Article(id=1322954370635137698, tenantId=1146029695717560320, journalId=1319373162502258839, issueId=1322954356680696647, articleNumber=null, orderNo=null, doi=10.16016/j.2097-0927.202504051, pmid=null, cstr=null, oa=null, hot=null, price=null, onlineType=0, articleFormat=0, articleType=null, articleTypeStr=null, receivedDate=1744560000000, receivedDateStr=2025-04-14, revisedDate=1760025600000, revisedDateStr=2025-10-10, acceptedDate=null, acceptedDateStr=null, onlineDate=1793346501262, onlineDateStr=2026-10-30, pubDate=1761753600000, pubDateStr=2025-10-30, doiRegisterDate=null, doiRegisterDateStr=null, onlineIssueDate=1793346501262, onlineIssueDateStr=2026-10-30, onlineJustAcceptDate=null, onlineJustAcceptDateStr=null, onlineFirstDate=null, onlineFirstDateStr=null, sourceXml=null, magXml=null, createTime=1793346501262, creator=13701087609, updateTime=1793346501262, updator=13701087609, issue=Issue{id=1322954356680696647, tenantId=1146029695717560320, journalId=1319373162502258839, year='2025', volume='47', issue='20', pageStart='2445', pageEnd='2580', issueExtLink='null', onlineDate='null', pubDate='1761753600000', pubDateStr='2025-10-30', beforeIssueId=null, nextIssueId=null, price=null, status=1, issueComplete=1, articleOrder=1, issueType=-1, specialIssue=null, createTime=1793346497936, creator='13701087609', updateTime=1793346497936, updator='13701087609', preIssue=null, nextIssue=null, articleTotal=null, ext=null, issueFiles=null, downloadFileDto=null}, startPage=2445, endPage=2450, ext={EN=ArticleExt(id=1322954370840658595, articleId=1322954370635137698, tenantId=1146029695717560320, journalId=1319373162502258839, language=EN, title=Research progress of supermicrosurgical lymphatic vein anastomosis in limb lymphedema, columnId=1320434417353470541, journalTitle=Journal of Army Medical University, columnName=Expert Review, runingTitle=null, highlight=null, articleAbstract=

Limb lymphedema is a chronic progressive disease of the lymphatic system that seriously affects the physical and mental health of patients. Supermicrosurgical lymphovenous anastomosis (LVA) can significantly improve the symptoms of early lymphedema and is regarded as a promising therapeutic option. However, this technology also faces many challenges, with only about 15% of patients receiving treatment each year, and 30% of patients progressing to refractory edema. The reported treatment efficacy vary greatly among different institutes. In this article, we review the development history, treatment status, and challenges faced by supermicrosurgical LVA in limb lymphedema, providing reference for clinical practice.

