^^- • • • •
NGHIEN C0U KHOA HOC
DANH GIA KET QUA VI PHAU NOI BACH MACH TiNH MACH TRONG Dl CHUfNG PHU BACH MACH SAU DIEU TRI UNG THU VU
T O M TAT:
Muc tieu: Danh gia ket qua sir dung ky thuat sieu vi phau ndi bach mach-tinh mach Uong dieu tri phu bach mach d benh nhan sau phau thuat cat bd vii do ung thu ket hgp vet bach va xa tri.
Doi tirong va phuong phap nghiin cuu Gom 50 benh nhan (BN) dugc chiin doan phu bach mach sau cat bd ung thu vii sii dung ky thuat sieu vi phau ndi bach mach-tinh mach tai Khoa PTTH- Vien Bong qudc gia tir thang 6/2015 d i n thang 6/2017.
Phuong phap nghien cuu: Tien ciiu mo ta, cac so lieu dugc xir ly bdi SPSS 21.0
Benh nhan chia thanh bai nhdm, dugc tien hanh nghien ciiu dac diem ton thuong giai phau benh va danh gia hieu qua su thay ddi chu vi va cac trieu chimg lam sang sau khi noi bach mach-tinh mach.
Ket qua:
Nhom I: Cac tdn thuong hau nhu khdng co hoac it va vdi miic do ton thuong nhe. Nhom II: Xuat bien tit ca t i n thuong tren: X o hoa da, md dudi da mirc dp vira va nang gap d tat cit cac trudng hgp. Mot so trudng hgp uang (giai doan V) mat toan bp Idp c o Uon cua thanh bach mach. Kich thudc giam tai cac vj tri md cua chi sau 1 tuin: V I : 6,44
± 0,41 cm; V2: 5,09 ± 0,47 cm; V 3 : 6 ± 0,52. Giam manh nhat tai VI la 6 cm. Sd lugng cau noi: Trung buib 3,44 ciu ndi/benh nhan. Dudng kich mach: nho nhit: 0,3mm; Idn nhat: 1mm, trung binh: 0.66 ± 0.11 mm. K6t qua gin: Tdt 91,67%; vira 8,33%. K i t qua xa. Tdt 93,33%; vira 6,67%.
Ket luan
Phuong phap ndi bach mach-tinh mach vdi k i t qua budc dau tit, tinh trang lam sang dugc cai thien ro rang.
Day la ky thuat mdi, an toan, kha thi trong d i l u tri phii bach mach sau dieu tri ung thu vit.
Tir khoa: Phii bach mach, sieu vi phau, ung thu vu
Tran Thj Nga', Vu Quang Vinh'
A B S T R A C T :
EVALUATION EFFECTIVE OF SUPERMICROSURGICALLYMPHATICOVENULAR ANSTOMOSIS FOR LYMPHEDEMA IN AFTER BREAST CANCER TREATMENT
Background and Objective:
Lymphedema complicating breast cancer treatment remains a challenging problem. The purpose of this study was to analysis of lymphaticovenualar for treatment of upper limb lymphedema in breast cancer patients.
Objects and M e t h o d s :
50 patients with upper extremity lymphedema secondary to Ueatment breast cancer underwent lymphticovenular anastomoses using "Supermicrosurgical technique". These apatients were also divided two groups.
Group I included patients of stage 1,2,3 and group II are patients of stage 3,4. Histological have been studied in 10 patients of group 1 and 10 patients of group II. Evaluation included qualitative assessment quantitaive circumferential analysis before and postoperation and follow up over six months at position upper wrist 5cm, below elbow 5cra and upper elbow 5cm
Results:
hi groupll, skin and under tissue appeared fibrosis from light to severe, lymphatic trunks included tunica media, endothelial cell and smooth muscle also injunes.
However, in group I it is almost fine. The circumference decreased at a week with means were V I : 6,44 ± 0,41 cm;
V2: 5,09 ± 0,47 cm; V 3 : 6 ± 0,52, respectively. The mean number of anastomoses performed per patient was mean of 3.44, and the diameter of vessels ranged from 0.3 to I m m The mean operarive time was 3 hours. The mean follow-up time was six months with 91.67% good; 8.33%
fine and 0 % poor.
