Akitatsu Hayashi

Efferent Lymphatic Vessel Anastomosis: Supermicrosurgical Efferent Lymphatic Vessel-to-Venous Anastomosis for the Prophylactic Treatment of Subclinical Lymphedema.

BackgroundIn lower extremity lymphedema secondary to pelvic cancer treatments, lymphedema develops despite that the inguinal lymph nodes (LNs) are preserved. Obstruction of the efferent lymphatic vessels of the inguinal LNs causes lower extremity lymphedema, and it is considered a radical treatment to bypass the efferent lymphatic vessel. MethodsEfferent lymphatic vessel anastomosis, supermicrosurgical efferent lymphatic vessel-to-venous anastomosis, was performed on 14 legs with subclinical lymphedema [leg dermal backflow (LDB) stage I]. Efferent lymphatic vessel anastomosis was performed under local anesthesia at the groin region, and an efferent lymphatic vessel of the inguinal LN is anastomosed to a recipient vein. Feasibility and postoperative results were evaluated. ResultsAll 14 efferent lymphatic vessel anastomoses were successfully performed without perioperative complication. All legs could be free from lymphedematous symptoms without perioperative compression at postoperative 1 year. Postoperative LDB stage included LDB stage 0 (n = 8) and LDB stage I (n = 6), which was significantly downstaged compared with preoperative LDB stage (P < 0.001). ConclusionsEfferent lymphatic vessel anastomosis allowed lymph flow bypass after filtration by the superficial inguinal LN through a skin incision along the inguinal crease, and was effective to prevent development of symptomatic lymphedema in subclinical lymphedema cases.

Arm Volumetry Versus Upper Extremity Lymphedema Index: Validity of Upper Extremity Lymphedema Index for Body-type Corrected Arm Volume Evaluation

BackgroundVolumetry, measurement of extremity volume, is a commonly used method for upper extremity lymphedema (UEL) evaluation. However, comparison between different patients with different physiques is difficult with volumetry, because body-type difference greatly affects arm volume. MethodsSeventy arms of 35 participants who had no history of arm edema or breast cancer were evaluated. Arm volume was calculated using a summed truncated cone model, and UEL index was calculated using circumferences and body mass index (BMI). Examinees’ BMI was classified into 3 groups, namely, low BMI (BMI, <20 kg/m2), middle BMI (BMI, 20–25 kg/m2), and high BMI (BMI, >25 kg/m2). Arm volume and UEL index were compared with corresponding BMI groups. ResultsMean (SD) arm volume was 1090.9 (205.5) mL, and UEL index 96.9 (5.6). There were significant differences in arm volume between BMI groups [low BMI vs middle BMI vs high BMI, 945.2 (107.4) vs 1045.2 (87.5) vs 1443.1 (244.4) mL, P < 0.001]. There was no significant difference in UEL index between BMI groups [low BMI vs middle BMI vs high BMI, 97.2 (4.2) vs 96.6 (4.6) vs 96.7 (9.9), P > 0.5]. ConclusionsArm volume significantly increased with increase of BMI, whereas UEL index stayed constant regardless of BMI. Upper extremity lymphedema index would allow better body-type corrected arm volume evaluation compared with arm volumetry.

Supermicrosurgical deep lymphatic vessel-to-venous anastomosis for a breast cancer-related arm lymphedema with severe sclerosis of superficial lymphatic vessels

Lymphatic supermicrosurgery or supermicrosurgical lymphaticovenular anastomosis (LVA) is becoming popular for the treatment of compression‐refractory upper extremity lymphedema (UEL) with its effectiveness and minimally invasiveness. In conventional LVA, superficial lymphatic vessels are used for anastomosis, but its treatment efficacy would be minimum when superficial lymphatic vessels are severely sclerotic. Theoretically, deep lymphatic vessels can be used for LVA, but no clinical case has been reported regarding deep lymphatic vessel‐to‐venous anastomosis (D‐LVA). We report a breast cancer‐related UEL case treated with D‐LVA, in which a less‐sclerotic deep lymphatic vessel was useful for anastomosis but superficial lymphatic vessels were not due to severe sclerosis. A 62‐year‐old female suffered from an 18‐year history of compression‐refractory right UEL after right breast cancer treatments, and underwent LVA under local infiltration anesthesia. Because superficial lymphatic vessels found in surgical fields were all severely sclerotic, a deep lymphatic vessel was dissected at the cubital fossa. A 0.50‐mm deep lymphatic vessel running along the brachial artery was supermicrosurgically anastomosed to a nearby 0.40‐mm vein. At postoperative 12 months, her right UEL index decreased from 134 to 118, and she could reduce compression frequency from every day to 1–2 days per week to maintain the reduced lymphedematous volume. D‐LVA may be a useful option for the treatment of compression‐refractory UEL, when superficial lymphatic vessels are severely sclerotic.