, authors=Tao WANG, Qinghui HAN, authorsList=Tao WANG, Qinghui HAN, authorCompany=null, correspAuthors=Tao WANG, authorNote=null, correspAuthorsNote=null, copyrightStatement=© 2025 Journal of Army Medical University, copyrightOwner=Editorial Office of Journal of Army Medical University, extLink=null, articleAbsUrl=null, sourceXml=null, magXml=null, pdfUrl=null, pdf=null, pdfFileSize=null, pdfExtLink=null, richHtmlUrl=null, mobilePdfUrl=null, reviewReport=null, pdfFirstPage=null, abstractGraph=null, abstractGraphContent=null, abstractVideo=null, citation=null, cebUrl=null, magXmlContent=null, mapNumber=null, fund=null), CN=ArticleExt(id=1322954371176202916, articleId=1322954370635137698, tenantId=1146029695717560320, journalId=1319373162502258839, language=CN, title=超显微外科淋巴管静脉吻合术在肢体淋巴水肿中的研究进展, columnId=1320434417496076879, journalTitle=陆军军医大学学报, columnName=专家述评, runingTitle=null, highlight=null, articleAbstract=

肢体淋巴水肿是淋巴系统的一种慢性进展性疾病,严重影响患者身心健康。超显微外科淋巴管静脉吻合术(lymphovenous anastomosis,LVA)能显著改善早期淋巴水肿患者的症状,给患者带来希望。但该技术也面临诸多挑战,每年仅有约15%患者得到治疗,30%患者进展为顽固性水肿,不同中心报告的治疗效果差异也较大。本文从超显微外科淋巴管静脉吻合术在肢体淋巴水肿中的发展历史、治疗现状以及面临挑战三个方面进行述评,为临床治疗提供参考。

, authors=王韬, 韩庆辉, authorsList=王韬, 韩庆辉, authorCompany=null, correspAuthors=王韬, authorNote=null, correspAuthorsNote=
王 韬,主任医师,教授,同济大学附属同济医院急诊创伤救治中心主任、断指再植中心主任。上海领军人才,首届“国之名医”。历任国家临床重点专科、上海市重中之重学科、上海市公共卫生重点学科、上海市中西医协同引导学科负责人。先后获得全国创新争先奖、国家科技进步奖二等奖、上海市科技进步奖一等奖、王正国创伤医学奖“突出贡献奖”。论文发表于The lancet、BMJ Global Health等国际顶级期刊,单篇最高影响因子44.002,入选ESI全球前1%高被引论文。主要研究方向为创伤医学、四肢显微外科、应急救援。E-mail:
WANG Tao,E-mail:
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超显微外科淋巴管静脉吻合术在肢体淋巴水肿中的研究进展
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王韬 , 韩庆辉
陆军军医大学学报 | 专家述评 2025,47(20): 2445-2450
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陆军军医大学学报 |专家述评 2025 , 47 (20) : 2445 -2450
超显微外科淋巴管静脉吻合术在肢体淋巴水肿中的研究进展
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王韬 , 韩庆辉
作者信息
  • 1同济大学附属同济医院急诊创伤救治中心,上海
通讯作者:
王 韬,主任医师,教授,同济大学附属同济医院急诊创伤救治中心主任、断指再植中心主任。上海领军人才,首届“国之名医”。历任国家临床重点专科、上海市重中之重学科、上海市公共卫生重点学科、上海市中西医协同引导学科负责人。先后获得全国创新争先奖、国家科技进步奖二等奖、上海市科技进步奖一等奖、王正国创伤医学奖“突出贡献奖”。论文发表于The lancet、BMJ Global Health等国际顶级期刊,单篇最高影响因子44.002,入选ESI全球前1%高被引论文。主要研究方向为创伤医学、四肢显微外科、应急救援。E-mail:
WANG Tao,E-mail:
Research progress of supermicrosurgical lymphatic vein anastomosis in limb lymphedema
Tao WANG , Qinghui HAN
Affiliations
  • 1Emergency Trauma Center,Tongji Hospital,School of Medicine,Tongji University,Shanghai,China
出版时间: 2025-10-30 doi: 10.16016/j.2097-0927.202504051
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肢体淋巴水肿是淋巴系统的一种慢性进展性疾病,严重影响患者身心健康。超显微外科淋巴管静脉吻合术(lymphovenous anastomosis,LVA)能显著改善早期淋巴水肿患者的症状,给患者带来希望。但该技术也面临诸多挑战,每年仅有约15%患者得到治疗,30%患者进展为顽固性水肿,不同中心报告的治疗效果差异也较大。本文从超显微外科淋巴管静脉吻合术在肢体淋巴水肿中的发展历史、治疗现状以及面临挑战三个方面进行述评,为临床治疗提供参考。

超显微外科  /  淋巴水肿  /  淋巴管静脉吻合术  /  血管化淋巴结移植术

Limb lymphedema is a chronic progressive disease of the lymphatic system that seriously affects the physical and mental health of patients. Supermicrosurgical lymphovenous anastomosis (LVA) can significantly improve the symptoms of early lymphedema and is regarded as a promising therapeutic option. However, this technology also faces many challenges, with only about 15% of patients receiving treatment each year, and 30% of patients progressing to refractory edema. The reported treatment efficacy vary greatly among different institutes. In this article, we review the development history, treatment status, and challenges faced by supermicrosurgical LVA in limb lymphedema, providing reference for clinical practice.

