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Spoer DL, Berger LE, Towfighi PN, Deldar R, Gupta N, Huffman SS, Sharif-Askary B, Fan KL, Parikh RP, Tom LK. Lymphovenous Coupler-Assisted Bypass for Immediate Lymphatic Reconstruction. J Reconstr Microsurg 2024; 40:334-347. [PMID: 37751886 DOI: 10.1055/a-2181-7559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Abstract
BACKGROUND Breast cancer-related lymphedema is the most common cause of lymphedema in the United States and occurs in up to 50% of individuals receiving axillary lymph node dissection (ALND). Lymphovenous bypass (LVB) at the time of ALND may prevent lymphedema, but long-term results and anastomotic patency are unclear. This study evaluates the feasibility and outcomes of performing immediate lymphatic reconstruction via coupler-assisted bypass (CAB). METHODS This is a retrospective review of all patients undergoing prophylactic LVB following ALND at two tertiary care centers between 2018 and 2022. Patients were divided into cohorts based on whether they received the "standard" end-to-end (E-E) suturing or CAB technique. The primary outcome of interest was development of lymphedema. Quantitative and qualitative assessments for lymphedema were performed preoperatively and at 3, 6, 12, and 24 months postoperatively. RESULTS Overall, 63 LVBs were performed, of which 24 lymphatics underwent immediate reconstruction via "CAB" and 39 lymphatics via "standard" end-to-end suture. Patient characteristics, including body mass index, and treatment characteristics, including radiation therapy, did not significantly differ between groups. CAB was associated with a greater mean number of lymphatics bypassed per vein (standard 1.7 vs. CAB 2.6, p = 0.0001) and bypass to larger veins (standard 1.2 vs. CAB 2.2 mm, p < 0.0001). At a median follow-up of 14.7 months, 9.1% (1/11) of individuals receiving CAB developed lymphedema. These rates were similar to those seen following standard bypass at 4.8% (1/21), although within a significantly shorter follow-up duration (standard 7.8 vs. CAB 14.7 months, p = 0.0170). CONCLUSION The CAB technique is a viable, effective technical alternative to the standard LVB technique. This comparative study of techniques in prophylactic LVB suggests that CABs maintain long-term patency, possibly due to the ease of anastomosing several lymphatics to single large caliber veins while reducing the technical demands of the procedure.
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Affiliation(s)
- Daisy L Spoer
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
- Department of Plastic and Reconstructive Surgery, Georgetown University School of Medicine, Washington, District of Columbia
- Department of Plastic and Reconstructive Surgery, MedStar Washington Hospital Center, Washington, District of Columbia
| | - Lauren E Berger
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
- Plastic & Reconstructive Surgery Division, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Parhom N Towfighi
- Department of Surgery, University of Pittsburgh Medical Center (UPMC) Mercy Hospital, Pittsburgh, Pennsylvania
| | - Romina Deldar
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
| | - Nisha Gupta
- Department of Plastic and Reconstructive Surgery, Georgetown University School of Medicine, Washington, District of Columbia
| | - Samuel S Huffman
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
- Department of Plastic and Reconstructive Surgery, Georgetown University School of Medicine, Washington, District of Columbia
| | - Banafsheh Sharif-Askary
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
| | - Kenneth L Fan
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
| | - Rajiv P Parikh
- Plastic & Reconstructive Surgery Division, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Laura K Tom
- Plastic & Reconstructive Surgery Division, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
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Li Y, Tang J, Mao D, Dragomir MP, Li Y, Sun K, Lv Z, Liu X, Meng X, Lu K. MRI-CEUS Fusion-Guided Lymphatic Mapping as a Preoperative Strategy for Lymphedema Patients Undergoing Lymphaticovenous Anastomosis Surgery. J Vasc Surg Venous Lymphat Disord 2024:101907. [PMID: 38759752 DOI: 10.1016/j.jvsv.2024.101907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 04/06/2024] [Accepted: 05/03/2024] [Indexed: 05/19/2024]
Abstract
