Hidehiko Yoshimatsu

Indocyanine green-enhanced lymphography for upper extremity lymphedema: a novel severity staging system using dermal backflow patterns.

Background: Management of arm lymphedema following breast cancer treatment is challenging, and emphasis should be put on early diagnosis and prevention of secondary lymphedema. Indocyanine green lymphography is becoming a method of choice for evaluation of lymphedema. Methods: Twenty patients with secondary arm lymphedema after breast cancer treatment underwent indocyanine green lymphography. Characteristic findings of indocyanine green lymphography were analyzed according to corresponding clinical stages and duration of edema. Based on changes in indocyanine green lymphography findings with progression of lymphedema, a new severity stage, arm dermal backflow stage, was developed and compared with clinical stages. Results: The indocyanine green lymphographic findings were classified into two large groups: linear pattern and dermal backflow patterns. The dermal backflow pattern could be subdivided into splash, stardust, and diffuse patterns. The dermal backflow patterns were found more frequently than the linear pattern in the proximal upper extremity (p = 0.001). The dermal backflow patterns also increased significantly in prevalence overall as the duration of lymphedema increased (p = 0.032). The arm dermal backflow stage was linearly correlated with clinical stage as described by the line y = 1.092x + 0.083 (R2 = 0.997; analysis of variance, p < 0.001). Conclusions: Indocyanine green lymphography is a safe and convenient evaluation method for lymphedema that allows qualitative pathophysiologic assessment of lymphedema. The arm dermal backflow stage, based on indocyanine green lymphographic findings, is a simple severity staging system that demonstrates a significant correlation with clinical stage. Indocyanine green lymphography may come to play an important role in early diagnosis of secondary arm lymphedema. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, V.

The earliest finding of indocyanine green lymphography in asymptomatic limbs of lower extremity lymphedema patients secondary to cancer treatment: the modified dermal backflow stage and concept of subclinical lymphedema.

Background: Early diagnosis and treatment are as important for management of secondary lymphedema following cancer treatment as in primary cancer treatment. Indocyanine green lymphography is the modality of choice for routine follow-up evaluation of patients at high risk of developing lymphedema after cancer therapy. Methods: Fifty-six limbs of 28 so-called unilateral secondary lower extremity lymphedema patients who underwent indocyanine green lymphography were compared with dermal backflow patterns of indocyanine green lymphography on 28 asymptomatic limbs and assessed using leg dermal backflow stage. Results: Of 28 asymptomatic limbs of secondary lower extremity lymphedema patients, the dermal backflow patterns were detected in 19 limbs but were absent in nine limbs. Significant differences were seen between asymptomatic limbs with dermal backflow patterns (n = 19) and limbs without them (n = 9): age, 51.4 ± 15.3 years versus 34.8 ± 12.7 years (p = 0.007); body weight, 75.1 ± 7.9 kg versus 50.1 ± 5.3 kg (p = 0.012); body mass index, 23.1 ± 4.2 versus 19.7 ± 1.8 (p = 0.005); leg dermal backflow stage of asymptomatic limb, 1.2 ± 0.4 versus 0.0 ± 0.0 (p < 0.001); and leg dermal backflow stage of symptomatic limb, 3.5 ± 0.6 versus 2.8 ± 0.8 (p = 0.033). Conclusions: The splash pattern is the earliest finding on indocyanine green lymphography of asymptomatic limbs of secondary lower extremity lymphedema patients. The leg dermal backflow stage allows early diagnosis of secondary lower extremity lymphedema even in a subclinical stage. The concept of subclinical lymphedema could play an important role in early diagnosis and prevention of lymphedema after cancer treatment. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, V.

Lambda-Shaped Anastomosis with Intravascular Stenting Method for Safe and Effective Lymphaticovenular Anastomosis

Background: Lymphaticovenular anastomosis has become an increasingly common treatment for lymphedema. Supermicrosurgical techniques are essential for the successful performance of lymphaticovenular anastomosis. A positive correlation between the number of lymphaticovenular anastomoses performed and therapeutic efficacy has been reported, and in performing these anastomoses, the establishment of as many bypasses as possible is important. Methods: Forty limbs of 20 patients with lower extremity lymphedema who underwent lymphaticovenular anastomosis in our department were assessed. All cases were performed under local anesthesia using two to four surgical microscopes. A new method of anastomosis, lambda-shaped anastomosis assisted by intravascular stenting, was chosen in required cases. Results: Lymphaticovenular anastomoses resulted in 186 anastomoses on 20 patients with lower extremity lymphedema; the average number of anastomoses per case was 9.3 (range, five to 18). The number of surgical microscopes used ranged from two to four (average, 3.3), and the duration of the operation ranged from 3 to 5 hours (average, 4.1). In the cases of lambda-shaped anastomosis (n = 11), the number of anastomoses was significantly greater than in the cases without lambda-shaped anastomosis (n = 9; 10.2 ± 2.3 versus 8.2 ± 1.4; p < 0.05). Conclusions: Lambda-shaped anastomosis assisted by intravascular stenting is a safe and relatively easy method that can be performed by surgeons with less than 1 year of experience in microsurgery. This in turn allows efficient lymphaticovenular anastomoses to be performed simultaneously by a team of surgeons, resulting in an increased number of bypasses.

