Takeshi Todokoro

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.

Pathological Steps of Cancer-Related Lymphedema: Histological Changes in the Collecting Lymphatic Vessels after Lymphadenectomy

Introduction To date, an electron microscopy study of the collecting lymphatic vessels has not been conducted to examine the early stages of lymphedema. However, such histological studies could be useful for elucidating the mechanism of lymphedema onset. The aim of this study was to clarify the changes occurring in collecting lymphatic vessels after lymphadenectomy. Methods The study was conducted on 114 specimens from 37 patients who developed lymphedema of the lower limbs after receiving surgical treatment for gynecologic cancers and who consulted the University of Tokyo Hospital and affiliated hospitals from April 2009 to March 2011. Lymphatic vessels that were not needed for lymphatico venous anastomosis surgery were trimmed and subsequently examined using electron microscopy and light microscopy. Results Based on macroscopic findings, the histochemical changes in the collecting lymphatic vessels were defined as follows: normal, ectasis, contraction, and sclerosis type (NECST). In the ectasis type, an increase in endolymphatic pressure was accompanied by a flattening of the lymphatic vessel endothelial cells. In the contraction type, smooth muscle cells were transformed into synthetic cells and promoted the growth of collagen fibers. In the sclerosis type, fibrous elements accounted for the majority of the components, the lymphatic vessels lost their transport and concentrating abilities, and the lumen was either narrowed or completely obstructed. Conclusions The increase in pressure inside the collecting lymphatic vessels after lymphadenectomy was accompanied by histological changes that began before the onset of lymphedema.

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.

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.

Comparison of indocyanine green lymphographic findings with the conditions of collecting lymphatic vessels of limbs in patients with lymphedema.

Background: The authors investigated the relationship between findings from indocyanine green lymphography and the condition of lymphatics according to the Normal, Ectasis, Contraction, Sclerosis Type classifications observed in each area during surgery. Methods: The authors examined 43 limbs of 25 patients who had undergone lymphaticovenous anastomosis from April to July of 2012 at the Department of Plastic and Reconstructive Surgery, University of Tokyo Hospital. After the injection of indocyanine green, linear, splash, stardust, and diffuse patterns were determined. Visual findings of the collecting lymph vessels during the anastomosis at each incision site were evaluated using the Normal, Ectasis, Contraction, Sclerosis Type classifications. Results: Lymphaticovenous anastomosis was conducted on 164 collecting lymph vessels within 43 limbs of 25 people. Normal-type lymph vessels were observed in 36, ectasis type in 43, contraction type in 52, and sclerosis type in 33. Many normal vessels were found in the linear region, but the proportion of this type declined in the more severe stardust and diffuse regions. In contrast, no sclerosis-type vessels were found in the linear region, while the proportion of this type increased with lymphedema severity. Conclusions: Indocyanine green lymphography findings and the Normal, Ectasis, Contraction, Sclerosis Type classification of collecting lymph vessels seem to have a relationship. An increase in the severity of lymphedema according to the indocyanine green lymphography findings indicated an increase in the stage of lymphedema according to the Normal, Ectasis, Contraction, Sclerosis Type classification. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, IV.

Digital artery perforator (DAP) flaps: Modifications for fingertip and finger stump reconstruction

UNLABELLED Various fingertip reconstructions have been reported for situations where microsurgical finger replantation is impossible. One method is the digital artery perforator (DAP) flap. Herein we report 13 DAP flaps for fingertip and finger stump reconstruction following traumatic finger amputations, highlighting modifications to the originally described DAP flap. METHODS From October 1998 to December 2007, a total of 13 fingers (11 patients) underwent fingertip and finger stump reconstruction with modified DAP flaps following traumatic finger amputations. We performed six adipocutaneous flaps, three adipose-only flaps, two supercharged flaps and two extended flaps. Flap size ranged from 1.44 to 8 cm(2) (average 3.25 cm(2)). RESULTS All flaps survived completely with the exception of partial skin necrosis in two cases. One of these cases required debridement and skin grafting. Our initial three cases used donor-site skin grafting. The donor site was closed primarily in the 10 subsequent cases. No patients showed postoperative hypersensitivity of repaired fingertips. Semmes-Weinstein (SW) test result for flaps including a digital nerve branch did not differ from those without (average 4.07 vs. 3.92). CONCLUSIONS Modified DAP flaps allow for preservation of digital length, volume and finger function. They can be raised as adiposal-only flaps or extended flaps and supercharged through perforator-to-perforator anastomoses. The donor defect on the lateral pulp can be closed primarily or by skin grafting. For traumatic fingertip and finger stump reconstructions, DAP flaps deliver consistent aesthetic and functional results.

Upper-limb lymphedema treated aesthetically with lymphaticovenous anastomosis using indocyanine green lymphography and noncontact vein visualization.

We have described a procedure to minimize surgical wounds, in which lymph vessels and skin venules are identified by indocyanine green (ICG) lymphography and the AV300 noncontact visualization system (AccuVein, Cold Spring Harbor, NY), respectively. This approach allows accurate decisions regarding sites of incision for lymphatic venous anastomosis (LVA). This method was applied in a patient with right upper-limb lymphedema after breast cancer therapy. The low-invasive procedure can be used before and during surgery. The incision size is minimal, and the incision site is at the joint area. Thus, we aim to establish this approach as a standard method for identifying lymph vessels and veins that are suitable for LVA. This innovative vascular-imaging machine makes LVA less invasive and more effective without side effects.