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Park JW, Kang JM, Choi SY, Woo KJ. Comparison of the rate of concomitant proximal venous stenosis between the upper and lower extremities in patients with secondary lymphedema undergoing lymphaticovenous anastomosis. J Vasc Surg Venous Lymphat Disord 2024:101947. [PMID: 39013516 DOI: 10.1016/j.jvsv.2024.101947] [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: 04/01/2024] [Revised: 06/05/2024] [Accepted: 07/09/2024] [Indexed: 07/18/2024]
Abstract
BACKGROUND Concomitant iatrogenic proximal venous stenosis increases venous pressure and can be a risk factor for unfavorable outcomes of lymphaticovenular anastomosis (LVA) in extremities with secondary lymphedema. This study investigated the frequency and relevant factors of venous stenosis in patients diagnosed with secondary lymphedema who underwent LVA. METHODS Patients who underwent preoperative computed tomographic venography (CTV) and LVA for secondary lymphedema of the extremities from October 2018 to March 2022 were included. The incidence of proximal venous stenosis in the affected limb on preoperative CTV and the rate of endovascular intervention were compared between upper and lower extremities. Factors affecting proximal venous stenosis were identified through multivariable analysis using independent variables, including patient age, body mass index, comorbidities, smoking history, radiation therapy, duration of lymphedema, and location of lymphedema. RESULTS A total of 211 patients were analyzed, including 83 patients with upper extremity and 128 patients with lower extremity lymphedema. The incidence of proximal venous stenosis in the preoperative CTV was 32.5% and 7.8% in upper extremity, and lower extremity lymphedema, respectively (P < .001). The incidence of venous stenosis requiring endovascular intervention was significantly higher in the upper extremity compared with the lower extremity (16.9% vs 6.3%; P = .014). In multivariable analysis, risk factors affecting incidence of venous stenosis requiring endovascular intervention was the patient age (P = .007) and upper extremity (P = .009). CONCLUSIONS Preoperative evaluation and treatment of venous stenosis in extremities with secondary lymphedema are necessary before LVA surgery, particularly in upper extremity lymphedema.
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Affiliation(s)
- Jin-Woo Park
- Department of Plastic Surgery, Ewha Womans University College of Medicine, Mokdong Hospital, Seoul, Republic of Korea
| | - Jung-Min Kang
- Department of Plastic Surgery, Ewha Womans University College of Medicine, Mokdong Hospital, Seoul, Republic of Korea
| | - Sun Young Choi
- Department of Radiology, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
| | - Kyong-Je Woo
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
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Kitayama S. Diagnosis and Treatments of Limb Lymphedema: Review. Ann Vasc Dis 2024; 17:114-119. [PMID: 38919315 PMCID: PMC11196164 DOI: 10.3400/avd.ra.24-00011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Accepted: 02/07/2024] [Indexed: 06/27/2024] Open
Abstract
Lymphedema is caused by dysfunction of the lymphatic system. It is divided into primary edema with no apparent cause and secondary edema with an exogenous cause. The main symptoms are edema and heaviness, skin changes such as skin hardening, lymphocysts, lymphorrhoea, papillomas, and recurrent cellulitis. They are often irreversible and progressive, thus greatly reducing quality of life of the patients. Diagnosis is made by image examinations that can evaluate lymphatic flow and functions such as lymphoscintigraphy and indocyanine green fluorescence lymphangiography. Linear pattern and dermal backflow are the main findings. Conservative treatment consists of four components: compression therapy with elastic garments, exercise therapy, manual lymphatic drainage, and skin care, which is called complex physical therapy (CPT). Although CPT has become the gold standard of treatment, with evidence of efficacy reported in terms of volume reduction, maintenance, and prevention of cellulitis, it is a symptomatic treatment and does not improve impaired lymphatic flow. On the other hand, surgical treatment, such as lymphaticovenous anastomosis and vascularized lymph node transplantation, can create new lymphatic flow and improve lymphatic dysfunctions. Although these techniques are expected to be effective in volume reduction, cellulitis prevention, and improving quality of life, there is a need for more studies with a higher level of evidence in the future. In Japan, lymphedema is treated with a combination of conservative and surgical therapies, but lymphedema is intractable and few cases are completely cured. Therefore, how to improve the outcome of treatment is an important issue to be addressed in the future. (This is a translation of Jpn J Vasc Surg 2023; 32: 141-146.).
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Affiliation(s)
- Shinya Kitayama
- Department of Orthopedic Surgery, Yokohama City University Hospital, Yokohama, Kanagawa, Japan
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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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Shimbo K, Kawamoto H, Koshima I. Comparative study of conservative treatment and lymphaticovenular anastomosis with compression therapy for early-stage breast cancer-related lymphoedema. J Plast Reconstr Aesthet Surg 2024; 88:390-396. [PMID: 38086324 DOI: 10.1016/j.bjps.2023.11.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 11/11/2023] [Accepted: 11/22/2023] [Indexed: 01/02/2024]
Abstract
This single-centre retrospective cohort study aimed to clarify the superiority of treatment by comparing the outcomes of lymphaticovenular anastomosis with compression therapy and conservative treatment centred on compression therapy in the early stage of breast cancer-related lymphoedema. Data were collected from all patients treated for breast cancer-related lymphoedema between January 2015 and December 2022. The patients were classified into conservative treatment and surgical treatment groups. The upper extremity lymphoedema index value was calculated, based on five circumference values of the upper extremity and body mass index, to compare the 6-, 12-, 18- and 24-month outcomes between the groups. Of 101 patients with breast cancer-related lymphoedema, 81 (conservative treatment: 52; surgical treatment: 29) were included in the analysis. The therapeutic effect was significantly higher in the surgical treatment group than in the conservative treatment group, when comparing the rate of change in oedema at 6 (-6.6% ± 7.3% vs. 0.9% ± 7.5%; p < 0.001), 12 (-7.3% ± 6.2% vs. 2.9% ± 8.6%; p < 0.001), 18 (-7.6% ± 8.0% vs. 3.9% ± 9.2%; p < 0.001) and 24 (-5.6% ± 6.0% vs. 4.4% ± 10.7%; p < 0.001) months. The incidence of cellulitis increased in the conservative treatment group (from 9.6% to 15.4%), whereas it was suppressed in the surgical treatment group (from 13.8% to 0%). Conservative treatment centred on compression therapy increased oedema over time; however, lymphaticovenular anastomosis with compression therapy effectively reduced oedema.
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Affiliation(s)
- Keisuke Shimbo
- Department of Plastic and Reconstructive Surgery, Hiroshima Prefectural Hospital, Hiroshima, Japan.
| | - Haruka Kawamoto
- Department of Plastic and Reconstructive Surgery, Hiroshima Prefectural Hospital, Hiroshima, Japan.
| | - Isao Koshima
- Department of Plastic and Reconstructive Surgery, Hiroshima University Hospital, Hiroshima, Japan; International Center for Lymphedema, Hiroshima University Hospital, Hiroshima, Japan.
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Karlsson T, Hoffner M, Ohlin K, Svensson B, Brorson H. Complete Reduction of Leg Lymphedema after Liposuction: A 5-Year Prospective Study in 67 Patients without Recurrence. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5429. [PMID: 38074499 PMCID: PMC10703118 DOI: 10.1097/gox.0000000000005429] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 10/05/2023] [Indexed: 09/07/2024]
Abstract
BACKGROUND Lymphedema leads to adipose tissue deposition that cannot be removed using conservative methods. Previous studies have shown a complete reduction in excess volume in limbs with lymphedema when treated with liposuction and controlled compression therapy (CCT). We present the long-term outcomes of all patients treated with liposuction and CCT for lower extremity lymphedema (LEL) who were followed up for 5 years. METHODS Sixty-seven LEL patients underwent liposuction and CCT. Thirty-six patients had primary lymphedema and 31 patients had secondary lymphedema. The outcomes included excess leg volume over a follow-up period of 5 years. Any association between patient characteristics and treatment outcomes was analyzed. RESULTS The preoperative excess volume prior was 3515 mL [interquartile range (IQR): 2225-5455 mL], and the volume ratio to the unaffected leg was 1.35 (IQR: 1.25-1.53). One year after treatment, the excess volume decreased by 101% (IQR: 84-116). The decrease in excess volume continued during the 5-year follow-up, and at the end of the study, the excess volume had decreased by 115% (IQR: 98-124). No major complications were noted. CONCLUSIONS Liposuction and CCT are safe and effective procedures for removing excess adipose tissue and normalizing the leg volume in patients with late-stage LEL. When no satisfactory results are obtained with conservative methods, such as complex decongestive therapy, and there is no or minimal pitting on limb examination, excess adipose tissue is present, and liposuction can be considered.
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Affiliation(s)
- Tobias Karlsson
- From the Department of Clinical Sciences, Malmö, Lund University, Lund, Sweden
- Australian Lymphoedema Education Research Treatment (ALERT) Program, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
- Department of Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, Sweden
| | - Mattias Hoffner
- From the Department of Clinical Sciences, Malmö, Lund University, Lund, Sweden
- Department of Surgery, Blekinge Hospital, Karlskrona, Sweden
| | - Karin Ohlin
- Department of Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, Sweden
| | - Barbro Svensson
- Department of Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, Sweden
| | - Håkan Brorson
- From the Department of Clinical Sciences, Malmö, Lund University, Lund, Sweden
- Department of Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, Sweden
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Shimbo K, Kawamoto H, Koshima I. Conservative treatment versus lymphaticovenular anastomosis for early-stage lower extremity lymphedema. J Vasc Surg Venous Lymphat Disord 2023; 11:1231-1240. [PMID: 37454902 DOI: 10.1016/j.jvsv.2023.06.013] [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: 03/28/2023] [Revised: 06/01/2023] [Accepted: 06/04/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVE Several options for the treatment of lower extremity lymphedema (LEL) can be broadly classified into conservative treatment, such as compression garments and decongestive lymphatic therapy, and surgical treatment, such as lymphaticovenular anastomosis (LVA). The purpose of our study was to clarify the superiority of these treatments by comparing the outcomes of LVA with those of conservative treatment for early-stage LEL. METHODS We performed a single-center, retrospective cohort study. The patients with LEL who presented to our department between January 2015 and December 2022 were identified and classified into two groups: conservative treatment and surgical treatment. The LEL indexes, calculated from the four lower extremity circumferences and the body mass index, were compared at the 6-, 12-, and 24-month follow-up between the two groups. RESULTS Of the 101 patients with LEL, 53 with 72 affected limbs (conservative treatment, 39 patients and 53 affected limbs; surgical treatment, 15 patients and 19 affected limbs) were included in the present analysis. The therapeutic effect for reducing edema, as determined by comparing the corrected LEL index at 12 months (103.7 ± 12.7 vs 91.9 ± 10.7; P = .005) and 24 months (103.1 ± 12.9 vs 83.8 ± 7.2; P < .001), was significantly higher in the surgical treatment group than that in the conservative treatment group. The conservative treatment group showed little change in the corrected LEL index at ≤24 months of follow-up (+3.1%; P = .299). In contrast, the surgical treatment group showed a significant reduction in edema at 24 months according to the corrected LEL index (-16.2%; P = .019). CONCLUSIONS In early-stage LEL, conservative treatment centered on compression therapy alone only maintained edema (ie, edema did not worsen or improve). In contrast, LVA with compression therapy reduced edema.