Indocyanine Green (ICG) Lymphography Is Superior to Lymphoscintigraphy for Diagnostic Imaging of Early Lymphedema of the Upper Limbs

Background Secondary lymphedema causes swelling in limbs due to lymph retention following lymph node dissection in cancer therapy. Initiation of treatment soon after appearance of edema is very important, but there is no method for early diagnosis of lymphedema. In this study, we compared the utility of four diagnostic imaging methods: magnetic resonance imaging (MRI), computed tomography (CT), lymphoscintigraphy, and Indocyanine Green (ICG) lymphography. Patients and Methods Between April 2010 and November 2011, we examined 21 female patients (42 arms) with unilateral mild upper limb lymphedema using the four methods. The mean age of the patients was 60.4 years old (35–81 years old). Biopsies of skin and collecting lymphatic vessels were performed in 7 patients who underwent lymphaticovenous anastomosis. Results The specificity was 1 for all four methods. The sensitivity was 1 in ICG lymphography and MRI, 0.62 in lymphoscintigraphy, and 0.33 in CT. These results show that MRI and ICG lymphography are superior to lymphoscintigraphy or CT for diagnosis of lymphedema. In some cases, biopsy findings suggested abnormalities in skin and lymphatic vessels for which lymphoscintigraphy showed no abnormal findings. ICG lymphography showed a dermal backflow pattern in these cases. Conclusions Our findings suggest the importance of dual diagnosis by examination of the lymphatic system using ICG lymphography and evaluation of edema in subcutaneous fat tissue using MRI.

Minimally invasive lymphatic supermicrosurgery (MILS): indocyanine green lymphography-guided simultaneous multisite lymphaticovenular anastomoses via millimeter skin incisions.

AbstractAmong various surgical treatments, lymphaticovenular anastomosis (LVA), which bypasses congested lymph into venous circulation, is the least invasive surgical treatment. However, it usually entails skin incisions of around 3 cm, and operation time of around 4 hours. With multiple supermicrosurgeons under guidance of indocyanine green lymphography, LVAs can be simultaneously performed under local anesthesia within approximately 2 hours via small skin incisions with length less than 1 cm, allowing minimally invasive lymphatic supermicrosurgery (MILS). We performed MILS on 11 limbs of compression-refractory peripheral lymphedema cases. Length of skin incision for LVA ranged from 1 to 9 mm. Average operation time was 1.82 hours. Of the11 limbs, 10 showed postoperative volume reduction. Indocyanine green lymphography clearly visualizes superficial lymph flows, which helps us to decide precise skin incision sites and find lymphatic vessels in LVA surgery, shortening skin incision length and operation time. Minimally invasive lymphatic supermicrosurgery can serve as the most reasonable treatment of compression-refractory peripheral lymphedema.

Simultaneous multi-site lymphaticovenular anastomoses for primary lower extremity and genital lymphoedema complicated with severe lymphorrhea

Primary lower extremity and genital lymphoedema (GL) is difficult to manage, especially when complicated with severe lymphorrhea. With abundant experience of treatment for lower-extremity lymphoedema (LEL), we performed simultaneous multi-site lymphaticovenular anastomoses (LVAs) for GL with severe lymphorrhea. In two cases of primary LEL and GL, LVAs were performed via 2-cm-long skin incisions using two to three operating microscopes under local anaesthesia. Symptoms of oedema and lymphorrhea improved clinically. LVA is a minimally invasive surgery, which is effective for the treatment of LEL and GL even in primary cases with severe lymphorrhea. Simultaneous multi-site LVAs can serve as the most effective therapy for lymphoedema.