1. Phong kham chuyen khoa phSu thuat t h i m my Thien Nga SDT: 0908894568, Email: [email protected]
2. B?nh vien QuSn y 103
Y>% Ngay nhan bai. 03/08/2018 Ngay phan bien: 09/08/2018 I » Ngay duyet dang: 20/08/2018 S O S (46)-Thang 09-10/2018 Website; yhoccongdong vn
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Conclusion:
Lymphaticovenular anastomoses is effective reduce the severity of lymphedema in beast cancer patients. Long- term analysis is need.
Key words: Supermicrosurgical, lymphedema, breast cancer
L DAT VAN DE
Phil bach mach (PBM) la tinh trang qua tai ve chirc nang cua be thdng bach mach, trong dd cac khoang ulng cac md dudi da gian rpng nhung khdng xay ra d mo CO, gay ra tich tu cac dai phan hi trong md ke dan den phii ne dai dang, d do hien tugmg viem te bao, bach huylt xay ra lien tuc va tai dien. Hau qua qua trinh nay la xo cirng da va md dudi da, rdi loan cam giac, dau nbuc, ban che van ddng, bien dang chi tiiy theo miic dp phu bach mach
Phil bach miich sau phau thuat ket hgp tia xa vung hi nach dieu tri ung thu vu la bieu hien lam sang thudng gap, d My chiem khoang 15-20% benh nhan K. Dieu nay giiy anh hudng den chirc nang, chat lupng song: bien dang chi the, mat chuc nang cua chi' thay doi cam giac chi, m?t moi va roi loan tam ly, giam chat lugng cugc song cua benh nhan.
Theo y van the gidi, tir trudc den nay da co nhieu phuong phap khac nhau dugc ap dung trong dieu tri phu bach mach Uong ung thu, duac cbia thanh hai nhdm phucmg phap (1) Dieu tri khdng xam lan, bao ton: bang vat ly tri lieu, bang ap luc, masage ap dung cho benh nhan ung thu giai doan dau, lam keo dai thdi gian dn dinh ciia benb.(2) Phucmg phap can thiep xam lan, phau thuat lay bo cac md, td chiic dudi da..
Hien nay xu hudng sii dung ky thuat sieu vi phiu ndi bach mach -tmh mach da mang lai ket qua tot, tuy nhien chi CO mgt sd it cac nude tren the gidi co kha nang ap dung dugc ky thuat nay. Olszewsky (1966) bao cao trucmg hgp dau tien, den nay ban 200 bai bao bang tieng Anh de cap din vin dl nay. Cac tac gia tren the gidi deu co cimg quan diem cac diu hieu lam sang dugc cai thien ngay sau khi ml, tilp tuc tiln tnen tdt khi theo dot xa.
6 Viet Nam, tir nam 2015, Trung tam phau thuat tao hinh thim my va tai tao, Vien Bong Quic gia, vdi 50 trudng hgp phu bach mach sau dieu tri K vii dupe ndi bach mach - tmh mach vdi kit qua tdt. Xuit phat tir cac kit qua budc diu kha quan, chiing tdi nghien cim phan tich va danh gia kit qua sdm, ddng thdi cbia se kinh nghiem qua 50 uudng hap.
n . D 6 I TU'ONG VA PHU'ONG PHAP NGHlfiN
cfu
2.1. Doi tugng nghien cihi
2.1.1. Dia di€m nghien cihi, thdi gian nghi&n cuu Trung tam phau thuat tao binh tham my va tai ta.o, Vien Bdng Quoc gia.
Thdi gian: Thang 06/2015 - 06/2017.
2.1.2. Doi tirong nghien cuu
Gdm 50 benh nhan nii, khdng phan biet tudi cd phii bach mach chi Uen sau dieu tri K vii. Cac benh nhan dugc chia thanh 2 nhdm (phan chia theo giai doan benh pbii bach mach chi tren).
2.1.2. Tiiu chuan loai tru
BN khdng hgp tac, BN cd phii tay voi ma ung thu chua dn dinh hoac tai phat ung thu. BN benh ly npi khoa nang kem theo nhu: lao tien trien, giang mai, roi loan dong mau, nhiem khuan tai vung du kien phau thuat.
2.2. Phuong phap nghigo cihi bhi cihi 2.2.1. Nghien cihi giai phiu b€nh
Tat ca cac benh nhan dugc sinh thiet da va to chiic dudi da nhd, tai 3 vi tri tren nep cd tay 5cm, Tren va dudi nep gap khuyu 5cm.