supermicrosurgery  /  lymphedema  /  lymphovenous anastomosis  /  vascularized lymph node transplantation
王韬, 韩庆辉. 超显微外科淋巴管静脉吻合术在肢体淋巴水肿中的研究进展. 陆军军医大学学报, 2025 , 47 (20) : 2445 -2450 . DOI: 10.16016/j.2097-0927.202504051
Tao WANG, Qinghui HAN. Research progress of supermicrosurgical lymphatic vein anastomosis in limb lymphedema[J]. Journal of Army Medical University, 2025 , 47 (20) : 2445 -2450 . DOI: 10.16016/j.2097-0927.202504051
超显微外科始于90年代中期,是显微外科的自然演变,其作为显微外科领域的重要分支,通过突破传统显微外科的技术极限,实现对直径≤0.8 mm的微小血管、神经束及淋巴管的精准吻合[1]。随着超显微技术的发展,超显微外科技术被用于不同的外科领域。淋巴管静脉吻合术(lymphovenous anastomosis,LVA)作为超显微外科的典型应用于淋巴水肿的治疗。肢体淋巴水肿为淋巴通道阻塞导致淋巴液积聚、局部肿胀、脂肪组织的异常增生与肥大,以及进一步的纤维化,从而引起患肢肿胀、疼痛和肢体严重功能障碍等,严重影响患者的生活质量。LVA通过建立淋巴管与真皮下浅静脉间的生理性通道,能明显改善肢体淋巴水肿患者的症状与生活质量[2]。然而,现有医疗技术治愈淋巴水肿仍面临较大挑战,包括功能淋巴管的确定、吻合术式选择、静脉返流、超显微技术壁垒及欠发达地区资源缺乏等方面。本述评旨在讨论超显微外科在淋巴水肿中的应用,为临床治疗提供参考。
1999年日本KOSHIMA等[3]首次报道应用超显微技术进行浅层淋巴管与真皮下浅静脉进行吻合,临床疗效显著。LVA已成为早期淋巴水肿患者一线治疗方案。YAMAMOTO等[4]在埃及无红外荧光淋巴造影设备情况下,通过常规显微镜对23名乳腺癌术后肢体淋巴水肿进行手术,取得显著临床疗效。因此,即使显微操作条件有限也不应放弃。近年来,机器人辅助超显微外科受到了关注。2020年推出的配备了操纵杆操作的显微外科器械MUSA机器人(荷兰Microsure公司)和2022年开发的唯一提供腕式显微器械的Symani手术系统(意大利Medical Microinstruments公司),可通过提供运动缩放和震颤过滤来改善外科医师的表现并应用于临床,大多数患者术后淋巴水肿或中枢淋巴疾病的改善,证实了机器人辅助淋巴管静脉吻合术的可行性,尤其涉及的深部手术部位具有明显优势[5-6]。
国际淋巴学会(International Society of Lymphology,ISL)淋巴水肿分期标准[7]:0期:又称亚临床前期淋巴水肿,该期患肢肿胀等主观感受不明显,双侧下肢体积相差<20%,仅有个别患者表现为间歇性疼痛、疲劳、患肢沉重等;Ⅰ期:表现为富含蛋白质的液体积聚引起的患肢肿胀和可凹性水肿,抬高患肢可完全减轻肿胀,双侧下肢体积相差20%~40%;Ⅱ期:表现为非可凹性水肿,皮肤纤维化明显,脂肪组织增殖,抬高患肢不能完全减轻肿胀;Ⅲ期:也称为淋巴性象皮病,表现为受累患肢相比健侧体积增加>40%并有皮下组织增生,皮肤皱褶生成、角化过度,新生疣状物和皮肤乳头状瘤。根据分期,有常见两种手术方式:LVA和血管化淋巴结移植术(vascularize lymph node transplantation,VLNT)。LVA主要针对早、中期(Ⅰ、Ⅱ期)肢体淋巴水肿患者;LVA术后观察短期效果好,但随着时间延长,长期效果有一定争议,部分患者淋巴水肿再次出现,这与疾病本身的进展、手术技术的局限性以及术后管理等多个因素相关[8]。VLNT通过淋巴结的“桥”功能和“泵”功能,重建受区淋巴网络,常用于晚期较为严重的肢体淋巴水肿患者(Ⅲ期),也可用于Ⅱ期患者。一项关于105名乳腺癌相关的肢体淋巴水肿患者两种手术效果的对比研究[58名(Ⅱ期:93.6%)患者接受了VLNT手术,而47名(Ⅱ期:93.2%)患者接受了LVA手术],2年随访发现VLNT与LVA相比具有更好的相对减容效果,分别为(2.64±4.64)cm和(2.14±2.25)cm,但在随访期结束时没有显示出任何显著差异。在VLNT中,发生了11例(19.0%)轻微并发症,而LVA没有发生并发症[9]。