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Affiliation(s)
- Keisuke Shimbo
- Department of Plastic and Reconstructive Surgery, Hiroshima Prefectural Hospital, Hiroshima, Japan.
| | - Haruka Kawamoto
- Department of Plastic and Reconstructive Surgery, Hiroshima Prefectural Hospital, Hiroshima, Japan
| | - Isao Koshima
- Department of Plastic and Reconstructive Surgery, Hiroshima University Hospital, Hiroshima, Japan; International Center for Lymphedema, Hiroshima University Hospital, Hiroshima, Japan
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Meuli JN, Guiotto M, Elmers J, Mazzolai L, di Summa PG. Outcomes after microsurgical treatment of lymphedema: a systematic review and meta-analysis. Int J Surg 2023; 109:1360-1372. [PMID: 37057889 PMCID: PMC10389392 DOI: 10.1097/js9.0000000000000210] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 01/03/2023] [Indexed: 04/15/2023]
Abstract
BACKGROUND Microsurgical treatment options for lymphedema consist mainly of lymphovenous anastomosis (LVA) and vascularized lymph node transfers (VLNTs). There are no standard measurements of the effectiveness of these interventions and reported outcomes vary among studies. METHODS A systematic review and meta-analysis were performed based on a structured search in Embase, Medline, PubMed, Cinahl, Cochrane, and ProQuest in October 2020, with an update in February 2022. Firstly, a qualitative summary of the main reported outcomes was performed, followed by a pooled meta-analysis of the three most frequently reported outcomes using a random effects model. Randomized controlled trials, prospective cohorts, retrospective cohorts, and cross-sectional and case-control studies that documented outcomes following microsurgery in adult patients were included. Studies of other surgical treatments (liposuction, radical excision, lymphatic vessel transplantation) or without reported outcomes were excluded. The study protocol was registered on PROSPERO (International Prospective Register of Systematic Reviews) (ID: CRD42020202417). No external funding was received for this review. RESULTS One hundred fifty studies, including 6496 patients, were included in the systematic review. The qualitative analysis highlighted the three most frequently reported outcomes: change in circumference, change in volume, and change in the number of infectious episodes per year. The overall pooled change in excess circumference across 29 studies, including 1002 patients, was -35.6% [95% CI: -30.8 to -40.3]. The overall pooled change in excess volume across 12 studies including 587 patients was -32.7% [95% CI: -19.8 to -45.6], and the overall pooled change in the number of cutaneous infections episodes per year across 8 studies including 248 patients was -1.9 [95% CI: -1.4 to -2.3]. The vast majority of the studies included were case series and cohorts, which were intrinsically exposed to a risk of selection bias. CONCLUSION The currently available evidence supports LVA and vascularized lymph node transfers as effective treatments to reduce the severity of secondary lymphedema. Standardization of staging method, outcomes measurements, and reporting is paramount in future research in order to allow comparability across studies and pooling of results.
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Affiliation(s)
| | | | | | - Lucia Mazzolai
- Angiology Division, Heart and Vessel Department, Lausanne University Hospital, University of Lausanne, Switzerland
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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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Kong X, Gao N, Du J, Zhao Q. Arrangement of Indocyanine Green in a 1.5-Nanometer Channel to Achieve High-Efficiency Imaging of the Intestinal Lymphatic System. Molecules 2022; 27:molecules27248704. [PMID: 36557838 PMCID: PMC9786184 DOI: 10.3390/molecules27248704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 12/03/2022] [Accepted: 12/06/2022] [Indexed: 12/13/2022] Open
Abstract
The complications of inflammatory bowel diseases (IBDs) seriously endanger people’s health, such as bleeding, polyp hyperplasia, and even cancer. Although the precise pathophysiology of IBD is unknown, alterations in the intestinal lymphatic network, such as lymphangiogenesis and lymphatic vessel dysfunction, are well-established features. Therefore, the development of a reliable technology is urgently required, with a stereoscopic, deep, and high-resolution technology for IBD lymphatic targeting imaging in clinical practice. However, indocyanine green, the only clinically approved imaging agent by the Food and Drug Administration, can easily cause self-aggregation or be interfered with by microenvironments, causing fluorescence quenching, which seriously affects the imaging and detective capabilities. Herein, indocyanine green molecules are arranged in a 1.5-nanometer one-dimensional channel (TpPa-1@ICG). Based on this specified structure, the fluorescence enhancement effect is observed in the TpPa-1@ICG resultant, and the fluorescence intensity is enhanced by 27%. In addition, the ICG-incorporated porous solid reveals outstanding solvent (dichloromethane, tetrahydrofuran, etc.) and thermal (>300 °C) stability. After modifying the target molecules, TpPa-1@ICG showed excellent imaging ability for intestinal lymphatic vessels, providing a new imaging tool for IBDs research.
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Affiliation(s)
- Xiangyi Kong
- Key Laboratory of Lymphatic Surgery Jilin Province, Jilin Engineering Laboratory for Lymphatic Surgery Jilin Province, China-Japan Union Hospital of Jilin University, Changchun 130031, China
| | - Nan Gao
- Key Laboratory of Polyoxometalate and Reticular Material Chemistry of Ministry of Education, Faculty of Chemistry, Northeast Normal University, Changchun 130024, China
- Correspondence: (N.G.); (J.D.)
| | - Jianshi Du
- Key Laboratory of Lymphatic Surgery Jilin Province, Jilin Engineering Laboratory for Lymphatic Surgery Jilin Province, China-Japan Union Hospital of Jilin University, Changchun 130031, China
- Correspondence: (N.G.); (J.D.)
| | - Qing Zhao
- Key Laboratory of Lymphatic Surgery Jilin Province, Jilin Engineering Laboratory for Lymphatic Surgery Jilin Province, China-Japan Union Hospital of Jilin University, Changchun 130031, China
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Verhey EM, Kandi LA, Lee YS, Morris BE, Casey WJ, Rebecca AM, Marks LA, Howard MA, Teven CM. Outcomes of Lymphovenous Anastomosis for Lower Extremity Lymphedema: A Systematic Review. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2022; 10:e4529. [PMID: 36225843 PMCID: PMC9542573 DOI: 10.1097/gox.0000000000004529] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 07/27/2022] [Indexed: 06/16/2023]
Abstract
UNLABELLED Lymphovenous anastomosis (LVA) is a microsurgical treatment for lymphedema of the lower extremity (LEL). This study systematically reviews the most recent data on outcomes of various LVA techniques for LEL in diverse patients. METHODS A comprehensive literature search was conducted in the Ovid MEDLINE, Ovid EMBASE, and Scopus databases to extract articles published through June 2021. Studies reporting data on objective postoperative improvement in lymphedema and/or subjective improvement in quality of life for patients with LEL were included. Extracted data comprised demographics, number of patients and lower limbs, duration of symptoms before LVA, surgical technique, duration of follow-up, and objective and subjective outcomes. RESULTS A total of 303 articles were identified and evaluated, of which 74 were ultimately deemed eligible for inclusion in this study, representing 6260 patients and 2554 lower limbs. The average patient age ranged from 22.6 to 76.14 years. The duration of lymphedema before LVA ranged from 12 months to 11.4 years. Objective rates of improvement in lymphedema ranged from 23.3% to 100%, with the greatest degree of improvement seen in patients with early-stage LEL. CONCLUSIONS LVA is a safe and effective technique for the treatment of LEL of all stages. Several emerging techniques and variations may lead to improved patient outcomes.
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Affiliation(s)
- Erik M. Verhey
- From the Mayo Clinic Alix School of Medicine, Mayo Clinic, Scottsdale, Ariz
| | - Lyndsay A. Kandi
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Mayo Clinic, Phoenix, Ariz
| | - Yeonsoo S. Lee
- From the Mayo Clinic Alix School of Medicine, Mayo Clinic, Scottsdale, Ariz
| | - Bryn E. Morris
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Mayo Clinic, Phoenix, Ariz
| | - William J. Casey
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Mayo Clinic, Phoenix, Ariz
| | - Alanna M. Rebecca
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Mayo Clinic, Phoenix, Ariz
| | - Lisa A. Marks
- Mayo Clinic Libraries, Mayo Clinic, Scottsdale, Ariz
| | - Michael A. Howard
- Division of Plastic Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Chad M. Teven
- Division of Plastic Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill
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11
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A meta-analysis of 37 studies on the effectiveness of microsurgical techniques for lymphedema. Ann Vasc Surg 2022; 86:440-451.e6. [PMID: 35589027 DOI: 10.1016/j.avsg.2022.04.038] [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: 12/02/2021] [Revised: 03/03/2022] [Accepted: 04/24/2022] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Microsurgery is a new technique for lymphedema treatment. Its advantages and disadvantages remain controversial. This study sought to collect clinical data from patients who underwent lymphovenous bypass and vascularized lymph node transplantation to explore whether surgical procedures can effectively treat lymphedema. METHODS We performed a meta-analysis of the effectiveness of lymphatic microsurgery. We searched the databases of literature for articles in Chinese and English. These articles were graded for quality. Report details and outcomes were recorded. Data extraction, systematic review, and meta-analysis were performed. RESULTS Thirty-seven studies were included. Patients who underwent microsurgery had a significantly better chance of achieving an excellent result than patients who received conservative treatment (odds ratio=7.07). The affected limb circumference was reduced by approximately 44.68% after the microsurgery. After the microsurgery, 63% of the patients did not need physiotherapy, and 96% were free from painful skin infections. Lymphography showed that lymphatic transport capacity was enhanced. Moreover, 12% of the patients reported that edema reappeared in the long-term, 26% required reoperation for unsatisfactory results, and 32% experienced lymphatic leakage. CONCLUSIONS A vast majority of patients derive more benefit from lymphatic microsurgery than from conventional treatment. The advantages of lymphatic microsurgery outweigh the disadvantages for patients in the early and middle stages of chronic secondary lymphedema and patients in whom conventional treatment failed.