OBJECTIVES Contrast-enhanced ultrasound (CEUS) is useful in mapping lymphatic vessels in upper limb lymphedema, this study was aimed to evaluate its efficiency in lower limb lymphedema and investigate whether magnetic resonance lymphangiography (MRL) enhance the efficiency of CEUS. METHODS This retrospective study enrolled 48 patients with lymphedema undergoing lymphaticovenous anastomosis (LVA) surgery who received MRL and/or CEUS in addition to conventional indocyanine green (ICG) lymphangiography. The number of anastomotic sites and the duration per site (DPS) for LVA surgery were described and compared. RESULTS Among the 48 patients subjected to analysis, it was observed that 12 (25%), 20 (41.67%), and 16 (33.33%) of them received ICG, ICG+CEUS, and ICG+CEUS+MRL, respectively. The ICG+CEUS group demonstrated a significant increase in the number of LVAs (median, 5 [range, 4 - 7]), compared to the ICG group (median, 2 [range, 1 - 4]) (p < .001). Moreover, the ICG+CEUS+MRL group exhibited a higher number of LVAs (median, 8 [range, 7 - 8.25]) compared to both the ICG+CEUS and ICG groups (p < .001). For lower limb lymphedema, the ICG+CEUS+MRL group displayed an elevated number of LVAs (median, 8 [interquartile range, 7 - 9]) (p = .003), in contrast to the ICG group (median, 3 [interquartile range, 1.75 - 4.25]). Furthermore, the DPS in the ICG+CEUS+MRL group (median, 50.56 [interquartile range, 48.13 - 59.29]) (p = .005) exhibited a remarkable decrease when compared to the ICG group (median, 131.25 [interquartile range, 86.75 - 198.13]). CONCLUSION MRL-CEUS fusion demonstrates superior performance in the identification of lymphatic vessel for lymphedema.
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Affiliation(s)
- Yongfeng Li
- General Surgery, Cancer Center, Department of Breast Surgery, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, 314408 Zhejiang, China
| | - Jinglan Tang
- Cancer Center, Department of Ultrasound Medicine, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, 314408 Zhejiang, China
| | - Dewang Mao
- Cancer Center, Department of Radiology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, 314408 Zhejiang, China
| | - Mihnea P Dragomir
- Institute of Pathology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu, Berlin, Berlin, Germany; German Cancer Consortium (DKTK), Partner Site Berlin, and German Cancer Research Center (DKFZ), Heidelberg, Germany; Berlin Institute of Health, Berlin, Germany
| | - Ying Li
- General Surgery, Cancer Center, Department of Breast Surgery, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, 314408 Zhejiang, China
| | - Kewang Sun
- General Surgery, Cancer Center, Department of Breast Surgery, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, 314408 Zhejiang, China
| | - Zhenye Lv
- General Surgery, Cancer Center, Department of Breast Surgery, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, 314408 Zhejiang, China
| | - Xiaozhen Liu
- General Surgery, Cancer Center, Department of Breast Surgery, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, 314408 Zhejiang, China
| | - Xuli Meng
- General Surgery, Cancer Center, Department of Breast Surgery, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, 314408 Zhejiang, China
| | - Kefeng Lu
- Cancer Center, Department of Ultrasound Medicine, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, 314408 Zhejiang, China.
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Lin CH, Yamamoto T. Supermicrosurgical lymphovenous anastomosis. J Chin Med Assoc 2024; 87:455-462. [PMID: 38517403 DOI: 10.1097/jcma.0000000000001088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2024] Open
Abstract
Lymphedema impairs patients' function and quality of life. Currently, supermicrosurgical lymphovenous anastomosis (LVA) is regarded as a significant and effective treatment for lymphedema. This article aims to review recent literature on this procedure, serving as a reference for future research and surgical advancements. Evolving since the last century, LVA has emerged as a pivotal domain within modern microsurgery. It plays a crucial role in treating lymphatic disorders. Recent literature discusses clinical imaging, surgical techniques, postoperative care, and efficacy. Combining advanced tools, precise imaging, and surgical skills, LVA provides a safer and more effective treatment option for lymphedema patients, significantly enhancing their quality of life. This procedure also presents new challenges and opportunities in the realm of microsurgery.
