Nana Yamamoto

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.

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.

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.

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.

Side-to-end Lymphaticovenular anastomosis through temporary lymphatic expansion.

Objective The number of bypasses is the most important factor in lymphaticovenular anastomosis (LVA) for lymphedema treatment. Side-to-end (S-E) LVA, which can bypass bidirectional lymph flows via one anastomosis, is considered to be the most efficient bypass, but creation of lateral window to a small lymphatic vessel is technically demanding. To overcome the difficulty, we introduced S-E anastomosis through temporary lymphatic expansion (SEATTLE) procedure in S-E LVA. Methods This was a retrospective observational study set in a teaching hospital. Forty eight lower extremity lymphedema (LEL) patients underwent LVA. S-E LVAs were performed with (SEATTLE group) or without (non-SEATTLE group) temporary lymphatic expansion. S-E LVAs were evaluated to compare anastomosis result in SEATTLE and non-SEATTLE groups. Results S-E LVAs resulted in 44 anastomoses in SEATTLE group (n = 25) and 37 anastomoses in non-SEATTLE group (n = 23). LEL index reduction in SEATTLE group was significantly greater than that in non-SEATTLE group (16.5±14.5 vs. 10.9±11.8, P = 0.041). Success rate of S-E LVA in SEATTLE group was significantly higher than that in non-SEATTLE group (95.5% vs 81.1%, P = 0.040). Thirty seven of 44 (84.1%) lymph vessels in SEATTLE group were successfully dilated by temporary lymphatic expansion maneuver. All of 9 failed S-E LVAs used a lymphatic vessel with diameter of 0.35 mm or smaller. Conclusions The SEATTLE procedure facilitates S-E LVA by a simple and easy maneuver. When the diameter of the lymphatic vessel is 0.35 mm or smaller even after the temporary lymphatic expansion maneuver, S-E LVA is not recommended due to relatively high failure rate.

Sequential Anastomosis for Lymphatic Supermicrosurgery: Multiple Lymphaticovenular Anastomoses on 1 Venule

BackgroundSupermicrosurgical lymphaticovenular anastomosis (LVA) is becoming a treatment option for progressive lymphedema. Various types of LVA such as end-to-end, end-to-side, side-to-end, and side-to-side are performed to improve the treatment efficacy. MethodsWe applied sequential anastomosis for LVA surgery, in which 2 lymphatic vessels were anastomosed to 1 venule using side-to-side and side-to-end anastomoses. Six lower extremity lymphedema (LEL) patients who underwent sequential anastomosis were included in this study. Feasibility, anastomosis patency, and treatment effect of the method were evaluated. ResultsSix sequential anastomoses were performed on 6 lymphedematous limbs. All sequential anastomoses showed good anastomosis patency after completion of anastomoses. A significant decrease in LEL index was seen postoperatively (244.0 ± 14.6; postoperative LEL index vs 263.5 ± 19.4; preoperative LEL index, P = 0.002). ConclusionsSequential anastomosis can divert both normograde and retrograde lymph flows from 2 lymphatic vessels into 1 venule. Sequential LVA is a useful method to increase lymph flow bypasses, when there are fewer venules than lymphatic vessels.

Dynamic Indocyanine Green (ICG) lymphography for breast cancer-related arm lymphedema.

BackgroundLymph transportation capacity is a critical function maintaining fluid circulation. After breast cancer treatments, lymph obstruction at the axilla leads to abnormal lymph circulation, resulting in lymph pump dysfunction. As well as lymph circulation, lymph pump function is important for lymphedema evaluation. MethodsWe assessed and analyzed lymph transportation capacity of 15 breast cancer-related arm lymphedema patients using dynamic indocyanine green (ICG) lymphography. ResultsICG 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 3 minutes after the dye injection, whereas that of transit time took more than 1 hour in severe cases. ConclusionsICG velocity can be easily obtained and is recommended for evaluation of lymph pump function. Dynamic ICG lymphography, which evaluates both lymph pump function and circulation, plays an important role in comprehensive assessment of lymphedema pathophysiology.

Split intravascular stents for side-to-end lymphaticovenular anastomosis.

AbstractSupermicrosurgical lymphaticovenular anastomosis (LVA) is becoming the treatment of choice for compression-refractory lymphedema. Among various types of LVA, side-to-end (S-E) LVA is considered to be the most efficient one, because it can divert bidirectional lymph flows into venous circulation via 1 anastomosis, but is technically difficult. We developed a new technique for safe and easy S-E LVA with modified intravascular stenting (IVaS) method. Different from the original IVaS method, a lymphatic vessel is pierced by an IVaS before creation of a lateral window. The IVaS is cut after window creation and the ends are inserted into the lymphatic vessel and the venule respectively, guiding the course of the needle throughout the S-E anastomosis procedure. This method makes S-E LVA easier without special instruments.

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.