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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: 7] [Impact Index Per Article: 3.5] [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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Duan M, Han D, Gao N, Shen W, Chang K, Wang X, Du J. A Facile and Highly Efficient Approach to Obtain a Fluorescent Chromogenic Porous Organic Polymer for Lymphatic Targeting Imaging. Molecules 2022; 27:molecules27051558. [PMID: 35268658 PMCID: PMC8911811 DOI: 10.3390/molecules27051558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 02/15/2022] [Accepted: 02/23/2022] [Indexed: 02/04/2023] Open
Abstract
Porous organic polymers have an open architecture, excellent stability, and tunable structural components, revealing great application potential in the field of fluorescence imaging, but this part of the research is still in its infancy. In this study, we aimed to tailor the physical and chemical characteristics of indocyanine green using sulfonic acid groups and conjugated fragments, and prepared amino-grafted porous polymers. The resulting material had excellent solvent and thermal stability, and possessed a relatively large pore structure with a size of 3.4 nm. Based on the synergistic effect of electrostatic bonding and π–π interactions, the fluorescent chromogenic agent, indocyanine green, was tightly incorporated into the pore cavity of POP solids through a one-step immersion method. Accordingly, the fluorescent chromogenic POP demonstrated excellent imaging capabilities in biological experiments. This preparation of fluorescent chromogenic porous organic polymer illustrates a promising application of POP-based solids in both fluorescence imaging and biomedicine applications.
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Affiliation(s)
- Man Duan
- Key Laboratory of Lymphatic Surgery Jilin Province, Jilin Engineering Laboratory for Lymphatic Surgery Jilin Province, China-Japan Union Hospital of Jilin University, Changchun 130031, China; (M.D.); (D.H.); (X.W.)
| | - Dongmei Han
- Key Laboratory of Lymphatic Surgery Jilin Province, Jilin Engineering Laboratory for Lymphatic Surgery Jilin Province, China-Japan Union Hospital of Jilin University, Changchun 130031, China; (M.D.); (D.H.); (X.W.)
| | - Nan Gao
- Key Laboratory of Polyoxometalate and Reticular Material Chemistry of Ministry of Education and Faculty of Chemistry, Northeast Normal University, Changchun 130024, China
- Correspondence: (N.G.); (J.D.)
| | - Wenbin Shen
- Department of Lymphology, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China; (W.S.); (K.C.)
| | - Kun Chang
- Department of Lymphology, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China; (W.S.); (K.C.)
| | - Xinyu Wang
- Key Laboratory of Lymphatic Surgery Jilin Province, Jilin Engineering Laboratory for Lymphatic Surgery Jilin Province, China-Japan Union Hospital of Jilin University, Changchun 130031, China; (M.D.); (D.H.); (X.W.)
| | - Jianshi Du
- Key Laboratory of Lymphatic Surgery Jilin Province, Jilin Engineering Laboratory for Lymphatic Surgery Jilin Province, China-Japan Union Hospital of Jilin University, Changchun 130031, China; (M.D.); (D.H.); (X.W.)
- Correspondence: (N.G.); (J.D.)
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Suzuki Y, Kajita H, Watanabe S, Okabe K, Sakuma H, Imanishi N, Aiso S, Kishi K. Application of Photoacoustic Imaging for Lymphedema Treatment. J Reconstr Microsurg 2021; 38:254-262. [PMID: 34959248 PMCID: PMC8904143 DOI: 10.1055/s-0041-1736518] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Background
Lymphatic vessels are difficult to identify using existing modalities as because of their small diameter and the transparency of the lymph fluid flowing through them.
Methods
Here, we introduce photoacoustic lymphangiography (PAL), a new modality widely used for lymphedema treatment, to observe limb lymphatic vessels. The photoacoustic imaging system used in this study can simultaneously visualize lymphatic vessels and veins with a high resolution (0.2 mm) and can also observe their three-dimensional relationship with each other.
Results
High-resolution images of the lymphatic vessels, detailed structure of the dermal back flow, and the three-dimensional positional relationship between the lymphatic vessels and veins were observed by PAL.
Conclusion
The clear image provided by PAL could have a major application in pre- and postoperative use during lymphaticovenular anastomosis for lymphedema treatment.
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Affiliation(s)
- Yushi Suzuki
- Department of Plastic and Reconstructive Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Hiroki Kajita
- Department of Plastic and Reconstructive Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Shiho Watanabe
- Department of Plastic and Reconstructive Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Keisuke Okabe
- Department of Plastic and Reconstructive Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Hisashi Sakuma
- Department of Plastic and Reconstructive Surgery, Tokyo Dental College Ichikawa General Hospital, Chiba, Japan
| | - Nobuaki Imanishi
- Department of Anatomy, Keio University School of Medicine, Tokyo, Japan
| | - Sadakazu Aiso
- Department of Anatomy, Keio University School of Medicine, Tokyo, Japan.,Luxonus Inc. Kawasaki, Japan
| | - Kazuo Kishi
- Department of Plastic and Reconstructive Surgery, Keio University School of Medicine, Tokyo, Japan
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15
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Akita S, Unno N, Maegawa J, Kimata Y, Ota Y, Yabuki Y, Shinaoka A, Sano M, Ohnishi F, Sakuma H, Nuri T, Ozawa Y, Shiko Y, Kawasaki Y, Hanawa M, Fujii Y, Imanishi E, Fujiwara T, Hanaoka H, Mitsukawa N. A phase III, multicenter, single-arm study to assess the utility of indocyanine green fluorescent lymphography in the treatment of secondary lymphedema. J Vasc Surg Venous Lymphat Disord 2021; 10:728-737.e3. [PMID: 34592477 DOI: 10.1016/j.jvsv.2021.09.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 09/15/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Indocyanine green (ICG) fluorescent lymphography might be useful for assessing patients undergoing lymphatic surgery for secondary lymphedema. The present clinical trial aimed to confirm whether ICG fluorescent lymphography would be useful in evaluating lymphedema, identifying lymphatic vessels suitable for anastomosis, and confirming patency of lymphaticovenular anastomosis in patients with secondary lymphedema. METHODS The present phase III, multicenter, single-arm, open-label, clinical trial (HAMAMATSU-ICG study) investigated the accuracy of lymphedema diagnosis via ICG fluorescent lymphography compared with lymphoscintigraphy, rate of identification of lymphatic vessels at the incision site, and efficacy for confirming patency of lymphaticovenular anastomosis. The external diameter of the identified lymphatic vessels and the distance from the skin surface to the lymphatic vessels using preoperative ICG fluorescent lymphography were measured intraoperatively under surgical microscopy. RESULTS When the clinical decision for surgery at each research site was made, the standard diagnosis of lymphedema was considered correct. For the 26 upper extremities, a central judgment committee who was unaware of the clinical presentation confirmed the imaging diagnosis was accurate for 100.0% of cases, whether the assessments had been performed via lymphoscintigraphy or ICG lymphography. In contrast, for the 88 lower extremities, the accuracy of the diagnosis compared with the diagnosis by the central judgment committee was 70.5% and 88.2% for lymphoscintigraphy and ICG lymphography, respectively. The external diameter of the identified lymphatic vessels was significantly greater in the lower extremities than in the upper extremities (0.54 ± 0.21 mm vs 0.42 ± 0.14 mm; P < .0001). Also, the distance from the skin surface to the lymphatic vessels was significantly longer in the lower extremities than in the upper extremities (5.8 ± 3.5 mm vs 4.4 ± 2.6 mm; P = .01). For 263 skin incisions, with the site placement determined using ICG fluorescent lymphography, the rate of identification of lymphatics vessels suitable for anastomosis was 97.7% (95% confidence interval, 95.1%-99.2%). A total of 267 lymphaticovenular anastomoses were performed. ICG fluorescent lymphography was judged as "useful" for confirming patency after the anastomosis in 95.1% of the cases. CONCLUSIONS ICG fluorescent lymphography could be useful for improving the treatment of patients with secondary lymphedema from the outpatient setting to surgery.
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Affiliation(s)
- Shinsuke Akita
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Chiba University Graduate School of Medicine, Chiba, Japan.
| | - Naoki Unno
- Department of Vascular Surgery, Hamamatsu Medical Center, Hamamatsu, Japan; Second Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Jiro Maegawa
- Department of Plastic and Reconstructive Surgery, Yokohama City University, Graduate School of Medicine, Yokohama, Japan
| | - Yoshihiro Kimata
- Department of Plastic and Reconstructive Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Yusuke Ota
- Department of Plastic and Reconstructive Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Yuichiro Yabuki
- Department of Plastic and Reconstructive Surgery, Yokohama City University, Graduate School of Medicine, Yokohama, Japan
| | - Akira Shinaoka
- Department of Plastic and Reconstructive Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Masaki Sano
- Second Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Fumio Ohnishi
- Department of Plastic and Reconstructive Surgery, Saitama Medical Center, Saitama Medical University, Kawagoe City, Japan
| | - Hisashi Sakuma
- Department of Plastic and Reconstructive Surgery, Ichikawa General Hospital, Tokyo Dental College, Tokyo, Japan
| | - Takashi Nuri
- Department of Plastic and Reconstructive Surgery, Osaka Medical College, Takatsuki, Japan
| | - Yoshihito Ozawa
- Clinical Research Center, Chiba University Hospital, Chiba, Japan
| | - Yuki Shiko
- Clinical Research Center, Chiba University Hospital, Chiba, Japan
| | - Yohei Kawasaki
- Clinical Research Center, Chiba University Hospital, Chiba, Japan
| | - Michiko Hanawa
- Clinical Research Center, Chiba University Hospital, Chiba, Japan
| | - Yasuhisa Fujii
- Clinical Research Center, Chiba University Hospital, Chiba, Japan
| | - Eri Imanishi
- Clinical Research Center, Chiba University Hospital, Chiba, Japan
| | - Tadami Fujiwara
- Clinical Research Center, Chiba University Hospital, Chiba, Japan
| | - Hideki Hanaoka
- Clinical Research Center, Chiba University Hospital, Chiba, Japan
| | - Nobuyuki Mitsukawa
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
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The Direct Observation of Lymphaticovenular Anastomosis Patency with Photoacoustic Lymphangiography. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3348. [PMID: 33552812 PMCID: PMC7858285 DOI: 10.1097/gox.0000000000003348] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 11/11/2020] [Indexed: 12/04/2022]
Abstract
Supplemental Digital Content is available in the text. It is difficult to evaluate the postoperative patency of lymphaticovenular anastomosis, but this evaluation is essential for determining surgical results. When using the current standard modality, near-infrared fluorescent lymphography, it is difficult to observe patency if the anastomotic point is veiled by dermal backflow. In this study, we used a new photoacoustic imaging device, PAI-05, to check the patency of anastomosis. We performed photoacoustic lymphangiography after lymphaticovenular anastomosis surgery. By digitally subtracting the superficial area, we can examine an area deeper than the dermal backflow, which is not visible by near-infrared fluorescent lymphography. The connection between the lymphatic vessel and the venule observed in the image is an indication of the patency of anastomosis. However, in a non-patent anastomosed site, the lymphatic vessel has a gap that separates it from the venule at the anastomosed site. Although photoacoustic lymphangiography cannot be used to visualize the lymphatic vessels that are not contrasted by indocyanine green, the resulting high-resolution images and clear anastomosis evaluation afforded by it will contribute to the development of future lymphedema treatments.