Tieu chi danh gia mo benh hoc: Miic do co xa hoa to chirc dudi da. Tdn thuong cau tnic bach mach
2.2.2. Nghi£n curu a?c diem lam sang Benh nhan dugc khai thac tien sir benh va kham lam sang: Danh gia tinh trang da tai chi phii: mau sac, do dan hdi ,bieu hien viem do, loet....
- Do chu VI hai tay d cac vi Ui: VO: d nep gap mu tay;
VI: phia Uen nip gip co tay 5cm; V2: Uen nip gip khuyu 5 cm; V3' dudi nip gip khuyu 5 cm bang thudc day mem, tinh bing cm. Danh gia van dong, cam giac tai tay phii:
cam giac te, dau budt...
- Phan loai giai doan phu theo Campisi 2001 - Phuong phap hau thuat tao cau noi BM-TM sieu vi phau.
- Cdc buac tien hdnh
BN dugc gay te dam roi than kinh canh tay va ket hop vdi tien me.
Qui trinh ml vi phau thuat: Xac dinh vi tri phau thuat,VI,V2vaV3.
• Xac dinh mach bach huyet dung dich xanh Methylen dugc tiem bang kim 30 dudi da ke ngdn tay I -2 va 2-3 Cac tieu bach mach dugc tim kiem thong su ngam chat mitu xanh Methylen. Kinh phdng dai 30 lan cac cac dung cu vi phau tich dugc sir dung tim tieu tinh mach lan can phuc vu cho ndi mach. Do kich thudc bach mach bang thudc palmer.
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NfiHIEN CUfU KHOA HOC
• Tilu bach mach va tilu tmh mach se dugc nii vdi nhau dudi kinh hien vi theo kieu tan - tan, tan - ben hoac ben - ben bang chi vi phau 11/0.
Hau phau: Khang sinh, giam dau, chdng phii ne, chdng viem, bang ep nhe, ke cao chi mo.
• Su tbay dli chu vi se dugc danh gia vao ngay thii bay sau ml va sau 3 thang, 6 thang Cam giac va van dong chi phu, cac UiSu chimg tai chd vl da, dnh trang viem, nl, phdng nude dugc theo doi vit danh gia.
• Cac biln chiing sau phSu thuat: Phat hien va xii tri kip thdi, nit ra bien phap khac phuc.
Chup anh benh nhan trudc- sau phau thuat Danh gia kit qua sau phSu diuat: Kich thudc chu vi tay phu. Tinh uang cam giac tai cho. Chirc nang van ddng tay phu. tinh trang viem, ne, loet, mitu sac da.. .tai tay ben phii.
Danh gid kit qua sdm (<3 thang sau ph3u thuat) Tdt: Chu vi tay phu giam, rd ret, chi sd Warerm <25%), trieu chiing roi loan cam giac, van dong hdi phuc (trir mgt sd trudng hgp liet day than kinh), an chi phii mem mai, cac diu bieu bien chiing tren be mat da giam va khdi.
Vira: Chu vi tay phii giam,cbi sd Warenn 25-50%, cac rdi loan van dong va cam giac c6 giara nhung van cdn bilu hien; cac trieu chimg benh ly da lieu lien quan Uen da
ciing giam, nhung van cdn, an chua mem.
Khdng thay ddi: Chu vi tay phu khdng giam, hoac giam rit it chi sl Warenn <25%i bien chiing van dgng vk cam giac van cdn, tay cdn va khong thuyen gi^m cac tri^u chiing ve benh ly ciia da. Tay an ciing.
r- Danh gia ket qua xa (sau phau thu^t 6 thang) Tdt: Chu vi tay phu giam dan deu; cam giac binh thudng (tru ca tdn thucmg than kinh) mat hoan toan nhiing tneu chiing Uen be mat da va an mem mai.
Vua: Chu vi tay phii giam nhung cham hoac khong tang; van cdn nhiing tneu chiing cam giac va v£in dgng chua mat hoan toan; an mem. Het cac tri|u chiing da lilu tren be mat.
Khdng thay ddi: Chu vi tay phii khdng giam hoac CO xu hudng tang len, cac rdi loan cam giac va v^n dong khdng cai thien, an cang tiic.
