Yusuke Yamamoto

The Intravascular Stenting Method for Treatment of Extremity Lymphedema with Multiconfiguration Lymphaticovenous Anastomoses

Background: In secondary extremity lymphedema, normal antegrade lymphatic flow is disrupted by the disease state. Attempts to capture aberrant retrograde lymphatic flow by means of microsurgical lymphaticovenous anastomoses have been hindered because of technical limitations. The authors applied the intravascular stenting method to the surgical correction of extremity lymphedema to generate multiconfiguration lymphaticovenous anastomoses capable of decompressing both proximal and distal lymphatic flow. Methods: Lymphatic channels were detected using indocyanine green injection and infrared scope imaging. Sites felt to be adequate for lymphaticovenous anastomosis were accessed through 2-cm skin incisions under local anesthesia. Using the intravascular stenting method, the authors performed a total of 39 lymphaticovenous anastomoses (15 flow-through, 11 end-to-end, eight end-to-side, two double end-to-end, two end-to-end/end-to-side, and one &pgr;-type) on both the proximal and distal ends of lymphatic channels in 14 female patients with upper (n = 2) and lower (n = 12) extremity lymphedema. Results: At an average follow-up of 8.9 months, average limb girth decreased 3.6 cm (range, 1.5 to 7 cm) or 11.3 percent (range, 4 to 33 percent). There was a greater reduction in cross-sectional area with increasing number of lymphaticovenous anastomoses per limb. Conclusions: The intravascular stenting method facilitated multiconfiguration lymphaticovenous anastomoses capable of decompressing both antegrade and retrograde lymphatic flow. This approach resulted in durable reduction of both upper and lower extremity lymphedema. As multiconfiguration lymphaticovenous anastomoses are now technically feasible, the influence of the number of lymphaticovenous anastomoses and the effectiveness of specific lymphaticovenous anastomosis configurations for the treatment of lymphedema deserves further study.

Recent Advancement on Surgical Treatments for Lymphedema

UNLABELLEDnTreatment for limb lymphedema is challenging. The recent development of the super-microsurgical technique has made lymphaticovenular (LV) anastomosis an easier and more accurate surgical method for lymphedema. A summary of our experience as well as recent developments in surgical treatments for lymphedema are described.nnnMETHODS AND RESULTSnUltra-microstructural analysis demonstrated that dysfunction of the lymphatics in lymphedema was caused by the degeneration and incomplete regeneration of smooth muscle cells and valve insufficiency in the lymphatic channel. ICG and infrared ray examinations have been proposed as new means of assessment of lymphatic function. LV anastomosis is suitable for genital edema, arm edema with severe phlegmone with leg edema, and early stage leg edema. Although pre- and postoperative compression therapy is generally required for limb edema, some cases do not require postoperative compression due to remaining or regenerated smooth muscle cells. As new methods of treatment, the vascularized lymphadiposal flap has been effective for progressive cases with LV anastomosis. LV anastomosis is also effective for congenital chyloabdomen. (*English Translation of J Jpn Coll Angiol 2008; 48: 173-178.).

Monitoring the changes in intraparenchymatous venous pressure to ascertain flap viability.

Background: Disruption of venous outflow can lead to tissue necrosis. Thrombosis of a venous channel at the coaptation site in instances of free tissue transfer could cause death of the transplanted tissues. Although various techniques have been used to monitor the viability of transferred tissues, there has been no technique designed specifically to check the flow within and the patency of the venous channel. The authors have devised an approach with which to monitor the changes in venous pressure in a composite tissue transferred by means of microsurgical technique for bodily reconstruction. Methods: The status of the venous system in various composite tissue grafts was monitored at the time of surgery or for 3 days after the completion of surgery by placing a small-caliber catheter in the vein within the transferred tissue. A total of 52 patients participated in the study. Results: The venous pressure noted in grafts with a patent venous channel remained constant within a range between 0 and 35 mmHg. Venous insufficiency was detected in three of the 52 cases, with unmistakable findings of an elevated venous pressure of over 50 mmHg. Conclusions: The technique of measuring the venous pressure by means of an indwelling venous catheter to monitor changes was found to accurately assess the patency of the venous channel and, by inference, the viability of the transferred tissue. No morbidity was associated with the technique.

Successful treatment of a case of electrical burn with visceral injury and full-thickness loss of the abdominal wall

A 13-year-old male received high-voltage electrical burns with a resultant large direct wound on the upper abdomen involving the full-thickness of the abdominal wall, including the peritoneum. Early debridement, exploratory laparotomy and temporary restoration of the excised abdominal wall with a fascial prosthesis were carried out at 6 h post-burn. The bilateral upper and right lower limbs were amputated on the 10th post-burn day. The patient developed a 4x4 cm duodenocutaneous fistula on the 28th post-burn day, but was free of peritonitis. After 5 months of the conservative treatment, the fistula closed, and the abdominal wall defect was reconstructed with a free latissimus dorsi musculocutaneous flap. One month later, the patient was discharged following an uneventful recovery.

Intravascular stenting (IVaS) method for fingertip replantation.