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17
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Abstract
Lymphedema occurs when interstitial fluid and fibroadipose tissues accumulate abnormally because of decreased drainage of lymphatic fluid as a result of injury, infection, or congenital abnormalities of the lymphatic system drainage pathway. An accurate anatomical map of the lymphatic vasculature is needed not only for understanding the pathophysiology of lymphedema but also for surgical planning. However, because of their limited spatial resolution, no imaging modalities are currently able to noninvasively provide a clear visualization of the lymphatic vessels. Photoacoustic imaging is an emerging medical imaging technique that provides unique scalability of optical resolution and acoustic depth of penetration. Moreover, light-absorbing biomolecules, including oxy- and deoxyhemoglobin, lipids, water, and melanin, can be imaged. Using exogenous contrast agents that are taken up by lymphatic vessels, e.g., indocyanine green, photoacoustic lymphangiography, which has a higher spatial resolution than previous imaging modalities, is possible. Using a new prototype of a photoacoustic imaging system with a wide field of view developed by a Japanese research group, high-resolution three-dimensional structural information of the vasculatures was successfully obtained over a large area in both healthy and lymphedematous extremities. Anatomical information on the lymphatic vessels and adjacent veins provided by photoacoustic lymphangiography is helpful for the management of lymphedema. In particular, such knowledge will facilitate the planning of microsurgical lymphaticovenular anastomoses to bypass the excess fluid component by joining with the circulatory system peripherally. Although challenges remain to establish its implementation in clinical practice, photoacoustic lymphangiography may contribute to improved treatments for lymphedema patients in the near future.
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Yasunaga Y, Nakajima Y, Mimura S, Yuzuriha S, Kondoh S. Magnetic resonance lymphography as three-dimensional navigation for lymphaticovenular anastomosis in patients with leg lymphedema. J Plast Reconstr Aesthet Surg 2020; 74:1253-1260. [PMID: 33277216 DOI: 10.1016/j.bjps.2020.10.099] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 09/29/2020] [Accepted: 10/26/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Precise mapping of functional lymphatic vessels is essential for successful lymphaticovenular anastomosis (LVA). This study aimed to clarify the precision of magnetic resonance lymphography (MRL) in detecting lymphatic vessels prior to LVA. METHODS Eighteen patients with leg lymphedema were recruited for this prospective study. All patients underwent MRL before LVA to obtain three-dimensional coordinates of lymphatic vessels from MRL images. The precision of MRL for detecting lymphatic vessels was evaluated and compared with those of other contrast techniques. RESULTS Twenty legs from 18 patients were analyzed. A total of 40 skin incisions were made, 32 of which were determined by MRL. The precision of MRL to detect lymphatic vessels was 94%. With the addition of MRL, the number of lymphatic vessels identified preoperatively was increased as compared with indocyanine green lymphography (ICG-L) alone. Assuming a detection sensitivity of MRL for lymphatic vessels of 1, those of other contrast techniques were 0.90 for ICG-L under microscopy, 0.73 for patent blue staining, and 0.43 for ICG-L before incision. Whereas ICG-L before incision could not detect lymphatic vessels at depths greater than 17.0 mm, all deeper anastomosed lymphatic vessels were identified by MRL. CONCLUSION Lymphatic vessels enhanced on MRL can be reliably identified intraoperatively. MRL is a promising preoperative examination in LVA that can selectively depict suitable lymphatic vessels even in deep tissue layers.
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Affiliation(s)
- Yoshichika Yasunaga
- Division of Plastic and Aesthetic Surgery, Ina Central Hospital, Ina, Japan; Division of Plastic and Reconstructive Surgery, Shizuoka Cancer Center, Nagaizumi, Japan.
| | - Yuta Nakajima
- Division of Plastic and Reconstructive Surgery, Shizuoka Cancer Center, Nagaizumi, Japan
| | - Shinei Mimura
- Division of Plastic and Reconstructive Surgery, Shizuoka Cancer Center, Nagaizumi, Japan
| | - Shunsuke Yuzuriha
- Department of Plastic and Reconstructive Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Shoji Kondoh
- Division of Plastic and Aesthetic Surgery, Ina Central Hospital, Ina, Japan
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19
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Tsai PL, Wu SC, Lin WC, Mito D, Chiang MH, Hsieh CH, Yang JCS. Determining factors in relation to lymphovascular characteristics and anastomotic configuration in supermicrosurgical lymphaticovenous anastomosis - A retrospective cohort study. Int J Surg 2020; 81:39-46. [PMID: 32739542 DOI: 10.1016/j.ijsu.2020.07.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 06/12/2020] [Accepted: 07/03/2020] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Supermicrosurgical lymphaticovenous anastomosis (LVA) can be performed in different configuration such as end-to-end (LVEEA), end-to-side (LVESA), and side-to-end (LVSEA). Each configuration has its own advantages and disadvantages. However, it has remained ambiguous as to which anastomotic o configuration to choose. The aim of this study is to analyze and compare the relative sizes of lymphatic vessel (LV) and recipient vein (RV), in attempts to provide the basis for proper selections of the anastomotic configuration. METHODS From March 2016 to October 2018, 100 lymphedema patients with 103 lymphedematous lower limbs (stage I-III) were included. All patients underwent supermicrosurgical LVA. Demographic data and intraoperative findings, including the number and size of the LV/RV, the size discrepancies, and the numbers of LVA performed were recorded. The severity of LVs were classified based on the lymphosclerosis classification (s0, s1, s2, and s3). One-way ANOVA test and post hoc analysis with Bonferroni's correction were performed for size discrepancy analysis. RESULTS A total 730 LVA were performed with 621 LVs and 468 RVs, averaging 7.1 LVA per limb. Of these, 367 (50.3%) were LVEEA, 333 (45.6%) were LVESA, and 30 (4.1%) were LVSEA. The average LV and RV size was 0.61 ± 0.35 mm and 0.87 ± 0.43 mm, respectively (p < 0.001). The average LV size in different configuration: LVEEA = LVESA < LVSEA (p < 0.001); The average RV size: LVEEA = LVSEA < LVESA (p < 0.001); The size discrepancy: LVESA > LVSEA > LVEEA (p < 0.001).The LVSEA group has more s1 lymphatic vessels as opposed to LVEEA and LVESA (p = 0.004). CONCLUSION The size and the comparative discrepancy between the LVs and RVs are the determining factors for proper anastomotic configuration selection during LVA. LVESA was more frequently performed when vessel size discrepancy was larger. The efficacy of each anastomotic configuration has yet to be determined.
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Affiliation(s)
- Po-Lun Tsai
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Shao-Chun Wu
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Wei-Che Lin
- Department of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Daisuke Mito
- Department of Plastic, Reconstructive, And Aesthetic Surgery University of Tokyo Hospital Tokyo, Japan
| | - Min-Hsien Chiang
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Ching-Hua Hsieh
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Johnson Chia-Shen Yang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan; Department of Plastic and Reconstructive Surgery, Xiamen Changgung Hospital, Xiamen, Fujian, China.
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20
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Yabuki Y, Maegawa J, Shibukawa N, Kagimoto S, Kitayama S, Matsubara S, Mikami T. A Novel Approach to Subcutaneous Collecting Lymph Ducts Using a Small Diameter Wire in Animal Experiments and Clinical Trials. Lymphat Res Biol 2020; 19:73-79. [PMID: 32721266 DOI: 10.1089/lrb.2019.0047] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: While performing microsurgery, including lymphaticovenous anastomosis (LVA) for chronic limb lymphedema, it is a common procedure to identify the subcutaneous collecting lymph ducts with near-infrared fluorescence lymphangiography (NIR) using indocyanine green. However, due to limitations such as minimum observable depth, only a few lymphatic ducts can be identified with this procedure. Hence, we developed a new smaller-diameter "lymphatic wire" (LW) that could be inserted directly into lymphatic collecting ducts of the limbs, enabling accurate identification and localization. Methods and Results: First, used the LW on the hind limbs of 6 swine, and 36 porcine lymphatic collecting ducts were identified, the outer diameter of which varied from 0.3-0.7 mm (mean 0.41 ± 0.11 mm). We could insert the LW after creating a side opening in 30 of these ducts. We encountered no difficulties during the procedure. In the pathological examination, adverse events such as valve dysfunction and perforation were not identified. Based on the results, a clinical evaluation of the LW was performed in two patients with lower extremity lymphedema, and the LW helped us identify lymphatic ducts in the subcutaneous layer, even at the sites where the NIR had proved ineffective. Conclusion: Based on our results, we suggest that the procedure for identifying lymphatic vessels using the newly developed LW is a useful technique that can be utilized before performing a LVA for lymphedema. However, further clinical study is required to develop this device and technique, for wider clinical application in the future.
