RU2356587C1 - Therapy of secondary lower limb lymphodema - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: therapy of secondary lower limb lymphodema refers to medicine, namely to clinical lymphology. The oatient is exposed to laser light of wavelength 0.6328 mcm combined with intravenous laser irradiation of power 1.2 mW and exposition 90 minutes and intravenous introduction of medicine solutions: Trental, Actovegin, Pheopolyglukine, vitamin B, C complexes, 0.15% xantinol nicotinate. Procedures are daily at seven procedures per course.

EFFECT: therapy provides stable reduction of secondary lower limb lymphodema without therapeutic by-effects, prevents recurrence.

2 cl, 2 ex

Description

The invention relates to medicine, to clinical lymphology, and in particular to methods of treating chronic lymphatic insufficiency of the lower extremities using low-intensity helium-neon lasers.

The well-known "Method of treating vascular diseases" (RF, patent for the invention No. 2119361, A61N 5/06, priority 06/20/1995, publ. 09/27/1998), in which extracorporeal irradiation of the patient’s blood in the amount of 2 ml per 1 kg of mass body in the hose section of the blood transfusion system during its reinfusion to the patient. The effect on the blood is carried out by radiation with a wavelength of 420-470 nm with the allocation of a narrow section of the spectrum within 10 nm, with a total dose of 15 J / cm ² per session at a reinfusion rate of 5-10 ml / min in a course of 6-8 sessions. The technique used is invasive.

For diseases of the vascular system, primarily, a violation of blood flow due to changes in the vascular wall (atherosclerotic plaques, inflammatory edema, thrombosis, pathological spasm, etc.) is characteristic. However, violations of the biophysical (rheological) properties of blood are of no less importance, in particular, an increase in the viscosity of plasma and whole blood, and a deterioration in the elastic properties of red blood cells. These disorders lead to a decrease in blood flow velocity, a decrease in volume perfusion of organs and tissues, and blocking of blood circulation in the microcirculation system.

However, irradiation of blood is carried out extracorporeally, with the ensuing consequences, that is, by mechanical action on the plasma, on blood enzymes.

Also known is the "Method for the treatment of erysipelas" (RF, patent for the invention No. 2175871, A61N 1/30, A61N 5/067, prior. 12/27/2000, publ. 09/27/2001) by administering an antibiotic against the background of traditional therapy. An antibiotic is administered by electrophoresis on the affected area, after which a cuff is placed above the injection site (except for the head, trunk and external genital organs) with a pressure of 40 mm Hg. for 2 hours. At the same time, with primary erysipelas, they are exposed to low-energy laser radiation in a pulsed infrared range with a wavelength of 0.81-0.98 μm, a frequency of 10-100 Hz, and a power of 2.5 mW at the site of inflammation and regional lymph vessels and lymph nodes in within 20 minutes With repeated and recurrent, intravenous laser blood irradiation is performed in the red range with a wavelength of 0.67 μm, a power flux at the end of the fiber of 1-2 mW, and 10 daily procedures are prescribed for the course of treatment.

However, this method of treatment stops only erysipelatous inflammation and does not eliminate the lower limb lymphodema.

Also known is the "Method of partial laser lymphostimulation in the treatment of lymphodema" (RF, patent for invention №2166338, A61N 5/067, priority 24.06.1998, publ. 10.05.2001), which consists in a helium-neon laser effect on the edema area. Irradiation is carried out along all major tracts of the lymphatic outflow of the organ in stages, with initial point irradiation of the skin projection of the regional lymph node responsible for the proximal region of the edema, and subsequent zonal irradiation of the proximal region of the edema, bordering on healthy tissue, with the capture of edematous tissue in a 2: 1 ratio. Then, spot irradiation of the skin projection of the lymph node responsible for the distal region of the edema and zonal irradiation of the distal region of the edema, bordering on healthy tissue, with capture of the edematous tissue in a ratio of 2: 1 are carried out. Moreover, with each subsequent session, the laser exposure zone is shifted taking into account the removal of puffiness.

