Retrograde Lymph Flow in the Lymphatic Vessels in Limb Lymphedema

A systematic review of indocyanine green lymphography imaging for the diagnosis of primary lymphoedema

OBJECTIVES

This systematic review aims to evaluate the use of indocyanine green lymphography (ICGL) for the investigation of the lymphatics in the lower limbs of primary lymphoedema patients.

METHODS

MEDLINE and EMBASE articles from January 1, 2000 to September 1, 2023 were searched for. A total of 11 studies were included in the review after a two-stage screening process.

RESULTS

Data on patient demographics, ICG contrast injection technique, imaging protocols, and imaging outcomes were summarized and reviewed in detail. The review highlights the lack of commonality in protocols used. Factors important for good imaging are highly variable, particularly the number of injections, their location, and whether they are delivered intradermally or subcutaneously.

CONCLUSIONS

ICGL has strong potential to become a diagnostic tool to diagnose lymphoedema due to its non-ionizing nature and cost-effectiveness. However, due to the lack of thorough phenotyping and genotyping of patients included in the studies, uncertainty still exists as to the value of the described imaging features such as splash, starburst, and diffuse dermal rerouting patterns. Future studies, therefore, should aim to explore the diagnostic utility of ICGL for lymphoedema further through the imaging of primary lymphoedema patients with a confirmed genetic diagnosis and using standardized imaging protocols.

ADVANCES IN KNOWLEDGE

ICGL is a strong candidate for advancing the diagnosis and understanding of primary lymphoedema, and monitoring response to treatment, but protocol heterogeneity and a lack of consistency in reporting imaging details and patient phenotyping currently hold it back.

Gastroepiploic Vascularized Lymph Node Transfer for Extremity Lymphedema: Tips and Insights from Extensive Clinical Experience

Background and Objectives: Lymphedema is a chronic and progressive condition that leads to significant morbidity, including recurrent infections, fibrosis, and functional limitations. Conservative treatments often offer limited relief, particularly in severe cases. Vascularized lymph node transfer (VLNT), especially using the gastroepiploic lymph node flap, has emerged as a promising intervention. This study evaluates the long-term outcomes of gastroepiploic VLNT combined with suction-assisted lipectomy (SAL) for extremity lymphedema. Materials and Methods: A retrospective review was conducted on 53 patients treated for lymphedema at our clinic in Taiwan from January 2016 to August 2023. The inclusion criteria required patients to have persistent lymphedema for at least six months despite conservative treatment. VLNT was performed using a laparoscopic approach, and postoperative assessments included limb circumference measurements, lymphoscintigraphy, and tonicity evaluations. Results: Follow-up data were collected for a minimum of 12 months. At a mean follow-up of 14.2 months, significant reductions in limb circumference were observed-35.5% ± 24.9% for upper limbs and 32.2% ± 4.5% for lower limbs. Tonicity improved by 6.2%, and no cellulitis episodes were reported post-surgery. Minor complications included hematoma and sensory changes, with no major donor-site morbidity. Lymphoscintigraphy confirmed improved lymphatic drainage. Conclusions: Gastroepiploic VLNT combined with SAL is an effective and safe treatment for severe extremity lymphedema, providing significant improvements in limb size and tissue tonicity. This technique offers a promising solution for refractory cases.

Fundamentals for Supermicrosurgical Lymphaticovenular Anastomosis: Part 1 Comprehensive Review of Anastomosis Techniques and Proposal for a Flowchart Algorithm

Supermicrosurgical lymphaticovenular anastomosis represents an established procedure for lymphedema treatment, the effectiveness of which has been well documented in international literature. Nevertheless, currently, no standards for supermicrosurgical lymphaticovenular anastomosis have been established regarding the type, location, and number of anastomoses so that the approach to surgical scenarios still depends on the surgeons' preference and ability. A comprehensive literature search for articles involving supermicrosurgical lymphaticovenular anastomosis techniques was performed on the PubMed/Medline/SCOPUS databases. Results, including the names of the technique and their characteristics, such as indications, surgical time, and configuration of the vessels, are reported. Each technique included was then performed five times, and for each of them, patency was tested intraoperatively and 30 days after surgery. Moreover, an efficacy score was assigned, taking into consideration the number of lymphatic vessels anastomosed, the average time for anastomosis, and the difficulty of each technique. A total of 148 articles resulted from the literature search. In total, 16 papers met the criteria for inclusion as defined in the methods and were included in the review as a "supermicrosurgical lymphaticovenular anastomosis technique." Efficacy scores ranged from 0.21 to 1, intraoperative patency ranged from 80% to 100%, and the 30-days patency test ranged from 60% to 100%. To perform effective anastomoses and aim to maximize the results of supermicrosurgical lymphaticovenular anastomosis, a modern microsurgeon should be trained to recognize and manage the most common vessel configurations, performing the most adequate one of the several techniques described. Further studies are required to validate and compare the use of the supermicrosurgical lymphaticovenular anastomosis techniques reviewed.