肢体淋巴水肿的特点是具有逆行和顺行两个方向的淋巴液流动。因此,淋巴管-静脉吻合应该兼顾引流两个方向的淋巴液。淋巴管-静脉吻合术的基本吻合方式有端-端、侧-端、端-侧和侧-侧吻合,其中端-端和侧-端吻合是常用的手术方式。其各有优缺点,如何选择最佳配置仍不明确。但要遵循基本的原则,端-端吻合技术需求相对较低,适用于淋巴管和静脉管径相近的情况,缺点是只能引流吻合口远端的淋巴液,需要在更多的近端部位进行更多的吻合,引流效果可能不如端-侧和侧-侧吻合。在进行LVA时,端-侧吻合更具优势,仅在阻塞潜在风险较低的情况下才考虑端-端吻合。KWON等[10]对123例淋巴水肿患者进行了端-端吻合与端-侧吻合的对比研究,结果显示两种术式在减容方面均有效,但在国际淋巴学会分期Ⅱ、Ⅲ期患者中,端-侧吻合的减容效果更佳。侧-端吻合适用于淋巴管和静脉管径大小差异较大的情况,通过一个吻合口可有效引流实现双向淋巴引流,技术上比端-端更具挑战性。同样,侧-侧吻合也可双向转移淋巴液,但与侧-端吻合相比所需时间更长,且静脉回流问题更多,易并发吻合部位血栓[11]。侧-侧吻合允许静脉远大于淋巴管,淋巴管直径<0.5 mm时即可进行。针对淋巴管和静脉之间的口径差异常导致吻合困难,推荐改良的缝线尺寸调整技术(suture size adjustment technique,SSAT)实现快速且准确的吻合,同时调整口径差异并抑制吻合口漏。SAAT尽量减小淋巴管壁的缝合宽度,但要求不会撕裂。具体方法为针头从内膜末端的边缘进针,出口在距离静脉末端边缘0.2~0.5 mm(与静脉壁的厚度相同)的位置,使得淋巴管壁末端和静脉壁处于内膜吻合状态,静脉外膜覆盖淋巴管末端;由于淋巴管壁像“喇叭”样伸入静脉,因此不太可能发生吻合口渗漏[12]。淋巴管-静脉吻合术的手术技术很具有挑战性,因此也衍生出很多特殊类型的吻合方式,如“袖套式”“序贯式”“阶梯状”“π”和“章鱼式”淋巴管静脉吻合术[13]。较为常用的是“章鱼式”淋巴管静脉吻合术,该吻合方式主要适用于管径极小的淋巴管与静脉吻合,即将多根淋巴管套入到单支静脉内。静脉从腔外向腔内缝合,缝线从静脉腔内引出后穿入淋巴管,由腔内向淋巴管腔外引出缝合线,将多根淋巴管重叠套入静脉,形成一个类似章鱼的淋巴管-静脉吻合复合体。针对吻合方式对的选择,我们的经验是需综合考虑淋巴管显影结果、管径匹配、病情分期和病变部位等因素,“章鱼式”淋巴管静脉吻合术因具有微创、解剖适应性好、高效引流、长期通畅性高及吻合口血栓发生率低等特征越来越受医师青睐。
在早期阶段,LVA能够显著减轻淋巴水肿;然而随着时间推移,淋巴管的压力会逐渐降低,直至淋巴管与静脉之间的压力差异恢复至正常状态,这可能导致淋巴液反流、血栓形成等并发症发生,从而对LVA的远期疗效产生不利影响。因此,在选择治疗方法时,需要综合考虑患者的身体状况和远期治疗效果。选择功能淋巴管和无反流现象的小静脉进行吻合是手术成功的关键。术前使用磁共振淋巴水肿成像(lymphedema magnetic resonance imaging,LMRI)、吲哚菁绿(indocyanine green,ICG)淋巴造影、高频超声和无创静脉显像仪等辅助检查,有助于评估和定位肢体远端淋巴管的功能,LMRI作为非侵入性成像方式应用越来越多,且不受肥胖影响,广泛应用于淋巴水肿严重程度的评估及治疗后随访,它能显示淋巴水肿的原因、脂肪沉积,并能对淋巴管进行分析。目前关于如何选择功能性淋巴管进行吻合尚无明确指南。