Ryohei Ishiura

Indocyanine Green Lymphographic Signs of Lymphatic Collateral Formation in Lower Extremity Lymphedema After Cancer Resection.

AbstractIndocyanine green lymphography has recently been used to assess lymphatic vessel function in lymphedema patients. Postoperative collateral lymphatic vessels toward ipsilateral axillary lymph nodes are rarely seen above the umbilical level in lower lymphedema patients. Between January 2012 and December 2014, we performed indocyanine green lymphography of 192 limbs in 96 lower extremity lymphedema cases. As a result, dermal back flow appeared in 95 cases, with 38 in the lower abdominal area and 31 in the genital area. We confirmed 3 cases of superficial lymphatic collateral ways extending above the umbilical level to the axillary lymph nodes. All 3 cases had similarity in lower abdominal edema, so excessive lymphatic fluid in the lower abdomen was assumed to be the cause. Lymphatic collateral ways from abdomen to axillary lymph nodes in this study was likely to be designed to prevent the progress of lymphedema.

Hands-free vein visualizer for selection of recipient vein with an intact valve in lymphatic supermicrosurgery

clear how an insidious infection of a multifilament silk mesh as Seri , which slowly interpenetrate the original tissue, being completely replaced by it, leads to devastating consequences. Literature doesn’t report any previous SeriScaffold infection, even though the U.S. Food and Drug Administration has announced a voluntary recall because of a mesh, used for laparoscopic surgery may have been packaged in improperly sealed pouches with resultant contamination and patient’s infection. Late infections can occur with all foreign materials, and we can’t prove that the multifilament silk mesh was the raison of the infection. A lack of mesh integration in the infected breast, let us suspect a bacterial growth on the silk-derived scaffold, that prevented its interpenetration with the human body. Thus, further studies on this material and on different ADM and non ADM-materials may shed light on the real ability of bacteria to adhere to the multifilament silk mesh, leading to late infections.

Comparison of Lymphovenous Shunt Methods in a Rat Model: Supermicrosurgical Lymphaticovenular Anastomosis versus Microsurgical Lymphaticovenous Implantation

Background: Lymphaticovenular anastomosis and lymphaticovenous implantation are the most popular lymphovenous shunt operations for the treatment of obstructive lymphedema. However, no study has been reported regarding direct comparison between lymphaticovenular anastomosis and lymphaticovenous implantation. This study aimed to compare postoperative patency of lymphaticovenular anastomosis and lymphaticovenous implantation using a rat model. Methods: Twelve Wistar rats were used for the study. The rats were randomized into the lymphaticovenular anastomosis group (n = 6) or the lymphaticovenous implantation group (n = 6). In the lymphaticovenular anastomosis group, the largest femoral lymphatic vessel was anastomosed to a similar-size vein in an end-to-end intima-to-intima coaptation manner, and the other lymphatics were ligated. In the lymphaticovenous implantation group, the femoral lymphatic vessel and surrounding tissue were inserted into the short saphenous vein with a telescopic anastomosis technique. Patency was evaluated intraoperatively and 1 week postoperatively with patent blue dye and indocyanine green lymphography. Results: The mean diameters of the lymphatic vessels and the veins were 0.242 mm (range, 0.20 to 0.35 mm) and 0.471 mm (range, 0.30 to 0.75 mm), respectively. Intraoperative patency was 100 percent (six of six) in both groups (p = 1.000). Postoperative patency was significantly higher in the lymphaticovenular anastomosis group compared with the lymphaticovenous implantation group [100 percent (six of six) versus 33.3 percent (two of six); p = 0.014] Conclusion: Postoperative patency of the lymphaticovenular anastomosis group was higher than that of the lymphaticovenous implantation group, although intraoperative patency rates of the lymphaticovenular anastomosis and lymphaticovenous implantation groups were comparable.

Successful treatment with dabigatran for consumptive coagulopathy associated with extensive vascular malformations

Vascular malformation is occasionally complicated by consumptive coagulopathy, known as localized intravascular coagulopathy (LIC), which is characterized by a reduced fibrinogen level, an elevated D-dimer level and a normal platelet count. We report the case of a 17-year-old Japanese girl who presented with LIC secondary to extensive vascular malformations, whose condition had progressed to disseminated intravascular coagulation (DIC). She suddenly presented with severe anaemia, despite the absence of obvious bleeding, and she began to require regular red blood cell (RBC) transfusions. As she was suffering from paroxysmal atrial fibrillation, we treated her with dabigatran, after obtaining informed consent. Immediately after the administration of dabigatran, the results of clotting tests improved dramatically. Seven months later, she has not required any RBC transfusions, and the dabigatran treatment has been well tolerated. The present case report suggests that dabigatran may be a useful treatment option for patients with DIC associated with vascular malformations.