Therapeutic strategy for lower limb lymphedema and lymphatic fistula after resection of a malignant tumor in the hip joint region: A case report

Lymphatic fistula complicating lymphedema is thought to occur due to communication between lymph vessels and the skin, which has yet to be shown objectively. The objective of this case report is to show the pathology and treatment using simultaneous lymphatic fistula resection and lymphatico‐venous anastomosis (LVA). A 40‐year‐old woman underwent extended resection and total hip arthroplasty for primitive neuroectodermal tumor in the right proximal femur 23 years ago. Right lower limb lymphedema developed immediately after surgery and lymphatic fistula appeared in the posterior thigh. On ICG lymphography, lymph reflux toward the distal side dispersing in a fan‐shape reticular pattern from the lymphatic fistula region was noted after intracutaneous injection of ICG into the foot. We performed simultaneous lymphatic fistula resection and of LVA. Pathological examination showed that the epidermis and stratum corneum of the healthy skin were lost in the lymphatic fistula region. Dilated lymph vessels were open in this region. The examinations provide the first objective evidence that the cause of lymphatic fistula may be lymph reflux from lymphatic stems to precollectors through lymphatic perforators.

Ultrasound visualization of the lymphatic vessels in the lower leg.

Identification of lymphatic vessels for lymphaticovenular anastomosis (LVA), which is an effective surgical treatment for obstructive lymphedema, is important. Indocyanine green (ICG) lymphography is useful for that purpose, but is not common in many institutions. Although ultrasound is a very common modality, no research has yet underlined the feasibility of the device to detect the lymphatic vessels.

Practicality of the Lower Extremity Lymphedema Index: Lymphedema Index Versus Volumetry-Based Evaluations for Body-Type–Corrected Lower Extremity Volume Evaluation

BackgroundVolume measurement is one of the most commonly used methods for lower extremity lymphedema (LEL) evaluation because of its objectivity. However, volume comparison between different patients with different body types may be inappropriate because body-type difference seems to significantly affect leg volume (LV). MethodsTwenty-seven nonedematous legs of 27 unilateral LEL patients were evaluated. The LEL index was calculated using circumferences and body mass index (BMI), and LV was calculated using a summed truncated cone model. The BMI of the examinees was classified into 3 groups: low BMI (BMI < 20), middle BMI (BMI, 20–25), and high BMI (BMI > 25). The LEL index, LV, LV divided by body surface area (LV/BSA), and LV divided by BMI (LV/BMI) were compared with the corresponding BMI groups. ResultsThe mean (SD) LEL index was 218.6 (12.9), and the mean (SD) LV was 4081.3 (835.6) mL. Between the low-, middle-, and high-BMI groups, there were no significant differences in the LEL index [223.2 (11.4), 217.8 (13.3), and 214.6 (14.2), P > 0.5] or in LV/BMI [185.5 (9.2), 179.3 (11.3), and 175.7 (15.8) mL per kg/m2, P > 0.3], whereas significant differences were seen in LV [3484.9 (366.0), 3924.4 (342.5), and 5387.7 (1038.4) mL, P < 0.001) and in LV/BSA [2404.3 (236.6), 2539.2 (141.4), and 3106.0 (460.8) mL/m2, P < 0.001]. ConclusionsThe LEL index and LV/BMI stayed constant regardless of BMI, whereas LV and LV/BSA significantly increased with increase in BMI. With simplicity of calculation, the LEL index would allow more practical body-type–corrected LV evaluation compared with volumetry-based evaluations.

Indocyanine green lymphography and lymphaticovenous anastomosis for generalized lymphatic dysplasia with pleural effusion and ascites in neonates.