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Affiliation(s)
- Yuichiro Yabuki
- Department of Plastic and Reconstructive Surgery, Yokohama City University School of Medicine, Yokohama, Kanagawa, Japan
| | - Jiro Maegawa
- Department of Plastic and Reconstructive Surgery, Yokohama City University School of Medicine, Yokohama, Kanagawa, Japan
| | - Naohiko Shibukawa
- Department of Plastic and Reconstructive Surgery, Yokohama City University School of Medicine, Yokohama, Kanagawa, Japan
| | - Shintaro Kagimoto
- Department of Plastic and Reconstructive Surgery, Yokohama City University School of Medicine, Yokohama, Kanagawa, Japan
| | - Shinya Kitayama
- Department of Plastic and Reconstructive Surgery, Yokohama City University School of Medicine, Yokohama, Kanagawa, Japan
| | - Shinobu Matsubara
- Department of Plastic and Reconstructive Surgery, Yokohama City University School of Medicine, Yokohama, Kanagawa, Japan
| | - Taro Mikami
- Department of Plastic and Reconstructive Surgery, Yokohama City University School of Medicine, Yokohama, Kanagawa, Japan
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Akita S, Unno N, Maegawa J, Kimata Y, Fukamizu H, Yabuki Y, Shinaoka A, Sano M, Kawasaki Y, Fujiwara T, Hanaoka H, Mitsukawa N. HAMAMATSU-ICG study: Protocol for a phase III, multicentre, single-arm study to assess the usefulness of indocyanine green fluorescent lymphography in assessing secondary lymphoedema. Contemp Clin Trials Commun 2020; 19:100595. [PMID: 32617434 PMCID: PMC7322679 DOI: 10.1016/j.conctc.2020.100595] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Revised: 06/07/2020] [Accepted: 06/14/2020] [Indexed: 11/06/2022] Open
Abstract
Introduction Secondary lymphoedema of the extremities is an important quality-of-life issue for patients who were treated for their malignancies. Indocyanine green (ICG) fluorescent lymphography may be helpful for assessing lymphoedema and for planning lymphaticovenular anastomosis (LVA). The objective of the present clinical trial is to confirm whether or not ICG fluorescent lymphography using the near-infrared monitoring camera is useful for assessing the indication for LVA, for the identification of the lymphatic vessels before the conduct of LVA, and for the confirmation of the patency of the anastomosis site during surgery. Methods and analysis This trial is a phase III, multicentre, single-arm, open-label clinical trial to assess the efficacy and safety of ICG fluorescent lymphography when assessing and treating lymphoedema of patients with secondary lymphoedema who are under consideration for LVA. The primary endpoint is the identification rate of the lymphatic vessels at the incision site based on ICG fluorescent lymphograms obtained before surgery. The secondary endpoints are 1) the sensitivity and specificity of dermal back flow determined by ICG fluorescent lymphography as compared with 99mTc lymphoscintigraphy—one of the standard diagnostic methods and 2) the usefulness of ICG fluorescent lymphography when confirming the patency of the anastomosis site after LVA. Ethics and dissemination The protocol for the study was approved by the Institutional Review Board of each institution. The trial was filed for and registered at the Pharmaceuticals and Medical Devices Agency in Japan. The trial is currently on-going and is scheduled to end in June 2020. Trial registration number jRCT2031190064; Pre-results. This study will examine the efficacy of a highly safe drug, indocyanine green for evaluating lymphatic anatomy. This is the first, multicentre, prospective, systematised clinical trial of Indocyanine green lymphography. The present clinical trial will not allow the assessment of the therapeutic efficacy of lymphaticovenular anastomosis.
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Affiliation(s)
- Shinsuke Akita
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Naoki Unno
- Department of Vascular Surgery, Hamamatsu Medical Center, Hamamatsu, Japan.,Second Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Jiro Maegawa
- Department of Plastic and Reconstructive Surgery, Yokohama City University, Graduate School of Medicine, Yokohama, Japan
| | - Yoshihiro Kimata
- Department of Plastic and Reconstructive Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Hidekazu Fukamizu
- Department of Plastic and Reconstructive Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Yuichiro Yabuki
- Department of Plastic and Reconstructive Surgery, Yokohama City University, Graduate School of Medicine, Yokohama, Japan
| | - Akira Shinaoka
- Department of Plastic and Reconstructive Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Masaki Sano
- Second Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Yohei Kawasaki
- Clinical Research Center, Chiba University Hospital, Chiba, Japan
| | - Tadami Fujiwara
- Clinical Research Center, Chiba University Hospital, Chiba, Japan
| | - Hideki Hanaoka
- Clinical Research Center, Chiba University Hospital, Chiba, Japan
| | - Nobuyuki Mitsukawa
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
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22
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Abstract
Lymphedema is a chronic, progressive disease caused by primary or secondary reasons. It is currently uncurable and conservative compression therapy is generally applied. Lymphovenous anastomosis and vascularized lymph node transfer (VLNT) are two main surgical treatment that are used in addition to conservative therapy. Lymphovenous anastomosis involves the anastomosing remaining functional lymphatic vessels to vein. When the lymphatic vessels are greatly damaged and in no case can they be used for anastomosis, VLNT provide the affected area with lymph nodes from elsewhere to restore the drainage function. During all these procedures, a clear image to identify related lymphatic structures and venous vessels can be greatly useful for preoperative planning, intraoperative navigation, and postoperative evaluation. Lymphoscintigraphy used to be the gold standard in evaluating lymphedema and mapping lymphatic systems. But due to the downside of radiation, invasive operation and complication, other modalities are gaining attention. In this article, we reviewed the application of Indocyanine green (ICG) lymphography, ultrasound, magnetic resonance lymphography (MRL), and single-photon emission computed tomography-computed tomography (SPECT-CT) in the field of surgical therapy in lymphedema.
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Affiliation(s)
- Xingyi Du
- Plastic Surgery Hospital (Institute), Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100043, China
| | - Chunjun Liu
- Plastic Surgery Hospital (Institute), Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100043, China
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Assessment of Lymphovenous Anastomosis Patency: Technical Highlights. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2718. [PMID: 32537366 PMCID: PMC7253279 DOI: 10.1097/gox.0000000000002718] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 12/17/2019] [Indexed: 11/26/2022]
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24
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The Long-term Patency of Lymphaticovenular Anastomosis in Breast Cancer-Related Lymphedema. Ann Plast Surg 2020; 82:196-200. [PMID: 30628927 DOI: 10.1097/sap.0000000000001674] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND AND OBJECTIVES Lymphedema is a condition that can greatly affect patient's quality of life. Promising results have been described with lymphaticovenular anastomosis (LVA) in the treatment of lymphedema. It is currently unknown at what rate anastomoses remain functional after a longer follow-up. The aim of this study was to determine LVA patency at 1-year follow-up. METHODS Retrospective chart review was performed on patients who underwent LVA surgery. Patients who had indocyanine green lymphography performed at 12 months' follow-up after LVA were included in this study. Volume measurements were performed prior to surgery and at 6 and 12 months' follow-up. Patients quality of life was measured prior to surgery and at 6 months' follow-up. RESULTS Twelve patients met inclusion criteria. In total, 15 (56.5%) of 23 LVAs were considered patent. In 8 patients (66.7%), at least 1 patent LVA was visible. The volume difference between the healthy and affected arms decreased 32.3% on average. Quality of life increased with 1.4 points on average. CONCLUSIONS This study is, to our knowledge, the first to evaluate long-term patency of LVA in upper limb lymphedema. Our study demonstrates that at least 56.5% of the anastomoses created are patent after 1-year follow-up.
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Mechanical Dilation Using Nylon Monofilament Aids Multisite Lymphaticovenous Anastomosis Through Improving the Quality of Anastomosis. Ann Plast Surg 2020; 82:201-206. [PMID: 30557189 DOI: 10.1097/sap.0000000000001681] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Lymphaticovenous anastomosis (LVA) is now a common treatment for lymphedema. It is important to create as many bypasses as possible to maximize the efficacy of LVA. We have developed a method whereby nylon monofilaments are placed inside the vessel lumen to act as dilators. We refer to this technique as mechanical dilation (MD) to distinguish it from intravascular stenting. In this study, we investigated the efficacy of the conventional supermicrosurgery technique performed with and without MD as a treatment for lower limb lymphedema. The LVA was performed using conventional supermicrosurgery alone in 10 patients (group without MD) and in combination with MD in another 10 patients (group with MD). The mean number of successful LVAs performed per hour was significantly higher in the group with MD than in the group without MD (1.42 ± 0.16 vs 1.14 ± 0.15; P < 0.05). The mean amount of improvement in the lower extremity lymphedema index was significantly greater in the group with MD than in the group without MD (7.34 ± 1.57 vs 4.41 ± 1.53; P = 0.003 < 0.05). A statistically significant correlation was found between the number of successful LVAs and amount of improvement in lymphedema (r = 0.449, P = 0.047 < 0.05). Our findings suggest that use of MD does not shorten the operating time or increase the number of LVAs that can be performed but may make it possible to increase the number of successful LVAs that can be performed between vessels with a diameter of less than 0.3 mm. Use of MD could increase the improvement rate of lymphedema to a greater extent than that achieved by conventional microsurgery alone.
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Forte AJ, Khan N, Huayllani MT, Boczar D, Saleem HY, Lu X, Manrique OJ, Ciudad P, McLaughlin SA. Lymphaticovenous Anastomosis for Lower Extremity Lymphedema: A Systematic Review. Indian J Plast Surg 2020; 53:17-24. [PMID: 32367914 PMCID: PMC7192660 DOI: 10.1055/s-0040-1709372] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Background Lymphedema is an accumulation of protein-rich fluid in the interstitial spaces resulting from impairment in the lymphatic circulation that can impair quality of life and cause considerable morbidity. Lower extremity lymphedema (LEL) has an overall incidence rate of 20%. Conservative therapies are the first step in treatment of LEL; however, they do not provide a cure because they fail to address the underlying physiologic dysfunction of the lymphatic system. Among several surgical alternatives, lymphaticovenous anastomosis (LVA) has gained popularity due to its improved outcomes and less invasive approach. This study aims to review the published literature on LVA for LEL treatment and to analyze the surgical outcomes. Methods PubMed database was used to perform a comprehensive literature review of all articles describing LVA for treatment of LEL from Novemeber 1985 to June 2019. Search terms included "lymphovenous" OR "lymphaticovenous" AND "bypass" OR "anastomosis" OR "shunt" AND "lower extremity lymphedema." Results A total of 95 articles were identified in the initial query, out of which 58 individual articles were deemed eligible. The studies included in this review describe notable variations in surgical techniques, number of anastomoses, and supplementary interventions. All, except one study, reported positive outcomes based on limb circumference and volume changes or subjective clinical improvement. The largest reduction rate in limb circumference and volume was 63.8%. Conclusion LVA demonstrated a considerable reduction in limb volume and improvement in subjective findings of lymphedema in the majority of patients. The maintained effectiveness of this treatment modality in long-term follow-up suggests great efficacy of LVA in LEL treatment.