Thus, the method of partial laser lymphostimulation allows effective therapy of common lymphatic edema of organs, the treatment of which often requires surgical intervention. The method is conservative, non-invasive. It can be performed on an outpatient basis, in a clinic.

However, the method can be used in surgery in the treatment of lymphatic edema of various localization and severity, but not in the treatment of lymphodema.

The closest in technical essence and the achieved effect to the claimed method is the "Method for the treatment of chronic lymphatic insufficiency of the lower extremities" (RF, patent for the invention No. 2284838, A61N 5/067, priority January 28, 2005, publ. 10.10.2006), based on catheterization of the lymphatic vessels of the patient’s foot and the introduction of medications into them. The photoditazine photosensitizer is injected into the lymphatic vessel once at a dose of 0.4-0.8 ml, after which it is exposed to laser radiation with a wavelength of 660 im, a radiation power density of 2.5 W / cm ² , an energy of 200 to 600 J per each zone of maximum edema of the lower extremities for 6-12 minutes.

However, this method of treating chronic lymphatic insufficiency of the lower extremities is a complex process, based on the operative catheterization of the lymphatic vessels of the patient’s foot and the introduction of medication chemicals into them, rather laborious and traumatic, can be performed in a hospital by a team of surgeons with a large number of related equipment. This circumstance limits the widespread dissemination of methods in practice. In addition, this method uses high power laser irradiation.

The objective to which the creation of this invention is directed is to increase the effectiveness of the treatment of chronic lymphatic insufficiency of the lower extremities.

The technical result that can be obtained by using the invention is to simplify the method of treatment and at the same time achieve a stable relief of secondary lymphodema of the lower extremities, without side effects from the treatment.

The problem is solved due to the fact that the method of treatment of secondary lymphodes of the lower extremities is based on exposure to laser radiation with a wavelength of 0.6328 microns and the introduction of medications. At the same time, at the same time, intravenous laser irradiation with a power of 1.2 mW with an exposure of 90 minutes and intravenous administration of medications in the form of solutions are carried out: trental, actovegin, reopoliglukin, vitamins of group B, C, xanthine-nicotinate 0.15%. Procedures are carried out daily, in the amount of seven procedures per course. Then, in a specific clinical situation, intra-articular irradiation of the knee joint is performed, for this, a 0.7 mm diameter quartz fiber is inserted into the knee by puncture of the joint with a puncture needle followed by the connection of a 1.2 mW helium-neon laser, irradiation is carried out with an exposure of 30 minutes, every other day, in the amount of seven procedures per course. The difference of this method lies in the fact that the exposure of the helium-neon laser to the blood is increased up to 90 minutes, and intra-articular irradiation is performed by means of a puncture of the knee joint. The set of essential features leads to the achievement of a qualitatively new result, expressed in the persistent relief of secondary lymphodema of the lower extremities, simplification of the treatment process by this method. In this case, no side effects from the treatment were observed, which is confirmed by the dynamics of clinical observation, functional and laboratory studies.

Lymphodemus treatment today is an urgent problem. This fact can be explained by the fact that lymphodema, as a rule, is a complication and the final stage of diseases of the venous and arterial systems, as well as a consequence of surgical infections, burns and injuries. The relevance of this problem for practical public health is determined by the increase in the incidence of lymphodema in all age groups of patients and the unsatisfactory results of surgical treatment and complex therapy of lymphodema. According to leading vascular surgeons, conservative treatment of chronic venous insufficiency (CVI) in combination with surgical correction of lower limb lymphodema is ineffective in 50% of cases (World Congress of Phlebologists, 1996).

Chronic lymphatic insufficiency of the lower extremities is one of the most important in practical and scientific importance section of clinical phlebolymphology. The relevance of this problem is due to the extremely high prevalence of this pathology among the population of highly developed countries of the world. Diseases of the lymphatic system of the lower extremities affects 10-12% of the world's adult population.

