Olszewski Waldemar L, Jain Pradeep, Ambujam G, Zaleska Marzanna, Cakala Marta
Department of Surgical Research and Transplantology, Medical Research Center, Polish Academy of Sciences, Warsaw, Poland.
Lymphat Res Biol. 2009 Dec;7(4):239-45. doi: 10.1089/lrb.2008.1023.
The knowledge of where does excess tissue fluid accumulate in obstructive lymphedema is indispensable for rational physical therapy. However, it has so far been limited to that obtained from lymphoscintigraphic, ultrasonographic, and MR images. None of these modalities provide composite pictures of dilated lymphatics and expanded tissue space in dermis, subcutis, and muscles. So far, only anatomical dissection and histological processing of biopsy material can visualize the tissue lymphatic network and the sites of accumulation of the excess of mobile tissue fluid.
We visualized the "tissue fluid and lymph" space in skin and subcutaneous tissue of foot, calf, and thigh in various stages of lymphedema in specimens obtained during lymphatic microsurgical procedures or tissue debulking, using special staining techniques. The volume of accumulated fluid was calculated from the densitometric data of stained tissue sections. We found that lymph was present only in the subepidermal lymphatics, whereas the collecting trunks were obliterated in most cases. Mobile tissue fluid accumulated in the spontaneously formed spaces in the subcutaneous tissue, around small veins and above and underneath muscular fascia. Deformation of subcutaneous tissue by free fluid led to formation of interconnecting channels. The volume of subcutaneous free fluid ranged around 50% of total tissue volume and there were no significant differences in various stages of lymphedema. This could be explained by the presence of thick layers of subcutaneous fat tissue even in the most advanced stage of lymphedema.
In lymphedema caused by obliteration of collecting trunks, lymph is present only in the subepidermal lymphatics, whereas the bulk of stagnant tissue fluid accumulates in the subcutaneous tissue and above and beneath muscular fascia. These findings should be useful for designing pneumatic devices for limb massage as well as for rational manual lymphatic drainage in terms of sites of massage and level of applied external pressures.
了解阻塞性淋巴水肿中多余组织液的积聚部位对于合理的物理治疗至关重要。然而，目前这仅限于通过淋巴闪烁造影、超声和磁共振图像获得的信息。这些检查方法均无法提供真皮、皮下组织和肌肉中扩张淋巴管和扩大组织间隙的综合图像。到目前为止，只有活检材料的解剖和组织学处理才能显示组织淋巴网络以及多余可移动组织液的积聚部位。
我们使用特殊染色技术，在淋巴显微外科手术或组织减容过程中获取的标本中，观察了不同阶段淋巴水肿患者足部、小腿和大腿皮肤及皮下组织中的“组织液和淋巴”间隙。根据染色组织切片的光密度数据计算积聚液体的体积。我们发现淋巴仅存在于表皮下淋巴管中，而在大多数情况下，集合干闭塞。可移动组织液积聚在皮下组织中自然形成的间隙、小静脉周围以及肌肉筋膜上方和下方。游离液体导致皮下组织变形，形成相互连通的通道。皮下游离液体的体积约占组织总体积的50%，在淋巴水肿的不同阶段无显著差异。这可以用即使在淋巴水肿最严重阶段仍存在厚层皮下脂肪组织来解释。
在集合干闭塞引起的淋巴水肿中，淋巴仅存在于表皮下淋巴管中，而大部分停滞的组织液积聚在皮下组织以及肌肉筋膜上方和下方。这些发现对于设计肢体按摩的气动装置以及在按摩部位和施加的外部压力水平方面进行合理的手动淋巴引流应是有用的。