我们的经验是根据ICG淋巴造影结果来寻找,结合术中刺激后有蠕动、富含淋巴液切开后淋巴液流出顺畅和外径>0.5 mm的淋巴管较为可靠。有研究表明使用超过淋巴管0.5 mm进行吻合可显著增强术后效果,推荐淋巴管0.5 mm可作为淋巴管静脉吻合术中有价值的功能性淋巴管尺寸截断点[14]。推荐淋巴管>0.5 mm作为评判功能淋巴管标准之一与我们经验相符合。在LVA的术前规划中,识别无纤维化且液体流动丰富的通畅淋巴管至关重要但也有一定难度。由于淋巴水肿组织的解剖和生理特性,手术视野中的淋巴管并不一定能在术前通过近红外荧光成像使ICG淋巴造影可视化。有研究报告,5例下肢淋巴水肿患者共进行了33次LVA,其中11次使用ICG淋巴造影阴性淋巴管进行吻合,可观察到强烈的淋巴引流,术后6个月患者报告肢体周长和压力感主观减轻[15]。因此,术中发现的ICG淋巴造影阴性淋巴管应进行额外LVA的评估,以最大化引流效果,尽可能提供更好的结果。ICG淋巴造影阴性标准为在注射ICG后,未观察到淋巴管正常引流功能的线性模式,出现了代表淋巴循环失代偿的真皮反流模式(包括溅射型、星尘型和弥漫型)[16]。要取得LVA治疗淋巴水肿较好的效果,从技术层面来说我们的经验是切口需按淋巴体区及解剖走行规律来设计切口(如6+X切口),便于寻找淋巴管与引流淋巴液;术前、术中要筛选功能性淋巴管与低压力静脉进行吻合;低压静脉主要表现为无反流静脉,使用无创静脉显像仪可以显著提高术前识别无反流静脉的灵敏度,减少术中探索时间,改善手术效果[17];术中可用显微剪将其远心端完全切断,低压力静脉表现为血液缓慢流出,甚至无血流出。采取有效的预防返流或栓塞的吻合方法(选择多条淋巴管与静脉“章鱼法”吻合等减少吻合口缝合线,减少术后栓塞机会)。当LVA未能满足治疗需求时,VLNT成为重度淋巴水肿或涉及大量纤维脂肪组织切除的复杂病例的可靠选择。单纯LVA手术在远期疗效上并不令人满意,联合手术正成为趋势,联合手术的最佳治疗时机为Ⅱ期晚期至Ⅲ期早期[18]。LVA术后康复十分重要,需遵循阶段性原则,目的是保护吻合口、促进淋巴正常回流并长期维持手术效果[7]。术后1~2周,以保护吻合口为主,避免剧烈运动和患肢血压升高的活动,活动关节需轻柔;术后2~6周,穿戴医疗压力袖套,康复师手法淋巴引流;长期(术后6周以后)进行健康教育,过渡到个体化综合消肿治疗,长期佩戴医疗压力袖套。
VLNT是从健康部位切取含淋巴结的组织瓣,并将其移植到受区,以重建一个新的淋巴循环的一种生理性手术,是目前治疗伴有严重淋巴管硬化和闭塞淋巴水肿的最佳外科手段。移植淋巴结还能促进受区淋巴管修复与再生,重建淋巴通路。移植后的淋巴结对肢体远端淤积的组织间液具有泵吸效果,淋巴液通过淋巴结内的淋巴管-静脉通路被引流入皮瓣内的静脉系统而实现回流。尽管目前该手术改善肢体淋巴回流的机制仍不明确,但VLNT对肢体淋巴水肿有显著疗效。目前普遍认为,VLNT作用机制非单一,而是多种机制协同作用的结果,早期生长因子的旁分泌效应首先发挥作用以改善局部微环境;中期桥接理论占主导,移植体长入新生淋巴管;后期稳定期泵理论发挥效应,形成正常功能的淋巴循环[19-21]。MOON等[22]对71例女性接受上肢或下肢VLNT治疗的晚期淋巴水肿患者,显示晚期淋巴水肿患者有效,且上肢淋巴水肿患者的效果优于下肢患者,但上肢和下肢间疗效差异的影响因素仍未知。腹股沟区、腋窝区、颈部或颏下区和腹腔内淋巴结是常用的组织供区。因腹股沟区淋巴结数量多,皮瓣切取方便,也是最常用的供区。常用腹股沟浅淋巴结(保留旋髂浅动静脉血管蒂),切取含2~3枚淋巴结的脂肪组织瓣,解剖患肢近端动静脉分支作为受区血管,选择性吻合2~3条集合淋巴管至邻近静脉。为了获得更好的治疗效果,须在移植前彻底切除受区的纤维瘢痕和病变组织。尽管有文献报道移植2~3个淋巴结比移植1个淋巴结对于肢体周径的减少更明显[23],但如何避免供区的医源性淋巴水肿、淋巴囊肿形成,是此类手术的难点,也是当前的研究热点。术前应用激光淋巴成像或ICG淋巴造影确定并定位功能性淋巴结簇,可有效减少供区并发症。针对供区相应并发症,可使用胃网膜或肠系膜淋巴结等作为供体部位的策略。使用胃网膜或肠系膜淋巴结做供体具有诸多优势,包括丰富的血管和淋巴供应、隐蔽的切口位置及较能减少供区并发症。BROWN等[24]大网膜作为首选供体部位具有显著优势,术后2年效果显著。尽管VLNT在晚期淋巴水肿患者治疗效果显著,但因其浸入性和供区淋巴受损,目前较少受青睐。