Lymphatic circulation is vital for the normal functioning of all cells and tissues of the body, and if violations occur in the lymphatic system, complications develop, leading to pathological changes. This pathology is prevalent mainly among the most able-bodied part of the population and therefore leads to high rates of temporary and permanent disability. Meanwhile, the results of surgical and conservative treatment of such patients are not always effective, and often lead to long-term permanent disability. Surgical interventions on the lymphatic system are often ineffective, and their implementation requires the use of expensive equipment and supplies.

For the period 1995-2006 in medical institutions of St. Petersburg and the Leningrad region this method was used to treat 107 patients aged 29 to 82 years with lymphodema of various etiologies. Stage 1 lymphodema was observed in 17 patients, stage 2 in 41 patients, stage 3a in 21 and stage 3 in 20 patients, stage 4 in 8 patients. CVI was also observed in 64 patients, erysipelas in 37 patients, trauma in 19 patients, burns in 3 patients and complex fractures of the ankles and long bones in 8 patients. Moreover, 32 patients had a combined pathology, including 23.6% were cases of a combination of erysipelas and CVI.

Of greatest interest is the group of patients with stages 3 and 4 of lymphodema, in which, according to WHO, the disease cannot be cured. Therefore, we will consider this category of patients in more detail. Their total number was 28 patients. Of these, post-thrombophlebitic disease of the lower extremities was observed in 13 patients, including 8 patients who had trophic ulcers, 12 patients had a history of erysipelas, 4 patients had an injury, 3 patients had a thermal soft tissue burn of degree 3, and one stage 3 lymphodema patient was formed due to cardiovascular failure. At the same time, 68% of patients had a combination of pathologies. Lymphodema in most cases was a complication of post-thrombophlebitic disease of the lower extremities or erysipelas.

At the preliminary stage and during treatment, all patients, without exception, underwent the necessary functional examination of the vessels of the lower extremities of the RVG or UZDK and laboratory tests (clinical analysis of blood + platelets, blood coagulation, prothrombin index, blood sugar). Out of a total of 10 patients, lymphoscintigraphy of the lower extremities was performed. If necessary, a coagulogram and an immunogram were performed.

In accordance with the proposed method of treatment, all patients underwent intravenous laser therapy using a helium-neon laser with a wavelength of 0.6328 μm and an output power of 1.2 mW, with an exposure of 90 minutes, and at the same time, intravenous administration of drug solutions: trental, Actovegin, reopoliglyukin, vitamins of group B, C, xanthinol-nicotinate 0.15%. The total number of procedures is 7, daily. After that, 23 patients underwent intraarticular laser irradiation of the knee joint of the affected limb. The exposure was 30 minutes. The number of procedures per treatment course was 7, every other day. The need to bring laser radiation into the cavity of the knee joint was determined by the specific clinical situation.

The effect of the treatment was observed in 97.7% of patients, which was manifested in the relief of lymphodema by 80-90%, the disappearance of pain and muscle cramps, which was confirmed by ultrasound of the vessels of the lower extremities, including the microvasculature of the feet.

The duration of treatment is from 3 to 12 months. The course of laser therapy was carried out with an interval of 3-4 months. Long-term treatment results were traced from 1 to 7 years. During the follow-up examination in the dynamics from 1 to 14 months, a functional study of the ultrasound of the vessels of the lower extremities was performed, including 12 patients examined microcircular blood flow of the feet. No disease recurrence was detected in any patient. In addition, laboratory blood analysis was performed on 12 patients: a blood test, intravascular activation of thrombosis, adhesion and aggregation of thrombosis, screening for coagulation hemostasis. No significant violations were found.

Thus, the distinctive essence of this method lies in the fact that the duration of exposure to a helium-neon laser on blood is increased to 90 minutes, and also, at the next stage, intra-articular irradiation is performed by puncture of the knee joint and introduction of a quartz optical fiber with a diameter of 0, 7 mm. At the same time, persistent relief of secondary limb lymphadenoma of the lower extremities is achieved without any side effects from the treatment, which is confirmed by the dynamics of clinical observation, functional and laboratory studies. Also, the proposed method is simple to implement, allowing it to be performed on an outpatient basis.