III. KET QUA
Nghien ciiu ciia chung tdi cd 20 benh nhan nghien cuu mo benh hpc cd 8 cas cd tinh trang xo hda thugc nhom 2 chiem 20 (chiem 40%) nhdm I khdng cd benh nhan xa hda, 10 cas (50%) cd tdn thuong co tran, 18 cas (90%) tin thuong ao Uong.
Bdng 1. Dac diim giai doan vd thdi gian khdi phdt bfnh sau khi ket thuc lieu trinh diiu tri K
^ ^ ^ ^ ^ ^ Giai do^n Tlioi gian ^ ^ ^ ^ . ^ ^
<6 thang 6-12 tiiang 13-36 thang
>36 thang T6ng
PhSn chi giai doan b€nh phii bach mach I
0 0 0 0 0
II 0 0 1 0 1 (2%)
III 3 2 5 5 15 (30%)
IV 0 5 9 8 22 (44%)
V 1 4 4 3 12 (24%) Bien chimg roi loan cam giac: Te bi 16 cas (32%.), dau co bien ehiing rdi loan van ddng la 88%. 5 b§nh nhan ban bull 10 cas (20%). chi van ddng (10%.) thudc nhdm V, 1 trudng hgp liet (2%)
Bien chiing rdi loan van dong. Ty le b?nh nhan khong thugc nhdm V.
Bang 2
Kieu cau noi Tan - Tan Tan - Ben Ben - Ben long Ti le %
. Kieu cau noi vd so m^ch noi bach m^ch - ttnh m^ch n = Vi tri noi
VO 14 52 2 68 39,53
VI 5 19 1 25 14,53
V2 10 45 0 55 31,97
V3 2 22 0 24 13,95
172
Tong s6 mach noi (lyif) 31(18,03%) 138 (80,23%)
3 (1,74%) 172 100
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Vi tri ndi mach cua nghien ciiu tap tmng vao vi tri VO (vi tri nay la nep gap mu ban tay) chiem ty le cao nhat la 68(39,53%) va vi tri VI (uen cd tay 5cm) chilm 25 (14,53%) vi tri V2 (tren khiiy tay 5 cm) chilm 55(31,97%) va V3 (dudi nip gip khuy) chilm 22(13,95%).
Ky thuat sii dung noi true tiep bach mach vao tinh mach cua chiing toi ap dung la kieu cau ndi "Tan-Ben"
chiem 138 sd mach ndi chiem 80,23% va kieu cau noi
"Ben-Ben" chiem ty le nhd chi 1,74% trong tdng sd mach ndi.
Bdng 3 Kich thu&c bach m^ch trong qud trinh phau thugt (n=50).
Cac chi so
n-172 ICich thuac mm
Duong kinh ngoai bach mach (mm)
<0.4 04 0.3
0.4 13
0.5 17
0.6 40
0.7 53
0.8 37 0.66 ±0.01mm
>0.8 08
1
Bang 4. Mirc dp giam kich thu&c tay phu tai cdc vi tri sau phau thuat
Kich thu'6'c giam chu vi tay phu (cm)
Giam Ion nhdt (cm)
Giam nho nhat (cm)
Vitri
VI V2 V3 VI V2 V3
Thoi gian sau phau thuSt 1 tuan
6,0 5,0 4,0 2,0 1,5 1,0
< 3 thang 6,5 5,2 4,5 2,5 2,0 1,4 Kich thudc lgi cdc vi tri gidm sau I tuan so vai truac
khi md.Vl: Chu vi chi phii da giam dugc nhieu nhSt: tdi 6,0cm, va giam duac 2 cm. TB giam 4,36 ± 0,3 cm. V3:
Chu vi chi phit giam nhieu nhat lit 4cm, trung binh chu vi tay tai V3 giam 2,87 ± 0,33cm.
Kich thuac lai cdc vi tri gidm <3 thdng so vai truac khimo:N\: Giam Idn nhat 6,5cm. Trung binh giam 4,84±
0,33 cm.V3: Giam Idn nhat 4,5 cm, nhd nhat 1,4 cm. giam TB: 2,78 ± 0,34cm
Kit qua g^n dieu tri phii bach mach sau md <3 thang:
Nhdm I cd 16 benh nhan, vdi 48 vi tri kiem tra dat dugc kit qua: tdt chilm 91,67%, kit qua vira 8,33%, kit qua x k 0%.
Nhom II34 benh nhan, vdi 102 vi tri kiem tra dat dugc ket qua:
^t chilm 76,48%, kit qua vira 15,68%, kit qua xiu 7,84%.
