Yoshihisa Yamaji

Early Detection of Lymphatic Disorder and Treatment for Lymphedema following Breast Cancer

Background: Upper extremity edema following surgical treatment for breast cancer does not always result in chronic breast cancer–related lymphedema. Changes in the findings of indocyanine green lymphography and upper extremity volume following breast cancer surgery were observed prospectively to understand the early changes in lymphatic function and to establish a new strategy for early diagnosis and treatment of breast cancer–related lymphedema. Methods: Lymphatic function for 196 consecutive breasts was examined using indocyanine green lymphography and bilateral upper extremity volume before surgery and 1, 3, 6, 9, and 12 months after surgery. When a “stardust,” “diffuse,” or “no flow” pattern was observed, patients were diagnosed with lymphatic disorder and subsequently underwent conservative treatments such as compression sleeve therapy. Result: In 35 patients, lymphatic disorder was observed after a mean of 5.2 ± 3.0 months after surgery. In 21 of these patients, no significant limb volume change was observed. In 14 patients, lymphatic disorder and volume change appeared simultaneously. In 11 of 35 patients, lymphatic function improved later, and compression therapy was discontinued. Lymph node dissection, radiation therapy to axillary lymph node, and the use of docetaxel chemotherapy were significant risk factors for lymphatic disorder. No patients experienced cellulitis during the study period. Conclusions: Lymphatic function disorder could be detected before volume changes. By early intervention with conservative treatments, lymphatic function improved in just under one-third of cases. Indocyanine green lymphography for high-risk patients may be useful for detecting lymphatic disorder early, thereby increasing the chance for disease cure. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Regional Oxygen Saturation Index: A Novel Criterion for Free Flap Assessment Using Tissue Oximetry.

Background: Tissue oximetry is a useful tool for postoperative free flap monitoring. Reported criterion values have been accurate; however, there are various complicated author-dependent criteria, and sometimes it is too late for flap salvage. The authors offer a new, simple criterion for faster and accurate detection of perfusion problems. Methods: Intraoperatively, perfusion areas of various free perforator flaps were assessed by both indocyanine green angiography and regional oxygen saturation. The elevated flap was categorized into the early-stained area, the delayed-stained area, and the no-stained area by indocyanine green angiography. The regional oxygen saturation index (regional oxygen saturation on the flap on the control nondissected portion) of each area was calculated. Postoperative continuous flap monitoring was conducted, recording the value of the regional oxygen saturation index at the early-stained area. The blood glucose measurement index was also recorded periodically. Results: In 60 cases of perforator-based free flaps, intraoperative indocyanine green areas were significantly correlated with the values of regional oxygen saturation index. The postoperative regional oxygen saturation index showed very stable values in various types of perforator flaps, provided that no vascular problem occurred, and it never went below 0.75. When vascular problems occurred, the regional oxygen saturation index dropped below 0.75 in all three cases before the blood glucose measurement index and the absolute value of regional oxygen saturation dropped below the criterion value. Conclusion: The regional oxygen saturation index may be a simple and fast criterion for detecting vascular problems following free flap reconstruction compared with existing criteria. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, II.

Development of a mouse model for the visual and quantitative assessment of lymphatic trafficking and function by in vivo imaging

Methods for quantitative analysis of long distance lymphatic transport of nanoparticles in live animals are yet to be established. We established a mouse model for analysis of time-dependent transport just beneath the abdominal skin to investigate lymph node-to-lymph node trafficking by in vivo imaging. For this purpose, popliteal lymph nodes (PLNs) as well as efferent and afferent lymphatic vessels, marginal veins, and feeding blood vessels were surgically resected to change the lymphatic flow from footpad injections. Using this model, we observed a novel lymphatic flow from the footpad to the proper axillary lymph node (ALN) via the inguinal lymph node (ILN). This drainage pathway was maintained over 12 weeks. Time-dependent transportation of 1,1′-dioctadecyltetramethyl indotricarbocyanine iodide-labelled liposomes from the footpad to the ILN was successfully quantified by an in vivo imaging system. Moreover, congestion and development of a new collateral lymphatic route was visualised under a lymphedema status. Histological analysis of abdominal skin tissues of this model revealed that PLN resection had no effect on the abdominal lymphatic system between the ILN and ALN. These data indicate that this model might be useful to clarify the mechanisms of lymphedema and study direct transportation of lymph or other substances between lymph nodes.