这项技术要求医师具备高水平的显微镜下手眼协调能力、耐心以及使用显微器械的控制力和平衡感。医师操作过程中需克服生理性震颤与器械精度限制[25]。鉴于人类手部的震颤、精确度和准确性可能受到外科医师心理和生理状态的影响,机器人可以通过减轻人为错误来改善手术结果。然而,机器人不应取代外科医师的关键作用,应被视为外科医师手术工具集中的一种额外仪器,能够不受身体疲劳的影响以所需的精确度执行手术。目前机器人辅助超显微手术仍处于创新研究阶段,大规模应用于临床还需待以时日。
另外,超显微外科医师还需接受良好培训以确保手术效果。目前训练模型未统一,有合成模型、活体动物模型、动物尸体组织模型以及鸡胚的卵黄动脉等四种模型。各模型有其优缺点,合成模型(如硅胶管)无法真实模拟生物血管的结构。活体动物模型(如啮齿类动物)被认为是理想的显微外科手术训练模型,但其成本高昂且涉及生物伦理问题。动物尸体组织模型(如鸡腿、鸡翅、猪脚和猪蹄)缺乏功能性的循环系统。使用鸡胚的卵黄动脉进行训练具有多项优势,首先该系统在伦理上是可接受的,因为鸡胚在孵化第11天前不含功能性神经;其次,该系统成本较低且易于管理;此外,卵黄动脉的直径与淋巴水肿患者的淋巴管直径相似,该系统适合作为超显微外科训练模型[26-27]。使用鸡胚的超显微外科吻合训练系统是一种新颖、高度可重复且易于操作的训练模型,具有成为最佳训练模型的潜力。但该模型目前未广泛普及应用。
医师进行LVA手术时面临三大难点:寻找淋巴管、判断功能淋巴管和减少LVA静脉返流。淋巴管的解剖分布存在个体差异,首选术前ICG淋巴造影结果判断的功能性淋巴管,基于ICG淋巴造影弥散区或水肿区的近侧或远侧,分别做1~2 cm切口。其次是超高频超声辅助定位和淋巴管解剖分布规律来判断。近来,提倡超高频超声联合ICG淋巴造影术前定位可提高功能性淋巴管的识别率。术中根据ICG淋巴造影结果,刺激后有蠕动、有淋巴液的淋巴管,外径>0.5 mm为优。另外,选压力低于淋巴管压的静脉进行吻合,否则反流静脉可能导致淋巴液回流,降低LVA的长期通畅率。使用无创静脉显像仪可以显著提高术前识别无反流静脉的灵敏度,从而减少术中探索时间,改善手术效果,并提高LVA的长期通畅率[20]。
国外侧重于前瞻性随机对照试验与长期疗效机制探索;国内研究优势则体现在技术层面、大量的临床病例资源以及相关的医疗器械研发方面。近来,我国在该领域快速发展,研究成果颇具特色,在技术层面,提出标准化的LVA手术流程、优化了VLNT的供区选择(如颏下、锁骨上淋巴结),提升了手术的可重复性与安全性;其次,在器械研发层面,国产吲哚菁绿荧光成像系统、便携式多普勒超声及微型吻合器械的成功研发与应用,打破了进口垄断,降低了技术推广门槛[28-29]。
LVA技术精细化将是未来发展的首要方向。未来新一代超高精度显微外科系统(如纳米显微外科),从目前放大40倍提升至60倍及以上,并配备双荧光成像功能,能够同时显示淋巴管和静脉的实时动态以提高手术精准度。纳米显微外科技术是超显微外科的进一步延伸,可以在更小的尺度上进行手术操作,提高了手术的精确度和成功率,改善淋巴水肿的治疗效果。在手术器械方面,直径<0.03 mm的显微器械和12-0至13-0超细缝线的应用,使医师能够处理更微小的淋巴管。小型化和便携化的设备也是重点,研发可穿戴便携式显微手术系统,使LVA手术能够在更多基层医疗机构开展。
人工智能(AI)和机器人辅助技术将为LVA手术带来革命性改变。未来有望生产专门针对淋巴管静脉吻合设计的微型机械臂,具备针对术中亚毫米级操作精度和触觉反馈功能,提升手术精度和降低手术难度。智能可视化导航系统是另一关键发展方向,结合术前淋巴显像数据和术中实时影像,AI系统能够自动规划最佳吻合路径,为医师提供实时决策。增强现实(AR)技术的应用将使医师通过能看到虚拟淋巴管网与真实解剖结构的精准重叠,提高手术效率。这些技术进步将使LVA手术从依赖医师经验转变为标准化、可复制的医疗技术。