Kit qua xa dieu tri phii bach mach sau md > 6 thang:
Nhdm I CO dap img tdt vdi pblu thuat nay, vdi 15 Uudng
hgp tdt 93,33% Ud lai sinh boat binh thudng, cac cam giac te bi, dau budt hay han che van dgng deu cai thien mgt each ro ret. Nhdm II, kit qua tdt (73,33%), dap ling d miic do vira (17,78%.)
IV. BAN LUAN
Nghien ciiu giai phlu berth tin thucmg bach mach vdi 20 benh nhan da cho thay co su pha buy te bao co tron bach mach, ton thucmg nay lam mat di Idp ao giiia lam thanh bach mach mong di va mat di su dan hdi. Ty le nay gap phan Idn trong benh nhan nhom II chiem ty le 100%.
Trong khi dd nhdm I khdng cd benh nhan nao. Tinh trang ton thucmg Idp ao ngoai gap 9/10 benh nhan nhdm II chiem ty !e 90%, uong khi do nhom I chi cd 2 benh nhan chiem ty le 20%. Nghien cuu ciia chiing toi cung phii hgp vdi tac gia Koshima cdng bo nam 1996 vdi ty le tdn
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thucmg Idp ca trcm vit lop ao trong len den 95%. benh nhan phii bach mach giai doan IV, V va tdn thuong nay tang dan tii canh tay din caog tay^'. Chiing toi ciing thSy dieu nay dugc minh chirng khi tien hanh tim bach mach tren lam sang. Altorfer va cdng su trong nghien ciiu ciia minh cho thiy rSng to chiic xo thudng bao xung quanh bach mach dan den phan img xung huyet'"'. Cac te bao viem di tni vao trong vao trong lap ao ngoai binh gay xo boa thanh bach mach din din su bit tac bach mach. Trong nghien ciiu ciia chiing toi ciing cho thay long bach mach hep dang ke Uen benh nhan thuoc nhom 11 do qua trinh viem va li dich keo dai dan den tinh trang xo hoa bach mach nhu Altorfer de cap d tren. Koshima vit cdng su ciing de cap trong nghien ciiu cua minh su tuong quan ket qua pblu thuat phii bach mach va tinh trang tdn thuong Idp CO Uon va ngi mac bach mach. Trong nghien cim ciia minh Koshima chi ra rang benh nhan bi xa boa bach mach ket qua phau thuat sau md thudng it hoac khdng cd su thay ddi chu vi ben thuong tdn. Trong nghien cuu cita chiing toi nhom benh nhan ton thuong Iiip co tron va Idp ao trong trong nhom II co ket qua tdt chi chiem 88,24%.
vdng I va 64,71% ciia vdng 3 so vdi lan lugt 100% va 81,25% ciia berth nhan nhdm I.
Nam 2010, Chang va cgng su cho thay rang cd su lien quan ket qua phau thuat va tinh Uang xa boa cua da va td chuc dudi da'". Chang cho rang co sir tuong ddng khi tham kham lam sang tay phii ne ciing, chac, an khdng Idm vdi ket qua nghien ciiu GPB la td chiic ke hi xo hoa, te bao ca tran bi teo det. Tinh trang xo hoa ciing la yeu to de chiing tdi tien lugng ket qua dieu tri, mac dii ky thuat ndi bach mach-tinh mach thanh cdng thi viec giam chu vi Uen benh nhan xo hoa bach mach cijng khdng thay ddi nhieu. nghien ciiu ciia chiing toi xa boa ciia da va to chiic dudi da 8/10 benh nhan thuoc nhom II, Uong khi do nhdm I khong cd benh nhan nao. Tuy nhien, tinh trang dau tiic, cam giac de ep deu giam va tay b?nh nhan khong tiep tuc to len niia.