It should be noted that no patient had a relapse of lymphodema. The effect of helium-neon laser radiation on tissues in this method is probably associated with exposure to the exudative phase of the inflammatory process and stops it, which leads to active tissue regeneration, as well as normalization of lymphodynamics and restoration of lymph properties. Studies and observations during the implementation of this laser treatment method confirm the occurrence of a diuretic effect, which depends directly on the exposure value and on the point of establishment of the laser exposure. At the same time, as one would expect, a direct relationship was observed between the amount of excreted fluid and a decrease in tissue swelling. At the same time, this effect did not lead to disturbances in electrolytic metabolism and disappeared as the lymphodema was stopped.

Example 1

Pashka L.D., 55 years old. With complaints of lymphadenoma of the right lower leg with the presence of trophic changes. For the first time, erysipelas of the lower leg suffered 30 years ago. Relapse after 5 years. As a result of the therapy (bicillin - 5 after 1 month for 3 years), remission lasted 5 years. Since 1995, relapse has been observed after 1.5 years. Swelling of the right foot appeared after the first relapse of the disease (25 years), which did not stop and increased after each exacerbation of the disease. Of the concomitant diseases, GB-2, cholelithiasis, obesity - 2, a history of cholecystectomy should be noted. Objectively: pronounced lymphodema is determined - 3 degrees of the right lower leg (swelling is dense, painful on palpation, trophic changes in the skin of the right lower leg in the form of an ulcer with a diameter of 2 × 3 cm with a flat bottom covered with fibrinous plaque).

The patient underwent a course of appropriate treatment, which is as follows: the introduction of intravenous solutions: trental, Actovegin, vitamins B, C, xanthinol-nicotinate. At the same time, an intravenous laser irradiation of blood with a helium-neon laser of 1.2 mW was carried out with an exposure of 1.5 hours (90 minutes), No. 7 daily.

Then the following procedure was carried out: a quartz optical fiber with a diameter of 0.7 mm was inserted into the right knee joint by means of a needle puncture of the joint with a 1.2 mW helium-neon laser and irradiation of the joint for 30 minutes, in a day, No. 7.

The effect of the treatment was observed on day 6, which was expressed in partial relief of lymphodema, cleansing the ulcer crater from fibrinous plaque. Lymphodema was completely stopped 20 days after the end of treatment, the trophic ulcer was closed.

The patient was observed for 4 years, no complaints, lymphodema, trophic changes in the skin were not detected.

It was noted that during treatment, the patient had increased diuresis. Daily urine volume increased to 3 liters, urine had a low specific gravity, pale yellow. This effect was observed until complete relief of lymphodema.

A number of laboratory and functional studies were performed in the first days after completion of the course. Clinical blood test: hemoglobin 144 g / l; erythrocytes - 4.8 · 10 ¹² / l, col. indicator 0.90, platelets 249.6 · 10 ⁹ / l, white blood cells 6.1 · 10 ⁹ / l, s-65, e-1, l-30, m-4, soe-17, coagulogram: hematocrit 0, 38, activated recalcification time 68 seconds, coagulation index 0.92, heparin tolerance 7 minutes 0.5 seconds, INR - 1.05, prothrombin index 96%, prothrombin time 12.45 seconds, fibrinogen 2.3 g / l, antithrombin 3-26 seconds - 104%.

Lymphocytes abs 1.52 · 10 ⁹ / l, SDZ + lymphocytes (T-lymphocytes)% 74, SDZ + lymphocytes (T-helpers) abs 0.78 · 10 ⁹ / l, SD8 + lymphocytes (cytotoxic T-lymphocytes)% 19, CD8 + lymphocytes (cytotoxic T-lymphocytes) abs 0.29 · 10 ⁹ / l, CD4 / SD8 conv. Units 2.6, CD20 + lymphocytes (B-lymphocytes)% - 10, abs - 0.15 · 10 ⁹ / l, neutrophil absorption activity% 94, IGA-0.57g / l, IGM - 0.9g / l, IgG 6.52g / l, also performed ultrasound of the vessels of the lower extremities and feet.

Conclusion: No lymphatic infections. The functional activity of platelets is within normal limits.