BACKGROUND The fatality rate of generalized lymphatic dysplasia (GLD) with chylous pleural effusion and ascites is particularly high when it persists over a prolonged period. The purpose of this report was to determine the utility of indocyanine green (ICG) lymphography and lymphaticovenous anastomosis (LVA) in GLD with chylous pleural effusion and ascites in neonates. METHODS We tested the lymphatic function in the 4 extremities for 8 GLD neonate patients using ICG lymphography, and on the basis of the results, we performed LVA for 5 of them. LVA was performed at the extremities under general anesthesia using incisions <1 cm in length. The outcome of LVA was evaluated with the amount of ascites discharged from thoracostomy tube or abdominal tube, except for 1 patient who had no drainage tube. RESULTS In all cases, ICG lymphography showed varying degrees of dermal backflow in the limbs with lymphostasis. After LVA surgery, effusion stopped in 2 cases and decreased in 1 case. In the cases where effusion stopped, backflow as observed with ICG lymphography was minimal, and in the case where effusion decreased but did not stop, backflow was moderate. CONCLUSIONS The application of ICG and LVA could possibly be used to diagnose and treat lymphatic pleural effusion or ascites.

Correlation between indocyanine green (ICG) patterns and real-time elastography images in lower extremity lymphedema patients

BACKGROUND/AIM Indocyanine green (ICG) lymphography is becoming a popular modality, but unfortunately it is not available in all institutions. Elastography is a relatively new ultrasonographic technique to evaluate tissue elasticity, which visualizes fluid retention as a red region in lymphedema patients. The aim of this study was to evaluate the correlation between elastography and ICG lymphology. METHODS Thirty-six legs in 18 patients with secondary lower extremity lymphedema (LEL) and 20 legs in 10 healthy volunteers were examined using elastography. Thirty-six legs in 18 secondary LEL patients were examined using ICG lymphography. Elastography was performed on both legs at the following three sites: medial thigh (MT), medial leg (ML), and anterior ankle (AA). The area of the red region in the subcutaneous tissue demonstrated by elastography was calculated using Image software. ICG lymphography findings were classified into the following four patterns: linear (ICG1), splash (ICG2), stardust (ICG3), and diffuse (ICG4) patterns. RESULTS As ICG pattern progressed, the red region area was likely to increase. There was a correlation between ICG patterns and red region area according to the severity at bilateral MT (rs = 0.665), ML (rs = 0.623), and AA (rs = 0.668). Significant difference was demonstrated among group means of the red region area by analysis of variance (healthy vs. ICG1 vs. ICG2 vs. ICG3 vs. ICG 4: 14.4 ± 5.7 vs. 15.1 ± 10.3 vs. 25.2 ± 6.2 vs. 30.8 ± 9.4 vs. 35.0 ± 2.8; P < 0.001). CONCLUSIONS The area of the red region in the subcutaneous tissue shown using elastography, which represents fluid, increases with the aggravation of lymphedema demonstrated by ICG patterns. As elastography is performed by ultrasonography, which is available in most institutions, elastography could be a useful alternative evaluation for lymphedema severity when ICG lymphography is not available.

Effective and efficient lymphaticovenular anastomosis using preoperative ultrasound detection technique of lymphatic vessels in lower extremity lymphedema

Identification of functional lymphatic vessels and localization of lymphatic vessels are important for lymphaticovenular anastomosis (LVA). Indocyanine green (ICG) lymphography is useful for localization of superficial lymphatic vessels where dermal backflow is not observed, but not for lymphatic vessels in deep layer or where dermal backflow is observed. Ultrasound has been applied in LVA and is considered useful for localization of lymphatic vessels with ICG lymphography cannot be visualized.

Ultrasound-Assisted Lymphaticovenular Anastomosis for the Treatment of Peripheral Lymphedema

1. Rome, Italy Department of Plastic and Reconstructive Surgery, Università Cattolica del “Sacro Cuore” – University Hospital “A. Gemelli” 2. Tokyo, Japan Plastic Surgeon, Department of Plastic and Reconstructive Surgery, Tokyo Metropolitan Bokutoh Hospital 3. Chiba, Japan Department of Plastic Surgery, Asahi General Hospital Corresponding Author: Akitatsu Hayashi, M.D. Address: 1326, I, Asahi, Chiba, 289-2511, Japan. Tel: +81-479-63-8111, Fax: +81-479-62-3757 E-mail: promise_me_now65@yahoo.co.jp AC CE PT ED