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Affiliation(s)
- Antonio J. Forte
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, Florida, United States
| | | | - Maria T. Huayllani
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, Florida, United States
| | - Daniel Boczar
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, Florida, United States
| | - Humza Y. Saleem
- Department of Surgery, Mayo Clinic, Jacksonville, Florida, United States
| | - Xiaona Lu
- Division of Plastic and Reconstructive Surgery, Yale School of Medicine, New Haven, Connecticut, United States
| | - Oscar J. Manrique
- Division of Plastic Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
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Prevention of venous reflux with full utilization of venoplasty in lymphaticovenular anastomosis. J Plast Reconstr Aesthet Surg 2020; 73:537-543. [DOI: 10.1016/j.bjps.2019.10.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Revised: 08/23/2019] [Accepted: 10/09/2019] [Indexed: 12/29/2022]
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Klingelhoefer E, Hesse K, Taeger CD, Prantl L, Stepniewski A, Felmerer G. Factors affecting outcomes after supermicrosurgical lymphovenous anastomosis in a defined patient population. Clin Hemorheol Microcirc 2020; 73:53-63. [PMID: 31561341 DOI: 10.3233/ch-199213] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND The optimal surgical treatment for lymphedema is still subject of intensive research. Therefore, it is vital to investigate what significance lymphovenous anastomosis (LVA) has in this context. OBJECTIVE This study aims to determine the short- and long-term results as well as the most important factors that can improve outcomes after LVA. METHODS This study includes a complete data set of 26 patients who received LVA for a therapy-resistant lymphedema. Patients were followed up for an average of 23 months. RESULTS 50% of the patients reported a subjective improvement. Without conservative treatment after the operation the patients showed significant better results (100% vs. 40.9%, p = 0.030). The localization of lymphedema as well as the region of LVA had a significant influence. In patients with lymphedema affecting the entire leg, symptom improvement was significantly lower (35.3% vs. 77.8%, p = 0.039). Patients who received LVA in an upper limb show a significantly higher improvement in symptoms than patients who received LVA in a lower limb (100% vs. 30%, p = 0.021). CONCLUSIONS We identified factors with a significant influence on the outcome of patients after receiving LVA. Patients with early-stage upper extremity lymphedema seem to benefit most from this procedure.
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Affiliation(s)
- Eric Klingelhoefer
- Division of Plastic Surgery, Department of Trauma Surgery, Orthopedics and Plastic Surgery, University Medical Center Goettingen, Germany
| | - Karl Hesse
- Division of Plastic Surgery, Department of Trauma Surgery, Orthopedics and Plastic Surgery, University Medical Center Goettingen, Germany
| | - Christian D Taeger
- Department of Plastic, Hand- and Reconstructive Surgery, University Hospital Regensburg, Germany
| | - Lukas Prantl
- Department of Plastic, Hand- and Reconstructive Surgery, University Hospital Regensburg, Germany
| | - Adam Stepniewski
- Division of Plastic Surgery, Department of Trauma Surgery, Orthopedics and Plastic Surgery, University Medical Center Goettingen, Germany
| | - Gunther Felmerer
- Division of Plastic Surgery, Department of Trauma Surgery, Orthopedics and Plastic Surgery, University Medical Center Goettingen, Germany
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Endogenous Calcitonin Gene–Related Peptide Deficiency Exacerbates Postoperative Lymphedema by Suppressing Lymphatic Capillary Formation and M2 Macrophage Accumulation. THE AMERICAN JOURNAL OF PATHOLOGY 2019; 189:2487-2502. [DOI: 10.1016/j.ajpath.2019.08.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 08/08/2019] [Accepted: 08/15/2019] [Indexed: 02/06/2023]
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Boyages J, Koelmeyer LA, Suami H, Lam T, Ngo QD, Heydon-White A, Czerniec S, Munot S, Ho-Shon K, Mackie H. The ALERT model of care for the assessment and personalized management of patients with lymphoedema. Br J Surg 2019; 107:238-247. [PMID: 31696506 DOI: 10.1002/bjs.11368] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 05/09/2019] [Accepted: 08/22/2019] [Indexed: 11/10/2022]
Abstract
BACKGROUND This study documents the development and evaluation of a comprehensive multidisciplinary model for the assessment and personalized care of patients with lymphoedema. METHODS The Australian Lymphoedema Education Research and Treatment (ALERT) programme originated as an advanced clinic for patients considering surgery for lymphoedema. The programme commenced liposuction surgery in May 2012 and then introduced lymph node transfer in 2013 and lymphovenous anastomosis (LVA) in 2016. An outpatient conservative treatment clinic was established in 2016. ALERT commenced investigations with indocyanine green (ICG) lymphography in late 2015, leading to the creation of a diagnostic assessment clinic offering ICG in 2017. RESULTS Since 2012, 1200 new patients have been referred to ALERT for assessment of lymphoedema for a total of 5043 episodes of care. The introduction of ICG lymphography in 2015 initially allowed better screening for LVA, but is now used not only to guide surgical options, but also as a diagnostic tool and to guide manual lymphatic drainage massage. The total number of new patients who attended the surgical assessment clinic to December 2018 was 477, with 162 patients (34·0 per cent) undergoing surgery. CONCLUSION The ALERT programme has developed a multidisciplinary model of care for personalized lymphoedema treatment options based on clinical, imaging and ICG lymphography. Patients are selected for surgery based on several individual factors.
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Affiliation(s)
- J Boyages
- Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - L A Koelmeyer
- Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - H Suami
- Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - T Lam
- Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Q D Ngo
- Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - A Heydon-White
- Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - S Czerniec
- Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - S Munot
- Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - K Ho-Shon
- Macquarie Medical Imaging, Macquarie University Hospital, Macquarie University, Sydney, Australia
| | - H Mackie
- Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia.,Mount Wilga Private Hospital, Hornsby, New South Wales, Australia
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Sakuma H, Watanabe S, Kono H. A Novel Surgical Approach for Refractory Secondary Lymphedema of the Lower Extremity Accompanying Micro-Arteriovenous Fistula. Ann Vasc Surg 2019; 65:284.e13-284.e18. [PMID: 31705986 DOI: 10.1016/j.avsg.2019.10.098] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 07/17/2019] [Accepted: 10/30/2019] [Indexed: 10/25/2022]
Abstract
Lymphaticovenous anastomosis (LVA) for lymphedema of the lower extremity has been established as a minimally invasive and effective surgical treatment to return static lymph fluid to the vein. However, we often experience cases in which the effect of LVA cannot be obtained sufficiently, or the anastomotic site becomes obstructed and the edema deteriorates over a long term. One of the causes is the combination of local venous hypertension (VT) by micro-arteriovenous fistula (mAVF). We report two cases of refractory lymphedema at the lower extremity caused by mAVF and incompetent perforating vein (IPV). In these cases, surgical ligation and separation of the mAVF and IPV is effective in reducing edema.
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Affiliation(s)
- Hisashi Sakuma
- Department of Plastic and Reconstructive Surgery, Yokohama Citizens' Municipal Hospital, Kanagawa, Japan.
| | - Shiho Watanabe
- Department of Plastic and Reconstructive Surgery, Yokohama Citizens' Municipal Hospital, Kanagawa, Japan
| | - Hikaru Kono
- Department of Plastic and Reconstructive Surgery, Yokohama Citizens' Municipal Hospital, Kanagawa, Japan
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Wolfs JAGN, de Joode LGEH, van der Hulst RRWJ, Qiu SS. Correlation between patency and clinical improvement after lymphaticovenous anastomosis (LVA) in breast cancer-related lymphedema: 12-month follow-up. Breast Cancer Res Treat 2019; 179:131-138. [PMID: 31542874 PMCID: PMC6985198 DOI: 10.1007/s10549-019-05450-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Accepted: 09/14/2019] [Indexed: 12/13/2022]
Abstract
PURPOSE Breast cancer-related lymphedema (BCRL) is caused by an interruption of the lymphatic system after breast cancer treatment. Lymphaticovenous anastomosis (LVA), by which one or more patent lymphatic collecting vessels are connected to subcutaneous veins, shows promising results. Postoperatively, the patency of these anastomosis can be evaluated; however, little is known concerning the long-term patency after LVA in patients with BCRL. The aim of this study was to analyse the long-term patency, quality of life (QoL) and arm circumference after LVA, and to explore differences between patent and non-patent anastomosis and its correlation with clinical improvement. METHODS Twenty-five patients underwent indocyanine green (ICG) lymphography, lymph ICF-questionnaire, and arm circumference measurement preoperatively and 12 months after the LVA procedure. RESULTS Seventy-six percent of the patients showed at least one patent anastomosis after 12 months. Quality of life according to the Lymph-ICF increased significantly (p < 0.000); however, arm circumference showed no significant decrease. Sixty-five percent discontinued wearing compression stockings. The patent anastomosis group, compared with the non-patent anastomosis group showed, without significance, more improvement in QoL, arm circumference, and discontinuation of compression stockings, as well as a lower rate of infections both pre- and postoperatively, a shorter duration of lymphedema preoperatively, and a higher rate of early lymphedema and ICG stage. CONCLUSIONS LVA showed an acceptable patency and positive correlation between a patent anastomosis and clinical improvement after 12 months. Further research with a larger study population is required to determine whether outcomes or patient characteristics significantly correlate with a patent anastomosis after LVA operation.
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Affiliation(s)
- Joost A G N Wolfs
- Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - Luuke G E H de Joode
- Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - René R W J van der Hulst
- Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - Shan S Qiu
- Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands.
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Correlations between Tracer Injection Sites and Lymphatic Pathways in the Leg. Plast Reconstr Surg 2019; 144:634-642. [DOI: 10.1097/prs.0000000000005982] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Watanabe Y, Koshiyama M, Seki K, Nakagawa M, Ikuta E, Oowaki M, Sakamoto SI. Development and Themes of Diagnostic and Treatment Procedures for Secondary Leg Lymphedema in Patients with Gynecologic Cancers. Healthcare (Basel) 2019; 7:healthcare7030101. [PMID: 31461980 PMCID: PMC6787693 DOI: 10.3390/healthcare7030101] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 08/22/2019] [Accepted: 08/23/2019] [Indexed: 12/23/2022] Open
Abstract
Patients with leg lymphedema sometimes suffer under constraint feeling leg heaviness and pain, requiring lifelong treatment and psychosocial support after surgeries or radiation therapies for gynecologic cancers. We herein review the current issues (a review of the relevant literature) associated with recently developed diagnostic procedures and treatments for secondary leg lymphedema, and discuss how to better manage leg lymphedema. Among the currently available diagnostic tools, indocyanine green lymphography (ICG-LG) can detect dermal lymph backflow in asymptomatic legs at stage 0. Therefore, ICG-LG is considered the most sensitive and useful tool. At symptomatic stage ≥1, ultrasonography, magnetic resonance imaging-lymphography/computed tomography-lymphography (MRI-LG/CT-LG) and lymphosintiography are also useful. For the treatment of lymphedema, complex decongestive physiotherapy (CDP) including manual lymphatic drainage (MLD), compression therapy, exercise and skin care, is generally performed. In recent years, CDP has often required effective multi-layer lymph edema bandaging (MLLB) or advanced pneumatic compression devices (APCDs). If CDP is not effective, microsurgical procedures can be performed. At stage 1–2, when lymphaticovenous anastomosis (LVA) is performed, lymphaticovenous side-to-side anastomosis (LVSEA) is principally recommended. At stage 2–3, vascularized lymph node transfer (VLNT) is useful. These ingenious procedures can help maintain the patient’s quality of life (QOL) but unfortunately cannot cure lymphedema. The most important concern is the prevention of secondary lymphedema, which is achieved through approaches such as skin care, weight control, gentle limb exercises, avoiding sun and heat, and elevation of the affected leg.