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Affiliation(s)
- Chih-Hsun Lin
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Surgery, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Takumi Yamamoto
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
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Lee JS, Kang HS, Chung JH, Ryu JY. Risk of congestive heart failure and mortality following lymphovenous anastomosis: a nationwide population-based retrospective cohort study. Int J Surg 2024; 110:1028-1038. [PMID: 38016291 PMCID: PMC10871649 DOI: 10.1097/js9.0000000000000946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 11/13/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND Lymphovenous anastomosis (LVA) enables lymphatic fluid to drain into the venous system. However, no study has investigated the association between LVA and heart failure (HF) caused by fluid overload in the blood circulating system. The purpose of our study was to determine whether LVA increases the risk of HF and mortality. MATERIAL AND METHODS This nationwide retrospective study evaluated a total of 1400 lymphedema patients who underwent LVA and two control cohorts with 28 000 lymphedema who did not undergo LVA and 70 000 age-matched and sex-matched participants from the Korean National Health Insurance database were included. Blood pressure, body mass index (BMI), glucose and cholesterol levels, smoking history, and comorbidities were obtained during National Health Insurance Service - Health Screening (NHIS-HealS). The incidence, adjusted risk for HF, and mortality were evaluated. RESULTS Adjusted HRs for HF were 1.20 (confidence interval [CI], 1.03-1.40) and 1.30 (CI, 1.12-1.50), referenced by the general population control cohort and patients with lymphedema without LVA, respectively. In age, sex, BMI, and smoking status-stratified analyses, heightened risk of HF was evident across all sexes, spanning both young and old age groups, encompassing individuals with various smoking statuses, and those with a BMI of 18.5 or higher. Among these groups, the risk was notably greater in males compared to females, higher in younger individuals as opposed to older ones, and further elevated within the BMI range of 18.5-25. CONCLUSIONS LVA is associated with an increased HF risk, independent of cardiovascular risk factors and associated comorbidities. This association is prominent in participants aged <50 years, in males, and in the normal-to-obese (BMI ≥18.5 kg/m 2 ) group. Among patients with lymphedema, LVA did not significantly affect mortality.
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Affiliation(s)
- Joon Seok Lee
- Department of Plastic and Reconstructive Surgery, School of Medicine, Kyungpook National University, Daegu
| | - Hyun Su Kang
- Department of Plastic and Reconstructive Surgery, School of Medicine, Kyungpook National University, Daegu
| | - Jae-Ho Chung
- Department of Plastic and Reconstructive Surgery, Korea University Hospital, Seoul, Republic of Korea
| | - Jeong Yeop Ryu
- Department of Plastic and Reconstructive Surgery, School of Medicine, Kyungpook National University, Daegu
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Hamada E, Onoda S, Satake T. Efficacy of Lymphaticovenular Anastomosis for Secondary Upper Extremity Lymphedema: Treatment Strategies with Effects of Compression Therapy Discontinuation and Site-Specific Evaluation of the Upper Extremity. Lymphat Res Biol 2023; 21:574-580. [PMID: 37252768 DOI: 10.1089/lrb.2022.0096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023] Open
Abstract
Background: Lymphaticovenular anastomosis (LVA) has recently become a mainstream surgical treatment for lymphedema and is a useful treatment option in addition to conservative therapies such as compression therapy, exercise therapy, and lymphatic drainage. We performed LVA with the goal of stopping compression therapy and report the effect of LVA on secondary lymphedema of the upper extremities. Methods and Results: The participants were 20 patients with secondary lymphedema of the upper extremities categorized as stage 2 or 3 according to the International Society of Lymphology classification. We measured and compared the upper limb circumference at six locations before and 6 months after LVA. Significant decreases in circumference after surgery were observed at 8 cm proximal to the elbow, the elbow joint, 5 cm distal to the elbow, and the wrist joints, but not at 2 cm distal to the axilla or the dorsum of the hand. At more than 6 months postoperatively, eight patients who had been wearing compression gloves were no longer required to wear them, and three patients who had been wearing both sleeves and gloves were no longer required to wear them. Conclusions: LVA is effective in the treatment of secondary lymphedema of the upper extremities, particularly in improving elbow circumference, and is one of the treatments that contributes significantly to the improvement of quality of life. For severe cases with limited range of motion of the elbow joint, LVA should be performed first. Based on these results, we present an algorithm for upper extremity lymphedema treatment.