Improvement of the efficacy of vascularized lymph node transfer for lower-extremity lymphedema via a prefabricated lympho-venous shunt through lymphaticovenular anastomosis between the efferent lymphatic vessel and small vein in the elevated vascularized lymph node

Following vascularized lymph node (VLN) transfer (VLNT), the VLN may be at a risk for sclerosis because of efferent lymphatic vessel obstruction. We developed a new technique to prevent VLN sclerosis via a prefabricated lympho‐venous (LV) shunt. This study compared the treatment outcomes of single VLNT with prefabricated LV shunt, conventional multiple VLNTs, and conventional single VLNT.

Noninvasive screening test for detecting early stage lymphedema using follow-up computed tomography imaging after cancer treatment and results of treatment with lymphaticovenular anastomosis

Although early detection is valuable for secondary lymphedema treatment, existing screening tests are not popular. This study aimed to propose a novel method of screening lymphedema patients based on the thickness of the subcutaneous fat measured with perioperative computed tomography (CT) and present the results from evaluation of patients who underwent those examinations was performed.

Contribution of Simultaneous Breast Reconstruction by Deep Inferior Epigastric Artery Perforator Flap to the Efficacy of Vascularized Lymph Node Transfer in Patients with Breast Cancer-Related Lymphedema

Background The contribution of simultaneous breast reconstruction by deep inferior epigastric artery perforator (DIEP) flap to the efficacy of vascularized groin lymph node transfer (LNT) for breast cancer‐related lymphedema (BCRL) was investigated. Methods Patients were divided into two groups: the first group underwent groin LNT + DIEP flap surgery for simultaneous breast reconstruction (groin LNT + DIEP flap group) and the second group underwent groin LNT only (groin flap alone group). Patients with BCRL were evaluated based on indocyanine green lymphography findings. LNT was indicated only in advanced‐stage BCRL cases, and groin nodes nourished by superficial circumflex iliac artery (SCIA) were used as donors. The side for the vascular pedicle(s) was decided based on our algorithm. In patients with pendulous breast, the flap was vertically transferred on the chest. Lymphatic function was assessed after LNT using imaging tests, and transferred lymph nodes were evaluated using ultrasonography. Results In this study, 27 patients with advanced‐stage BCRL underwent LNT. Of them, 13 belonged to the groin LNT + DIEP flap group and 14 belonged to the groin flap alone group. Although reduction volume was not significantly different between the groups, the number of patients in whom lymphatic function was improved and the need for compression therapy could be reduced was significantly higher in the groin LNT + DIEP flap group than in the groin flap alone group. Conclusion When a patient with advanced‐stage BCRL undergoes LNT based on SCIA, simultaneous breast reconstruction using DIEP flap may reduce the need for compression therapy.

Intraoperative objective evaluation of venous congestion in deep epigastric artery perforator flap breast reconstruction: A pilot study

In a deep epigastric artery perforator (DIEP) flap breast reconstruction, the necessity of additional anastomosis of the superficial inferior epigastric vein (SIEV) should be determined intraoperatively. The purpose of this pilot study is to propose a method to detect venous congestion intraoperatively using the blood glucose measurement index (BGMI).

Abstract: Prefabricated Lympho-Venous Shunt Increases the Efficacy of Lymph Node Transfer for Lymphedema

CONCLUSION: Our findings show that there is considerable measurement error between perometry and perimetry when measuring the absolute or relative volumes of the arms and that their results should be compared with caution. Furthermore, we observed an increasingly relevant measurement error as outcomes are derived from arm volumes originally measured in error. Our findings suggest that the lymphedema surgery community should concentrate efforts to validate more precise and reliable outcomes to assess the effect of surgical treatment.

Reconstruction using ‘triangular approximation’ of bone grafts for orbital blowout fractures

There are many orbital wall reconstruction materials that can be used in surgery for orbital blowout fractures. We consider autogenous bone grafts to have the best overall characteristics among these materials and use thinned, inner cortical tables of the ilium. A bone bender is normally used to shape the inner iliac table to match the orbital shape. Since orbital walls curve three-dimensionally, processing of bone grafts is not easy and often requires much time and effort. We applied a triangular approximation method to the processing of bone grafts. Triangular approximation is a concept used in computer graphics for polygon processing. In this method, the shape of an object is represented as combinations of polygons, mainly triangles. In this study, the inner iliac table was used as a bone graft, and cuts or scores were made to create triangular sections. These triangular sections were designed three-dimensionally so that the shape of the resulting graft approximated to the three-dimensional orbital shape. This method was used in 12 patients with orbital blowout fractures, which included orbital floor fractures, medial wall fractures, and combined inferior and medial wall fractures. In all patients, bone grafts conformed to the orbital shape and good results were obtained. This simple method uses a reasonable and easy-to-understand approach and is useful in the treatment of bone defects in orbital blowout fractures when using a hard graft material.