Remarkable progress has been made in microsurgery. However, fingertip replantation following amputation has not gained much popularity because of its technical difficulty. We have developed the intravascular stenting (IVaS) method, in which a nylon monofilament is placed inside the vessel lumen to act as a temporary stent, facilitating anastomosis completion. This report describes 7 fingertip replantations using the IVaS method. Intravascular stent size varied from 4-0 to 6-0 (0.199–0.07 mm diameter). There were no cases in which the back wall of a vessel became inadvertently caught in the anastomosis. The overall survival rate for distal digital replants was 85% (6/7 replants). It is very difficult to evenly anastomose vessels of differing diameter, especially on a supermicrosurgical scale. In this respect, the IVaS method plays a role in stably anchoring the 2 vessel ends, allowing for the even spacing of suture knots, even in vessels of different caliber. Because of its ease of use and exactitude, many surgeons may be able to use the IVaS method to reliably complete small anastomoses in fingertip replantations.

The versatile perifascial areolar tissue graft: Adaptability to a variety of defects

Abstract Reconstruction using flaps with good blood circulation is appropriate for covering an intractable ulcer or a fistula in which tendon or bones are exposed. A non-vascularised perifascial areolar tissue (PAT) graft can also survive in such an area. This study reports the versatile application of a PAT graft for use as a non-vascularised graft material. A total of 32 patients were treated between April 2004 and December 2010 (16 men and 16 women). The donor sites were the inguinal region in 20, the thigh in 11, and the subclavian region in one. There were 13 inlay grafts to the dead space after tumour resection, eight closures for cerebrospinal fluid leakage, seven skin ulcers with exposed bones and tendons, three fistulas, and one vascular leak of the common carotid artery. The total survival rate of the grafts was 91%. The complications associated with this procedure included infection in 9% and seroma in the donor site in 19%. However, all cases improved after conservative treatment. The PAT is a pliable loose areolar tissue with a rich vascular plexus, and the harvesting technique is quite simple and minimally invasive. The PAT graft could therefore represent an alternative for flaps that are used as a free graft material for the reconstruction of such defects as intractable skin ulcers, fistulas or dead spaces that usually require reconstruction with vascularised flaps.

Effect of vascular augmentation on the haemodynamics and survival area in a rat abdominal perforator flap model

SUMMARYnA major drawback of the DIEP flap is the compromised venous drainage in the distal area, which is the rationale behind the creation of additional venous anastomoses for better flap survival. Although venous congestion is defined as an increase in the venous pressure, the effect of vascular augmentation on the venous pressure has not been elucidated. We investigated the effects of arterial supercharge and venous superdrainage on the venous pressure and the flap survival area in a rat abdominal perforator flap model. An abdominal perforator flap was raised in each of 30 Wistar rats, with the contralateral superficial inferior epigastric artery (SIEA) and vein (SIEV) isolated for pressure measurements. The changes in the SIEV pressure were recorded while proximal sites of these vessels were opened and closed. Thereafter, the animals were divided into three groups: a control group (n=10, both the SIEA and SIEV were ligated), an enhanced arterial inflow (EAI) group (n=10, the SIEA was left intact) and a supplemental venous outflow (SVO) group (n=10, the SIEV was left intact). The flap survival area was determined 7 days after surgery. The SIEV pressure without vascular augmentation was only 13.2+/-5.9 mm Hg. Compared with the control group, the flap survival area was significantly larger in the EAI group, but not in the SVO group. An extremely high venous pressure was noted when the SIEA was opened and the SIEV was occluded, but there was great variation among the individual animals (range: 21.2-79.6 mm Hg). The necrotic area in the EAI group correlated well with the SIEV pressure (r=0.861). These findings indicate that the major factor contributing to distal necrosis in this rat perforator flap model is arterial insufficiency rather than venous congestion. The results suggest that, as long as the arterial inflow is secure, the venous pressure is a reliable parameter for deciding the necessity of venous superdrainage.

Endoscope-assisted perforator flap harvest.

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Hair Transplantation for Reconstruction of Scalp Defects Using Artificial Dermis

The most commonly performed procedures for reconstruction of scalp defects use skin grafts, which lack hair growth, or flap transfers, which are invasive and result in a significant scar. Both procedures often prohibit hair regrowth in the area of skin grafting or surgical scarring, and expander implantation with rotational hair-bearing flaps is frequently needed for final coverage of the glabrous skin area with hair. Our report describes a new procedure for reconstruction of scalp defects that uses artificial dermal coverage followed by hair transplantation.

Lateral intercostal artery perforator-based reversed thoracodorsal artery flap for reconstruction of a chronic radiation ulcer of the lower back wall.

Flaps with adequate blood supply are the best methods for covering the radiation ulcer defect. Our report is on the use of the lateral intercostal artery perforator-based reversed thoracodorsal artery (TA) flap for treatment of a patient with a large radiation ulcer on his lower back. When the flap was elevated, we could use an infrared imaging device to confirm the location of the perforators and demonstrate the communication with the TA. The communication between the main TA and the lateral intercostal artery perforator has previously not been reported in the literature in detail. We used an indocyanine green dye and infrared imaging device to seek out the perforators and their communication. Even in a small communication, we were able to use the device to check the perforators and to elevate this flap with more assurance, without having to be concerned about further radiation exposure for the patient.