Near-infrared illumination system-integrated microscope for supermicrosurgical lymphaticovenular anastomosis

Background: Lymphatic supermicrosurgery, lymphaticovenular anastomosis (LVA), is becoming a treatment option for progressive lymphedema with its effectiveness and minimal invasiveness. It is important to detect and anastomose large functional lymphatic vessels for LVA surgery. This study aimed to evaluate usefulness of a near‐infrared illumination system‐integrated microscope for lymphatic supermicrosurgery. Methods: We performed LVA on 12 lower extremity lymphedema (LEL) patients with or without intraoperative microscopic indocyanine green (ICG) lymphography guidance. An operating microscope equipped with an integrated near‐infrared illumination system (OME‐9000; Olympus, Tokyo, Japan) was used for intraoperative microscopic ICG lymphography guidance. Feasibility, anastomosis patency, and treatment effect of the method were evaluated. Results: Forty LVAs were performed (24 LVAs with intraoperative microscopic ICG lymphography‐guidance on 7 limbs, and 16 LVAs without the guidance on 5 limbs). Lymphatic vessels were enhanced by intraoperative microscopic ICG lymphography in 11 of 12 skin incision sites. Time required for detection and dissection of lymphatic vessels in cases with intraoperative microscopic ICG lymphography guidance was significantly shorter than that in cases without the guidance (2.3 ± 1.7 min vs. 6.5 ± 4.0 min, P = 0.010). There was no statistically significant difference in LEL index reduction between cases with and without intraoperative microscopic ICG lymphography guidance (18.3 ± 5.5 vs. 15.0 ± 5.5, P = 0.337). Conclusions: Intraoperative microscopic ICG lymphography visualized lymphatic vessels, which helps a lymphatic supermicrosurgeon to find and dissect lymphatic vessels earlier.

Lower extremity lymphedema index: a simple method for severity evaluation of lower extremity lymphedema.

Measurement of the circumference is the most commonly used method for evaluating extremity lymphedema. However, comparison between different patients is difficult with this measurement. To resolve this problem, we have formulated a new index, lower extremity lymphedema (LEL) index, which can be easily obtained from measurements of the body. We evaluated correlation between lower LEL index and clinical stage in patients with LEL. The LEL indices were significantly correlated with clinical stages and could be used as a severity scale. The LEL index makes objective assessment of the severity of lymphedema through a numerical rating, regardless of the body type. This numerical rating makes the index useful for evaluation of lymphedema severities between different cases.

Indocyanine green velocity: lymph transportation capacity deterioration with progression of lymphedema.

AbstractLymph transportation capacity is a critical function maintaining fluid circulation. After pelvic cancer treatments, lymph obstruction at the pelvic region leads to abnormal lymph circulation, resulting in lymph pump dysfunction. Besides lymph circulation, lymph pump function is important for lymphedema evaluation. We assessed and analyzed lymph transportation capacity of secondary lower extremity lymphedema patients using indocyanine green (ICG) lymphography according to corresponding severity stage. Indocyanine green velocity and transit time could evaluate lymph pump function; ICG velocity decreases and transit time increases as the lymphedema severity stage progresses. Measurement of ICG velocity required 5 minutes after the dye injection, whereas that of transit time took more than 1 hour in severe cases. Indocyanine green velocity can be easily obtained and is recommended for evaluation of lymph pump function compared with transit time. Dynamic ICG lymphography, which evaluates both lymph pump function and circulation, plays an important role in comprehensive assessment of lymphedema pathophysiology.

Navigation Lymphatic Supermicrosurgery for the Treatment of Cancer-Related Peripheral Lymphedema

Background: Lymphatic supermicrosurgery is becoming the treatment of choice for refractory lymphedema. Detection and anastomosis of functional lymphatic vessels are important for lymphatic supermicrosurgery. Methods Navigation lymphatic supermicrosurgery was performed using an operating microscope equipped with an integrated near-infrared illumination system (OPMI Pentero Infrared 800; Carl Zeiss, Oberkochen, Germany). Eight patients with extremity lymphedema who underwent navigation lymphatic supermicrosurgery were evaluated. Results: A total of 21 lymphaticovenular anastomoses were performed on 8 limbs through 14 skin incisions. Lymphatic vessels were enhanced by intraoperative microscopic indocyanine green (ICG) lymphography in 12 of the 14 skin incisions, which resulted in early dissection of lymphatic vessels. All anastomoses showed good anastomosis patency after completion of anastomoses. Postoperative extremity lymphedema index decreased in all limbs. Conclusions: Navigation lymphatic supermicrosurgery, in which lymphatic vessels are visualized with intraoperative microscopic ICG lymphography, allows a lymphatic supermicrosurgeon to find and dissect lymphatic vessels earlier and facilitates successful performance of lymphaticovenular anastomosis.