiotherapy, infection, and trauma. This impairment leads to abnormal interstitial accumulation of protein-rich lymphatic fluid, causing chronic, progressive tissue swelling. The disease predominantly affects the extremities but may also involve the breast, vulva, trunk, and head and neck regions. As the disease progresses, patients may develop subcutaneous fibrosis, adipose deposition, skin thickening, recurrent cellulitis, and functional impairment of the affected limb, significantly compromising quality of life and long-term prognosis. Lymphaticovenular anastomosis (LVA) is one of the primary surgical treatments for lymphedema. By performing multiple anastomoses between subcutaneous superficial lymphatic vessels and small veins in the affected limb, LVA bypasses the lymphatic obstruction and diverts lymphatic fluid into the venous circulation. It offers the advantages of being minimally invasive and having a favorable safety profile. Contrast-enhanced ultrasound (CEUS) enables real-time, dynamic visualization of contrast agent flow within lymphatic vessels, clearly delineating the boundaries and diameters of lymphatic vessels. The application of CEUS-based localization techniques aims to meet the clinical demand for precision and functional advancement in microsurgical treatment of lymphedema. Objective: To evaluate the value of CEUS localization in LVA, specifically its impact on optimal lymphatic vessel transection diameter, surgical efficiency, and postoperative outcomes. Methods: This retrospective cohort study included 58 patients who underwent lower extremity LVA at the Department of Burn and Plastic Surgery, Yan’an University Affiliated Hospital, between September 2024 and September 2026. The study group comprised 27 patients (September 2025~September 2026) who received preoperative CEUS to identify optimal functional lymphatic vessels; the control group comprised 31 patients (September 2024~August 2025) who received preoperative indocyanine green lymphography (ICG-L) for target vessel localization. The two groups were compared regarding time for anastomosing a single lymphatic vessel, total operative time, transection diameter, and the Lower Extremity Lymphedema Index (LELI) measured preoperatively and at 3 and 6 months postoperatively. Results: The total operative time was significantly shorter in the study group (214.23 ± 13.54 min) than in the control group (223.34 ± 23.64, t = 5.347, P = 0.002). The time for anastomosing a single lymphatic vessel was also significantly reduced in the study group (29.89 ± 3.24 min vs. 35.48 ± 9.66 min, t = 3.873, P = 0.003). The mean transection diameter of anastomosed lymphatic vessels was significantly larger in the study group (0.67 ± 0.06 mm) compared to the control group (0.39 ± 0.13 mm, P < 0.001). Preoperative LELI values were comparable between groups. At 3 and 6 months postoperatively, LELI was significantly lower in the study group than in the control group. Repeated-measures ANOVA revealed significant time effects (control group: F = 85.334, P < 0.001; study group: F = 41.23, P < 0.001), between-group effect (F = 3.78, P = 0.001), and interaction effect (F = 5.446, P = 0.004), indicating a greater reduction in LELI in the study group over time. CEUS localization technique may significantly enhance the edema improvement effect of LVA surgery. Conclusion: Preoperative CEUS localization significantly increases the optimal transection diameter of lymphatic vessels in LVA, shortens the time for single-vessel anastomosis, improves surgical efficiency, and enhances postoperative reduction of lower extremity lymphedema and patients’ quality of life, demonstrating substantial clinical application value.