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Affiliation(s)
- Erika Hamada
- Department of Plastic Surgery, Toyama Nishi General Hospital, Toyama, Japan
- Department of Plastic and Reconstructive Surgery, Toyama University Hospital, Toyama, Japan
| | - Satoshi Onoda
- Department of Plastic and Reconstructive Surgery, Toyama University Hospital, Toyama, Japan
| | - Toshihiko Satake
- Department of Plastic and Reconstructive Surgery, Toyama University Hospital, Toyama, Japan
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Onoda S, Satake T, Hamada E. Super-microsurgery technique for lymphaticovenular anastomosis. J Vasc Surg Venous Lymphat Disord 2023; 11:177-181. [PMID: 36182085 DOI: 10.1016/j.jvsv.2022.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 08/13/2022] [Accepted: 08/21/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND In super-microsurgery, such as lymphaticovenular anastomosis (LVA), the diameter of the target vessel can be small and difficult to manage, and the basic surgical technique of microsurgery, such as inserting a forceps into the lumen and applying countertraction, can be difficult. In addition, it can be difficult to confirm the success or failure of the postoperative anastomosis, unlike with normal free-flap transfer, or to learn the technique by reviewing the results. METHODS We have described a safe, quick, and accurate technique for LVA based on our experience performing several hundred such cases at our institution. RESULTS Before LVA, the location of the significant lymphatic vessels and veins proximal to the lymphatic vessels should be marked using indocyanine green fluorescence angiography and a vein viewer to help determine the skin incision site. We used super-microsurgical titanium needles and surgical scissors and an end-to-end anastomosis. The lymphatic vessels should be dissected as far as possible from the skin incision to the center, and the veins should be dissected as far as possible from the periphery. First, a stay suture should be applied to the upper and lower ends of the anastomosis at 180°. Next, the anterior wall should be sutured. In some cases, countertraction can be applied by inserting the tip of a forceps into the vascular vessel. However, because its insertion could damage the lymphatic vessel wall, it would be more appropriate to perform the anastomosis using the involved stitch technique. After anastomosis of the anterior wall, the vessel should be inverted and the posterior wall anastomosed using the same technique. CONCLUSIONS We have reported the key points necessary to perform LVA quickly and accurately and the precautions necessary to maintain long-term patency. This sophisticated LVA technique can be applied to improve the outcomes for patients with lymphedema.
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Affiliation(s)
- Satoshi Onoda
- Department of Plastic, Reconstructive and Aesthetic Surgery, Toyama University Hospital, Toyama, Japan.
| | - Toshihiko Satake
- Department of Plastic, Reconstructive and Aesthetic Surgery, Toyama University Hospital, Toyama, Japan
| | - Erika Hamada
- Department of Plastic Surgery, Toyama Nishi General Hospital, Toyama, Japan
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Treatment of Early-Stage Gynecological Cancer-Related Lower Limb Lymphedema by Lymphaticovenular Anastomosis-The Triple Incision Approach. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58050631. [PMID: 35630048 PMCID: PMC9143574 DOI: 10.3390/medicina58050631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 04/23/2022] [Accepted: 04/26/2022] [Indexed: 11/17/2022]
Abstract
Background and Objectives: Lower extremity lymphedema (LEL) is one of the most relevant chronic and disabling sequelae after gynecological cancer therapy involving pelvic lymphadenectomy (PL). Supermicrosurgical lymphaticovenular anastomosis (LVA) is a safe and effective procedure to treat LEL, particularly indicated in early-stage cases when conservative therapies are insufficient to control the swelling. Usually, preoperative assessment of these patients shows patent and peristaltic lymphatic vessels that can be mapped throughout the limb to plan the sites of skin incision to perform LVA. The aim of this study is to report the efficacy of our approach based on planning LVA in three areas of the lower limb in improving early-stage gynecological cancer-related lymphedema (GCRL) secondary to PL. Materials and Methods: We retrospectively reviewed the data of patients who underwent LVA for the treatment of early-stage GCRL following PL. Patients who had undergone groin dissection were excluded. Our preoperative study based on indocyanine green lymphography (ICG-L) and color doppler ultrasound (CDU) planned three incision sites located in the groin, in the medial surface of the distal third of the thigh, and in the upper half of the leg, to perform LVA. The primary outcome measure was the variation of the mean circumference of the limb after surgery. The changes between preoperative and postoperative limbs’ measures were analyzed by Student’s t-test. p values < 0.05 were considered significant. Results: Thirty-three patients were included. In every patient, three incision sites were employed to perform LVA. A total of 119 LVA were established, with an average of 3.6 for each patient. The mean circumference of the operated limb showed a significant reduction after surgery, decreasing from 37 cm ± 4.1 cm to 36.1 cm ± 4.4 (p < 0.01). Conclusions: Our results suggest that in patients affected by early-stage GCRL secondary to PL, the placement of incision sites in all the anatomical subunits of the lower limb is one of the key factors in achieving good results after LVA.
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Blei F. Update December 2021. Lymphat Res Biol 2021; 19:585-624. [PMID: 34958250 DOI: 10.1089/lrb.2021.29113.fb] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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