Thirty-micron needle for precise supermicrosurgery

Supermicrosurgery deals with vessels around 0.5 mm, and is becoming popular for the treatment of lymphedema and various reconstructions using perforator-to-perforator anastomosis (Yamamoto et al., 2011). Although a 50to 80-micron needle microsuture (11-0 or 120) is enough to anastomose vessels with diameter of 0.3 mm or larger, it is still challenging to anastomose smaller (0.1-0.3 mm) vessels even with 12-0 microsutures (Yamamoto et al., 2013; in press). To address this challenge, “13-0” microsuture with a 30-micron needle was applied in supermicrosurgical anastomosis of 0.3 mm or smaller vessels. There were 0.2 mm lymphatic vessel and 0.25 mm vein in a lymphedematous limb. As previously reported, lymphatic vessel and vein were prepared for anastomosis (Yamamoto et al., 2011). The vessels were anastomosed in an end-to-end intima-to-intima coaptation manner using a 30-micron microsuture (12-0S, Crownjun, Japan). The needle was 0.03-mm-wide and 1.2-mm-long attached with 8-cm-long nylon thread, and costed 14,250 yen (Figure 1A). Anastomosis was conducted using a jeweler forceps, since the needle cannot be securely held even with a supermicrosurgical needle-holder. Anastomosis was completed with five stitches. After supermicrosurgical lymphaticovenous anastomosis, the recipient vein was fulfilled with translucent lymph, demonstrating anastomosis patency (Figure 1B). The “13-0” microsuture may have a potential to be essential for precise supermicrosurgery.

Diagnosis of trauma-induced lymphedema using indocyanine green lymphography

Diagnoses of lymphedema are often difficult to make unless the patient has an obvious episode of lymph node dissection or irradiation in the surgery of cancer. Conservatively, diagnosis of lymphedema could be suggested in the case of lower leg swelling only if every cause of edema is ruled out such as deep venous thrombosis, acute and chronic heart failure, renal or hepatic failure, and malnutrition. Indocyanine green (ICG) lymphography has been reported to be useful for diagnosis of lymphedema. Here we report the case where the diagnosis of acquired lymphedema is successfully made by the visualization of lymphatic disruption using ICG lymphography. The patient is 45-year-old male who presented in our hospital with right lower leg swelling and pain after car

Application of a multi-directional transformable retractor for lymphatic supermicrosurgery using SEKI method

Treatment of lower extremity lymphedema (LEL) is challenging, because LEL is progressive in nature and sometimes refractory to conservative treatments. Supermicrosurgical lymphaticovenular anastomosis (LVA) has been reported to be useful to treat compression-refractory cases, and is becoming popular due to its effectiveness and less invasiveness (Yamamoto, Narushima et al., 2011; Yamamoto et al., 2014). However, it is difficult for a beginner LVA surgeon to find a lymphatic vessel suitable for LVA. Seki et al. reported superior edge of the knee incision (SEKI) method, in which a large lymphatic vessel and a suitable recipient vein could be constantly found at the SEKI point (Seki et al., 2015). Although the SEKI method allows more effective LVA compared with a conventional method, surgical procedures for SEKI method is difficult, because the surgical field is almost horizontal to a surgeon’s view; incision is made at postero-medial aspect of the distal thigh. To solve this problem, we employed a multi-directional transformable retractor for SEKI-LVA. A skin incision was made at the postero-medial aspect of the distal thigh as previously reported by Seki. To make the surgical field vertical to a surgeon’s view and to make it easy for a surgeon to dissect a lymphatic vessel in deep layer of fat tissue, a multi-directional transformable retractor (Lone Star Retractor System, CooperSurgical, USA) was used; hooks were applied to retract the wound edges and fixed to the retractor system to make the surgical field as vertical to the surgeon’s view as possible (Figure 1). With this retractor system, a surgeon did not feel difficulty to dissect adiposal tissue to the deep fat layer, and a lymphatic vessel under the superficial fascia could be more easily dissected with applying the hooks to the superficial fascial edges to open them. Although SEKI-LVA is useful and effective for treatment of refractory lymphedema, technical difficulty, especially difficulty in lymphatic vessel dissection, has prevented dissemination of the surgery. Even when lymphatic imaging such as indocyanine green lymphography visualizes lymphatics, dissection of lymphatic vessels in the distal thigh is difficult due to poor visibility of a surgical field (Seki et al., 2015; Yamamoto, Narushima et al., 2014; Yamamoto et al., 2015). The multidirectional transformable retractor allows easier dissection of a lymphatic vessel in SEKI-LVA procedures. Although further clinical studies are required to confirm efficacy, the retractor system can be a useful tool to facilitate SEKI-LVA. Takumi Yamamoto, MD, PhD, Nana Yamamoto, MD, Ryohei Ishiura, MD Department of Plastic Surgery, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan

Pocketable ultrasonography for bedside flap monitoring

Dear Sirs, Free tissue transfer has become a choice of methods for various reconstructions. For successful flap transfer, it is important to monitor a flap vascularity for early detection and revision of vascular compromise especially when a flap is transferred without a skin paddle and buried subcutaneously (Jones, 1992). Although ultrasonography (US) allows early detection of pedicle thrombosis by clear visualization of blood flows, US is inconvenient for frequent bedside monitoring (Chae et al., 2015). To address this challenge, we applied a pocketable US for bedside flap monitoring. A lateral thoracic lymph node adiposal flaps was transferred to the groin with navigation lymphatic surgical techniques by anastomosing the vascular pedicle of the lateral thoracic vessels to the superficial circumflex iliac vessels; vessel diameters were around 1 mm (Yamamoto et al., 2011, 2013, 2014). Using a pocket-size US (SonoSite iViz, Fujifilm, Japan), blood flows of the anastomosis site were visualized; both arterial and venous flow could be visualized using a color-Doppler mode. An examiner can easily control the monitor of a tablet by one hand, while evaluating blood flows using the probe by the other hand (Figure 1). The pocketable US consists of a 150 mm 3 94 mm monitor and a 6.4 MHz echo probe. Since the US can be put into a conventional white court’s pocket, a medical staff can bring it in a pocket and easily evaluate blood flows at bedside. Sound Doppler and implantable sound Doppler are applied to monitor a buried flap, but they are not optimal to monitor venous flow and have a risk of accidental removal or retrograde infection (Chae et al., 2015; Jones, 1992). The pocketable US can be applicable anywhere and anytime a medical staff needs, and is especially useful

Inguinal seroma prevention by reverse mapping using inodocyanine green lymphography

Superficial circumflex iliac artery perforator (SCIP) flap is a useful perforator flap in that it has a long pedicle and the donor site is concealable. However, SCIP flap elavation can cause seroma, lymphorrhea, and lymphedema, because many lymphatic vessels run to the groin region. Some reports suggest that meticulous coagulation or ligation in the inguinal region may reduce the risk, but it is much better not to damage the lymphatic system. To achieve this, we visualized lymph flows in the groin region using indocyanine green (ICG) lymphography during SCIP elevation. When elevating a SCIP flap, we performed reverse mapping; lymph flows from the lower extremity were visualized. 0.2 mL of 0.25% ICG was injected at the lateral, the middle and the medial aspect of the superior border of the patella before skin incision. During the elevation of a SCIP flap, especially during dissecting the medial inguinal region near the femoral vessels, lymph flows were examined with ICG lymphography. Pedal lymph flows were clearly visualized in the inguinal region near the flap pedicle (Fig. 1), so we were able to elevate the flap without sacrificing it. Postoperative drainage volume at the donor site was little and seroma and other complications did not occur. Here, we have shown that ICG is a safe and convenient tool to visualize lymph flows in the groin region to preserve them during SCIP flap elevation. Since intractable seroma formation or lymphorrhea are due to damage to the lymphatic system, preservation of the lymphatic system is the most important. Although further studies are required, the method may be useful to prevent seroma, lymphorrhea, and lymphedema in other operative procedures in the groin region.

Hands‐free vein visualizer for preoperative assessment of recipient veins

Chronic distal leg/foot soft tissue defect after trauma requires challenging reconstruction, because local flaps cannot be used and pedicle vessels are affected by posttraumatic inflammation. It is important to select an intact artery and a vein for free flap transfer. For preoperative evaluation of recipient artery, computed tomography angiography greatly helps a surgeon to select and dissect an intact recipient artery.