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Affiliation(s)
- Yumiko Watanabe
- Department of Women's Health, Graduate School of Human Nursing, The University of Shiga Prefecture, Shiga 522-8533, Japan
| | - Masafumi Koshiyama
- Department of Women's Health, Graduate School of Human Nursing, The University of Shiga Prefecture, Shiga 522-8533, Japan.
| | - Keiko Seki
- School of Human Nursing, The University of Shiga Prefecture, Shiga 522-8533, Japan
| | - Miwa Nakagawa
- School of Human Nursing, The University of Shiga Prefecture, Shiga 522-8533, Japan
| | - Eri Ikuta
- School of Human Nursing, The University of Shiga Prefecture, Shiga 522-8533, Japan
| | - Makiko Oowaki
- Department of Women's Health, Graduate School of Human Nursing, The University of Shiga Prefecture, Shiga 522-8533, Japan
| | - Shin-Ichi Sakamoto
- School of Engineering, Department of Electronic Systems Engineering, The University of Shiga Prefecture, Shiga 522-8533, Japan
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Proximal ligation after the side-to-end anastomosis recovery technique for lymphaticovenous anastomosis. Arch Plast Surg 2019; 46:344-349. [PMID: 31336423 PMCID: PMC6657183 DOI: 10.5999/aps.2018.01382] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 06/21/2019] [Indexed: 11/29/2022] Open
Abstract
Background Lymphaticovenous anastomosis is an important surgical treatment for lymphedema, with lymphaticovenous side-to-end anastomosis (LVSEA) and lymphaticovenous end-to-end anastomosis being the most frequently performed procedures. However, LVSEA can cause lymphatic flow obstruction because of regurgitation and tension in the anastomosis. In this study, we introduce a novel and simple procedure to overcome this problem. Methods Thirty-five female patients with lower extremity lymphedema who underwent lymphaticovenous anastomosis at our hospital were included in this study. Eighty-five LVSEA procedures were performed, of which 12 resulted in insufficient venous blood flow. For these 12 anastomoses, the proximal lymphatic vessel underwent clipping after the anastomotic procedure and the venous inflow was monitored. Subsequently, the proximal ligation after side-to-end anastomosis recovery (PLASTER) technique, which involves ligating the proximal side of the lymphatic vessel, was applied. A postoperative evaluation was performed using indocyanine green 6 months after surgery. Results Despite the clipping procedure, three of the 12 anastomoses still showed poor venous inflow. Therefore, it was not possible to apply the PLASTER technique in those cases. Among the nine remaining anastomoses in which the PLASTER technique was applied, three (33%) were patent. Conclusions Our findings show that achieving patent anastomosis is challenging when postoperative venous inflow is poor. We achieved good results by performing proximal ligation after LVSEA. Thus, the PLASTER technique is a particularly useful recovery technique when LVSEA does not result in good run-off.
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Lymphatic Vessel Thrombosis in a Patient with Secondary Lymphedema. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2268. [PMID: 31333981 PMCID: PMC6571332 DOI: 10.1097/gox.0000000000002268] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 04/05/2019] [Indexed: 11/30/2022]
Abstract
Supplemental Digital Content is available in the text. Lymphatic thrombosis is rarer than venous thrombosis. This case report describes a patient with secondary lymphedema, who was found to have lymphatic thrombosis during lymphaticovenous anastomosis (LVA). A 51-year-old woman underwent hysterectomy and pelvic lymph node dissection for uterine cancer when she was 48 years old, and lymphedema developed in the left leg soon after the operation. She was diagnosed with lymphedema based on lymphoscintigraphic finding. Preoperative echography showed 2 hypoechoic circles measuring about 0.5 mm in diameter that did not collapse with pressure from the probe, although the veins collapsed with pressure. We diagnosed the 2 hypoechoic circles as lymphatic vessels based on the location and longitudinal continuity. During LVA, we identified 2 parallel white vessels beneath the superficial fascia. After they were cut, white material was extruded. A diagnosis of lymphatic thrombosis was made, and we ligated the lymphatic vessels, closed the wound at this site, and performed LVA at other sites (4 sites in the left and 1 site in the right leg). The postoperative course was uneventful. Histopathological examination showed hyperplasty of fibroblasts and organization in the thrombus. Lymphatic thrombosis is sometimes found in the lymphedema-affected extremities. On retrospective consideration, lymphatic thrombosis can be detected with preoperative echography.
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Suzuki Y, Sakuma H, Yamazaki S. Comparison of patency rates of lymphaticovenous anastomoses at different sites for lower extremity lymphedema. J Vasc Surg Venous Lymphat Disord 2019; 7:222-227. [DOI: 10.1016/j.jvsv.2018.10.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Accepted: 10/22/2018] [Indexed: 10/27/2022]
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Seki Y, Kajikawa A, Yamamoto T, Takeuchi T, Terashima T, Kurogi N. The dynamic-lymphaticovenular anastomosis method for breast cancer treatment-related lymphedema: Creation of functional lymphaticovenular anastomoses with use of preoperative dynamic ultrasonography. J Plast Reconstr Aesthet Surg 2019; 72:62-70. [DOI: 10.1016/j.bjps.2018.09.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Revised: 08/15/2018] [Accepted: 09/07/2018] [Indexed: 10/28/2022]
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Evaluation of patency rates of different lymphaticovenous anastomosis techniques and risk factors for obstruction in secondary upper extremity lymphedema. J Vasc Surg Venous Lymphat Disord 2019; 7:113-117. [DOI: 10.1016/j.jvsv.2018.05.030] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 05/28/2018] [Indexed: 11/20/2022]
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Tackling the diversity of breast cancer related lymphedema: Perspectives on diagnosis, risk assessment, and clinical management. Breast 2018; 44:15-23. [PMID: 30580170 DOI: 10.1016/j.breast.2018.12.009] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 12/06/2018] [Accepted: 12/17/2018] [Indexed: 01/20/2023] Open
Abstract
Breast cancer related lymphedema (BCRL) develops as a consequence of surgical treatment and/or radiation therapy in a significant number of breast cancer patients. The etiology of this condition is multifactorial and has not yet been completely elucidated. Risk factors include high body mass index, radical surgical procedures (i.e. mastectomy and axillary lymph node dissection), number of lymph nodes removed and number of metastatic lymph nodes, as well as nodal radiation, and chemotherapy. However, these predisposing factors explain only partially the BCRL occurrence, suggesting the possible involvement of individual determinants. Despite the implementation of conservative approaches, BCRL still remains in a proportion of cases an incurable and progressive condition with major physical and psychological implications. To date, diagnostic methods and staging systems lack uniformity, leading to a possible underestimation of the real incidence of this condition, decreasing early detection and thus the possibility of an effective treatment. Several preventive and therapeutic options are available, both conservative and surgical, but are not included in a standardized intervention protocol, tailored on patient's specific characteristics. In this review, we provide a comprehensive overview of the current state-of-knowledge of BCRL management, novel advantages in the assessment of pre-operative evaluation and risk prediction and discuss strengths and weaknesses of diagnostic and treatment strategies currently accessible in clinical practice.
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Hara H, Mihara M. Multi-area lymphaticovenous anastomosis with multi-lymphosome injection in indocyanine green lymphography: A prospective study. Microsurgery 2018; 39:167-173. [DOI: 10.1002/micr.30398] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Revised: 03/10/2018] [Accepted: 08/07/2018] [Indexed: 12/27/2022]
Affiliation(s)
- Hisako Hara
- Department of Lymphatic and Reconstructive Surgery; Saiseikai Kawaguchi General Hospital; Saitama Japan
| | - Makoto Mihara
- Department of Lymphatic and Reconstructive Surgery; Saiseikai Kawaguchi General Hospital; Saitama Japan
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Liu S, Ma X. [Clinical progress of microsurgical management for lymphedema]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2018; 32:1223-1226. [PMID: 30129327 DOI: 10.7507/1002-1892.201803018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective To review the clinical progress of microsurgical management for lymphedema. Methods The literature on microsurgical treatment for lymphedema at home and abroad in recent years was reviewed and analyzed. Results At present, conservative treatment is the main treatment for lymphedema, which has limited effectiveness only for early stages of lymphedema; and it is not curative and demands patient compliance. In contrast, microsurgical approaches can solve the problems in the prevention or management of lymphedema and showed promising results, such as lymphatic-venous anastomosis (LVA), vascularized lymph node transfer (VLNT), and other lymphatic reconstructions. Conclusion Microsurgical approaches like LVA and VLNT have been broadly used in recent years, the effectiveness and safety have been proved. But the evidence of long-term randomized controlled studies is still required to establish standard treatment practices.