随着社会老龄化和肿瘤发病人群日益增多,肿瘤相关肢体淋巴水肿诊治重新成为临床关注的热点和难点。目前仍然面临专业人员缺乏、治疗手段多而疗效不一和疗程长的诊治现状。探索一套高效的协作模式,实现单学科分段诊疗的现状向流程闭环和要素衔接转变的专病诊疗服务,依托显微外科为主导,整合妇产科、乳腺外科、血管外科、放疗科和康复科的淋巴水肿患者,结合影像科、超声科客观评估病情,设立淋巴水肿专病门诊,建立多学科联合诊疗(multidisciplinary team,MDT)运行机制,为肢体淋巴水肿患者提供了全流程、全方位的“一站式”诊疗康复服务,提高患者生活质量。

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doi: 10.16016/j.2097-0927.202504051
  • 接收时间:2025-04-14
  • 首发时间:2026-10-30
  • 出版时间:2025-10-30
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  • 收稿日期:2025-04-14
  • 修回日期:2025-10-10
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    1同济大学附属同济医院急诊创伤救治中心,上海

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王 韬,主任医师,教授,同济大学附属同济医院急诊创伤救治中心主任、断指再植中心主任。上海领军人才,首届“国之名医”。历任国家临床重点专科、上海市重中之重学科、上海市公共卫生重点学科、上海市中西医协同引导学科负责人。先后获得全国创新争先奖、国家科技进步奖二等奖、上海市科技进步奖一等奖、王正国创伤医学奖“突出贡献奖”。论文发表于The lancet、BMJ Global Health等国际顶级期刊,单篇最高影响因子44.002,入选ESI全球前1%高被引论文。主要研究方向为创伤医学、四肢显微外科、应急救援。E-mail:
WANG Tao,E-mail:
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2种不同金属材料的力学参数
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genus
种数
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species
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Percentage of
total species (%)
属
Genus
种数
Number of
species
占总种数比例
Percentage of total
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鹅膏菌科Amanitaceae 2 11 5.26 鹅膏菌属 Amanita 10 4.78
小菇科 Mycenaceae 2 12 5.74 丝盖伞属 Inocybe 5 2.39
多孔菌科 Polyporaceae 8 14 6.70 蜡蘑属 Laccaria 5 2.39
红菇科 Russulaceae 3 23 11.00 小皮伞属 Marasmius 6 2.87
小菇属 Mycena 11 5.26
光柄菇属 Pluteus 5 2.39
红菇属 Russula 17 8.13
栓菌属 Trametes 5 2.39
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