Example 2

Drya-na L.G., 65 years old. Diagnosis: CVI 3 degrees, varicose disease of the lower extremities 2-3 degrees. Lymphodema of the left tibia of the 3rd degree, trophic changes in the medial surface of the lower third of the left tibia. She complained of edema in November 2003, pain in both legs is more pronounced on the left, trophic changes in the left leg, varicose veins of the lower extremities. On examination, lymphodema of the 3rd degree of the left tibia, closed trophic ulcer of the medial surface of the lower third of the left tibia, varicose veins in the pool of the great saphenous vein of the left tibia and small saphenous vein of the right tibia were revealed. Examined:

clinical analysis of blood Hb - 123g / 1, Er - 4.5 10 12/1, ESR - 16 mm · h, prothrombin index 79%. According to rheovasography (RVG) revealed violations of the main venous outflow of both legs, more pronounced on the left.

The patient underwent a course of treatment: the introduction of intravenous solutions: trental, Actovegin, vitamins B, C, xanthinol-nicotinate. At the same time, an intravenous laser irradiation of blood with a 1.2 mW helium-neon laser was carried out with an exposure of 90 minutes, a course of seven daily procedures.

Then the following procedure was carried out: a quartz optical fiber with a diameter of 0.7 mm was inserted into the right knee joint by puncture of the joint with a needle, a 1.2 mW helium-neon laser was connected, and the joint was irradiated for 30 minutes, every other day, with a course of seven procedures.

Subsequently, sclerotherapy of varicose sections of the venous system of the lower sections was performed.

Control examination after a month: no complaints, lymphodema and varicose veins stopped. Trophic changes in the left lower leg were blocked by 80%. Survey completed. Coagulogram - APTT - 28 seconds, prothrombin index 94%, INR - 1.07, fibrinogen - 3.4 g / l, ethonol and B-naphthol test is negative. Clinical blood test - er. 4.4 · 10 ¹² / l, platelets - 250 · 10 ⁹ / l. Indicators of intravascular platelet activation, platelet forms in% - discocytes 85, discoechinocytes 14, spherocytes 1, spheroechinocytes 0, bipolar forms 0, the sum of the active forms of platelets in 15%, the number of platelets involved in aggregates 9.3, per 100 free platelets the number of small aggregates 5.0, the number of medium and large aggregates 0. Also performed USDG feet and lower legs.

Conclusion: Intravascular platelet aggregation is moderately increased. Arterial peripheral blood flow on the legs and feet - the main, within normal limits. Signs of valvular venous insufficiency were not detected.

This treatment method is based on the use of minimally invasive technology and is one of the most effective modern treatment methods. This invention achieves an increase in the effectiveness of treatment of chronic lymphatic insufficiency of the lower extremities and persistent relief of secondary lymphodema of the lower extremities, without side effects from the treatment, which is confirmed by the dynamics of clinical observation, functional and laboratory studies. It should be noted that in no patient recurrence of lower limb lymphodema was observed. The treatment method is possible and appropriate to use on an outpatient basis due to the simplicity of its implementation. Thus, all of these indicators lead to an increase in the effectiveness of the treatment of such a common disease as secondary lymphodema of the lower extremities.

Claims (2)

1. A method of treating secondary lymphadenomas of the lower extremities, based on exposure to laser radiation with a wavelength of 0.6328 μm and the administration of drugs, characterized in that they simultaneously carry out intravenous laser irradiation with a power of 1.2 mW with an exposure of 90 minutes and intravenous administration of drugs in in the form of solutions: trental, actovegin, reopoliglukin, vitamins of group B, C, xanthinol - 0.15% nicotinate, carried out daily in the amount of seven procedures per course. 2. A method of treating secondary lymphadenomas of the lower extremities according to claim 1, characterized in that, additionally, after intravenous laser irradiation and drug administration, intraarticular irradiation of the knee joint is carried out, for this an optical fiber with a diameter of 0.7 mm is introduced into the knee joint by needle puncture of the joint followed by the connection of a helium neon laser with a power of 1.2 mW and irradiation is carried out with an exposure of 30 minutes every other day in the amount of seven procedures per course.