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Affiliation(s)
- Shiqiang Liu
- Department of Plastic and Reconstructive Surgery, Xijing Hospital, Air Force Military Medical University, Xi'an Shaanxi, 710032, P.R.China
| | - Xianjie Ma
- Department of Plastic and Reconstructive Surgery, Xijing Hospital, Air Force Military Medical University, Xi'an Shaanxi, 710032,
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Cornelissen AJM, van Mulken TJM, Graupner C, Qiu SS, Keuter XHA, van der Hulst RRWJ, Schols RM. Near-infrared fluorescence image-guidance in plastic surgery: A systematic review. EUROPEAN JOURNAL OF PLASTIC SURGERY 2018; 41:269-278. [PMID: 29780209 PMCID: PMC5953995 DOI: 10.1007/s00238-018-1404-5] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 02/12/2018] [Indexed: 01/15/2023]
Abstract
Background Near-infrared fluorescence (NIRF) imaging technique, after administration of contrast agents with fluorescent characteristics in the near-infrared (700–900 nm) range, is considered to possess great potential for the future of plastic surgery, given its capacity for perioperative, real-time anatomical guidance and identification. This study aimed to provide a comprehensive literature review concerning current and potential future applications of NIRF imaging in plastic surgery, thereby guiding future research. Methods A systematic literature search was performed in databases of Cochrane Library CENTRAL, MEDLINE, and EMBASE (last search Oct 2017) regarding NIRF imaging in plastic surgery. Identified articles were screened and checked for eligibility by two authors independently. Results Forty-eight selected studies included 1166 animal/human subjects in total. NIRF imaging was described for a variety of (pre)clinical applications in plastic surgery. Thirty-two articles used NIRF angiography, i.e., vascular imaging after intravenous dye administration. Ten articles reported on NIRF lymphography after subcutaneous dye administration. Although currently most applied, general protocols for dosage and timing of dye administration for NIRF angiography and lymphography are still lacking. Three articles applied NIRF to detect nerve injury, and another three studies described other novel applications in plastic surgery. Conclusions Future standard implementation of novel intraoperative optical techniques, such as NIRF imaging, could significantly contribute to perioperative anatomy guidance and facilitate critical decision-making in plastic surgical procedures. Further investigation (i.e., large multicenter randomized controlled trials) is mandatory to establish the true value of this innovative surgical imaging technique in standard clinical practice and to aid in forming consensus on protocols for general use. Level of Evidence: Not ratable
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Affiliation(s)
- Anouk J M Cornelissen
- 1Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
| | - Tom J M van Mulken
- 1Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
| | - Caitlin Graupner
- 1Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
| | - Shan S Qiu
- 1Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
| | - Xavier H A Keuter
- 1Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
| | - René R W J van der Hulst
- 1Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands.,2NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
| | - Rutger M Schols
- 1Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
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Single Lymphaticovenular Anastomosis for Early-Stage Lower Extremity Lymphedema Treated by the Superior-Edge-of-the-Knee Incision Method. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2018; 6:e1679. [PMID: 29616175 PMCID: PMC5865933 DOI: 10.1097/gox.0000000000001679] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Accepted: 12/19/2017] [Indexed: 11/26/2022]
Abstract
Supplemental Digital Content is available in the text. Background: Surgical treatment of lower extremity lymphedema (LEL) remains challenging. Application of the superior-edge-of-the-knee incision method for lymphaticovenular anastomosis (LVA) is reported to have a strong therapeutic effect in patients with LEL because lymph-to-venous flow at the anastomosis is enhanced by knee joint movement during normal walking. We investigated whether a single LVA created by this method is adequate for early LEL. Methods: The study involved 10 patients with LEL characterized by stage 2 or 3 leg dermal backflow and treated by a single LVA at the thigh via the superior-edge-of-the-knee incision method. The lymphatic vessel and direction of flow were assessed intraoperatively, and reduction in lymphedema volume was assessed postoperatively. Results: Use of our incision method yielded a single anastomosis in all patients with stage 2 leg dermal backflow and in all patients with stage 3 leg dermal backflow. The lymphatic vessel was 0.65 ± 0.08 mm in diameter (0.65 ± 0.09 and 0.65 ± 0.09 mm, respectively; P = 1.000). No venous reflux occurred in any patient. Mean follow-up was 7.70 ± 3.30 months (9.60 ± 3.29 and 5.80 ± 2.17 months, respectively; P = 0.068). Mean reduction in the LEL index was 20.160 ± 9.892 (22.651 ± 12.272 and 17.668 ± 7.353, respectively; P = 0.462). Conclusion: A single LVA created by the superior-edge-of-the-knee incision method can be expected to have a strong therapeutic effect in patients with stage 2 or 3 leg dermal backflow.
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Mihara M, Hara H, Kawakami Y, Zhou HP, Tange S, Kikuchi K, Iida T. Multi-site lymphatic venous anastomosis using echography to detect suitable subcutaneous vein in severe lymphedema patients. J Plast Reconstr Aesthet Surg 2018; 71:e1-e7. [DOI: 10.1016/j.bjps.2017.10.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 07/09/2017] [Accepted: 10/04/2017] [Indexed: 12/31/2022]
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Mihara M, Hara H, Kawakami Y, Zhou HP, Tange S, Kikuchi K, Iida T. Site Specific Evaluation of Lymphatic Vessel Sclerosis in Lower Limb Lymphedema Patients. Lymphat Res Biol 2018; 16:360-367. [PMID: 29338554 DOI: 10.1089/lrb.2017.0055] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Histological changes in the collecting lymphatics in patients with lymphedema are classified as Normal type, Ectasis type, Contraction type, and Sclerosis type (NECST) classification. In this study, we investigated the condition of the lymphatic vessels in different sites of the legs. PATIENTS AND METHODS We prospectively investigated the lymphatic vessels of patients with lymphedema who underwent lymphaticovenous anastomosis (LVA) from August 8, 2014 to August 4, 2015 based on the NECST classification. Lymphedema was diagnosed using lymphoscintigraphy, indocyanine green (ICG) lymphography, and the International Society of Lymphology (ISL) Classification. The affected limbs were divided into four sites: proximal thigh (Site 1), distal thigh (Site 2), proximal crus (Site 3), and distal crus (Site 4). RESULTS A total of 109 patients (205 limbs and 1028 lymphatics) were included in this study. Of the 109 patients, there were 100 women and 9 men with an average age of 61 years. The ratio of Ectasis type vessels increased toward the distal end of the limb with the highest occurrence rate being 54% at Site 4. As ISL stage, ICG stage, and lymphoscintigraphy stage advanced, so too did the ratio of Sclerosis type. In secondary lymphedema patients with lymphedema, the ratio of Ectasis type was more predominant in the distal end of the limb, whereas this tendency was not observed in primary lymphedema patients. CONCLUSIONS Sclerotic lymphatics are more predominantly found in the proximal limb whereas nonsclerotic vessels are more often found toward the distal end. These findings help lymphatic surgeon determine incision sites.
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Affiliation(s)
- Makoto Mihara
- 1 Department of lymphatic and Reconstructive Surgery, JR Tokyo, General Hospital , Tokyo, Japan .,2 Department of Plastic and Reconstructive Surgery, Fukuoka University , Fukuoka, Japan .,3 Department of Plastic and Reconstructive Surgery, Nadogaya Hospital , Chiba, Japan
| | - Hisako Hara
- 1 Department of lymphatic and Reconstructive Surgery, JR Tokyo, General Hospital , Tokyo, Japan
| | - Yoshihisa Kawakami
- 2 Department of Plastic and Reconstructive Surgery, Fukuoka University , Fukuoka, Japan
| | - Han Peng Zhou
- 4 Clinical Resident, Fujieda Municipal General Hospital , Shizuoka, Japan
| | - Shuichi Tange
- 5 Clinical Resident, NTT East Japan Hospital , Tokyo, Japan
| | - Kazuki Kikuchi
- 3 Department of Plastic and Reconstructive Surgery, Nadogaya Hospital , Chiba, Japan
| | - Takuya Iida
- 6 Department of Plastic and Reconstructive Surgery, The University of Tokyo , Tokyo, Japan
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Hemi-Intravascular Stenting for Supermicrosurgical Anastomosis. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2017; 5:e1533. [PMID: 29263952 PMCID: PMC5732658 DOI: 10.1097/gox.0000000000001533] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Accepted: 08/23/2017] [Indexed: 11/26/2022]
Abstract
Supplemental Digital Content is available in the text. Background: Although supermicrosurgical anastomosis is a widely known reconstructive microsurgical technique, it is difficult to perform. To expand the clinical use of supermicrosurgery, we used hemi-intravascular stenting (hemi-IVaS), which is performed by inserting an intravascular stent into one side of the vessel. We conducted lymphaticovenular anastomosis, free perforator flap transfer, and fingertip replantation with supermicrosurgical anastomosis using hemi-IVaS technique and examined its usefulness. Methods: Between January 2013 and February 2015, 11 anastomoses in 11 cases of lymphaticovenular anastomosis for lymphedema patients, 14 anastomoses in 7 cases of free perforator flap transfer with supermicrosurgical perforator-to-perforator anastomosis, and 9 anastomoses in 5 cases of fingertip replantation were performed using hemi-IVaS. Time required for anastomosis and complications were examined. Flap survival rate was also examined in free perforator flap transfer cases and fingertip replantation cases. Results: In all cases, anastomoses were performed without complications such as inadvertent catching of the back wall of the vessel during the procedure or the need for reanastomoses. The average time required to complete the anastomosis was 16.4 ± 3.20 minutes using the hemi IVaS technique. All flaps survived in the supermicrosurgical perforator-to-perforator anastomosis as well as fingertip replantation cases. Conclusions: Hemi-IVaS could be a useful alternative to conventional intravascular stenting techniques and is also effective for supermicrosurgical perforator-to-perforator anastomosis. Further studies are needed to improve the success rate and to explore its other possible utilizations in supermicrosurgery.
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Comparison of Lymphovenous Shunt Methods in a Rat Model: Supermicrosurgical Lymphaticovenular Anastomosis versus Microsurgical Lymphaticovenous Implantation. Plast Reconstr Surg 2017; 139:1407-1413. [PMID: 28538568 DOI: 10.1097/prs.0000000000003354] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Mazzei MA, Gentili F, Mazzei FG, Gennaro P, Guerrieri D, Nigri A, Gabriele G, Weber E, Fausto A, Botta G, Volterrani L. High-resolution MR lymphangiography for planning lymphaticovenous anastomosis treatment: a single-centre experience. Radiol Med 2017; 122:918-927. [DOI: 10.1007/s11547-017-0795-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 07/20/2017] [Indexed: 02/06/2023]
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Kitayama S, Maegawa J, Matsubara S, Kobayashi S, Mikami T, Hirotomi K, Kagimoto S. Real-Time Direct Evidence of the Superficial Lymphatic Drainage Effect of Intermittent Pneumatic Compression Treatment for Lower Limb Lymphedema. Lymphat Res Biol 2017; 15:77-86. [DOI: 10.1089/lrb.2016.0031] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Shinya Kitayama
- Department of Plastic and Reconstructive Surgery, Yokohama City University School of Medicine, Yokohama, Japan
| | - Jiro Maegawa
- Department of Plastic and Reconstructive Surgery, Yokohama City University School of Medicine, Yokohama, Japan
| | - Shinobu Matsubara
- Department of Plastic and Reconstructive Surgery, Yokohama City University School of Medicine, Yokohama, Japan
| | - Shinji Kobayashi
- Department of Plastic and Reconstructive Surgery, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Taro Mikami
- Department of Plastic and Reconstructive Surgery, Yokohama City University School of Medicine, Yokohama, Japan
| | - Koichi Hirotomi
- Department of Plastic and Reconstructive Surgery, Yokohama City University School of Medicine, Yokohama, Japan
| | - Shintaro Kagimoto
- Department of Plastic and Reconstructive Surgery, Yokohama City University School of Medicine, Yokohama, Japan
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