Theo Koshima, ket qua giai ph5u benh cho th§y tinh trang xa hoa giam dkn tir dau glc chi Uen xudng nggn
chi. Them nua, ap luc tilu tinh mach dudi da thudng thdp hon tinh mach sau^'. Do vay, chgn lua cac tilu b ^ h m^ict va tieu tinh mach dudi da cho ndi bach m^cb tinh mgch la lira chgn tdi uu va nd se cho ket qua ben viing. Trong nghien ciru ciia chiing tdi vi tri dugc uu tien noi mach la vi tri tren nep gap cd tay 5 cm. Do tinh trang xo hoa d day it ban, nhieu tieu tinh mach vai dudng kinh tuong dong de dang cho ndi bach mach tinh mach. Do gSn vi tri tiem xanh methylen tai ke ngdn tay, khi xanh methylen ngSm vito he bach mach thi vi tri nay cho thay su ngam deu gidp cho viec tim kiem bach mach Ud nen de dang hon^'. Cdc ky thuat noi mach duac chiing tdi sir dung la ky thuat noi tan ben chiem da sd 80,23%
Cbiing tdi danh gia hieu qua dat dugc sau 1 tuan, voi ca 2 nhdm, tit ca cac benh nhan deu cd dap ling va hau nhu dat ket qua tdt sau md I tuan. Chi co mgt sd benh nhan 6 nhdm II (tai vj tri V3) dap img kem vdi phau thuat do miic do tdn thuong bach mach, tmh trang xo hda va phu ne da va md dudi da. Tuy v^y vdi ket qua budc dau nay, chiing toi cho rang phau thuat cd the mang Itii ket qua ngay sau phau thuat vai ngay, dieu nay phii hgp vdi nhan xet ciia mgt sd tac gia kha''*".
f'cW/i/io/rt/(benh nhan d giai doan 1,2,3): Chimg t6i nhan thay hieu qua dat dugc <3 thang sau md vdi 16 benh nhan dat kit qua tSt 91,67 %, vira 8,33 %.
Khi danh gia ket qua xa (> 6 thang), dat ket qua nhu sau vdi 15 benh nhan dugc tai kham: tdt 93,33%, vka 6,67%, khdng thay ddi 0%.
Khong CO trudng hgp nao khdng dap ling. Tat ca cac benh nhan deu hai Idng vdi ket qua dieu tri, benh nhan co the tham gia lao ddng, lam viec, sinh boat binh thudng, khong cdn cac trieu chiing rdi loan van ddng hay cam gidc tai tay phii nua.
V. KET LU4JS
Phuong phap nii bach mach-tinh mach vdi ket qua budc dau tot, tinh trang lam sang dugc cai thien ro rang.
Day la ky thuat mdi, an toan , kha thi trong dieu tri phii bach mach sau dieu tri ung thu vii.
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[ T A I LI|:iI THAM KHAO
1. Anne G.Warren, B., et al. (2007), ''Lymphedema a comprehensive review". Annals of Plastic Surgery 59 Number 4,October 2007: p. 464-472.
2. Cormier, J.N., et al. (2012), "The surgical treatment of lymphedema: a systematic review of the contemporary literature (2004-2010) ". Ann Surg Oncol, 19(2): p. 642-51
3. Koshima, 1., et al. (2012), "Recent advancement on surgical treatments for lymphedema". Ann Vase Dis, 5(4):
p.409-15.
4. Isao Koshima MD, et al. (2004), " Minimal Invasive Lymphaticovenular Anastomosis Under Local Anesthesia for leg Lymphedema is it Effective for stage III,IV". Armals of Plast Surgery 53: p. 261 -266
5. Olszewki WL. The treatment of lymphedema of the extremities with microsurgical lympho-venous anastomoses (!988).lntAngiol7:312
6. O'Brien BM, Mellow CO, Khazanchi RK, et al. Long term results after microlymphaticovenous anastomoses for the treatment of obstructive lymphedema (1990). Plast Reconstr Surg. P 562-85
7. C. Camp\s\,M.T>. anAM.D.'^.'Qoccdiido {200\),''Lymphedema and microsurgery". PRS, 10: p. 74-80.
8. Warren, L.E., et al. (2014), "'The impact of radiation therapy on the risk of lymphedema after treatment for breast cancer: a prospective cohort study". Int J Radiat Oncol BiolPhys, 88(3): p. 565-71.
9. Koshima, I., et al. (1996), "Ultrastructural observations of lymphatic vessels in lymphedema in human extremities". Plast ReconsU Surg, 97(2)- p. 397-405; discussion 406-7.
10. Altorfer.J; HedingerC.H.R; Clodius L Light and electron microscopic investigation of extremities of dogs with experimental chronic lymphostasis (1977). Folia Angiol.p 141
11. Chang, D.W. (2010), ''Lymphaticovenular bypass for lymphedema management in breast cancer patients: a prospective study" Plast Reconstr Surg, 126(3): p. 752-8