The role of non-enhanced angiography in toe tip transfer with small diameter pedicle

BACKGROUND

Toe tip transfer allows functional and esthetic reconstruction of the lost fingertip, but it is still uncommon because identification and dissection of donor and recipient veins can be challenging. Nonenhanced angiography (NEA) is a device that emits infrared light at a wavelength of 850 nm, which is exclusively absorbed by hemoglobin. The light penetrates the bones and other soft tissues, effectively visualizing veins in real time. The aim of this report is to present the experience on the preoperative use of nonenhanced angiography for visualization of donor and recipient veins in toe tip transfers in a series of patients.

PATIENTS AND METHODS

Four cases of toe tip transfer and one case of free nail flap were performed for reconstruction of the tips of thumb and finger with preoperative examination using NEA. Patients' age ranged from 29 to 52 years old (average, 29.2 years old). Before the operation, the veins in the donor and recipient sites were marked using NEA, and the blood flow of the veins in the recipient site was confirmed.

RESULTS

Pedicles in all transferred toe tips were less than 2 cm in length, with diameters smaller than 0.8 mm. The postoperative courses were uneventful, and all transferred toe tips survived completely, with satisfying functional and aesthetic results.

CONCLUSIONS

NEA may facilitate venous dissection of the donor and the recipient sites, allowing safe and efficient toe tip transfer with a small pedicle.

Vascularized anal autotransplantation model in rats: preliminary report

Ostomy has served as an effective surgery for various anorectal disfunctions. However, it must also be noted that those patients suffered greatly from stresses caused by their stoma. Many alternative therapies have been developed, but none have solved this critical issue. Meanwhile, due to the improvements in operative methods and immunosuppressive therapy, allotranplantation has gained great popularity in recent years. Therefore, we began development of an anal transplantation model. The operation was performed in six adult Wistar rats that were divided into two groups. Group 1 underwent vascular anastomoses, while group 2 did not Group 1 grafts survived, fully recovering anal function. However, many of the group 2 grafts did not survive; those that did survive showed major defects in their anus, never recovering anal function. We succeeded in establishing the rat anal transplantation model utilizing super-microsurgery. While research in anal transplantation was behind compared to that in other fields, we hope that this model will bring significant possibilities for the future.

Lymphaticovenular anastomosis to prevent cellulitis associated with lymphoedema

BACKGROUND

One of the complications of lymphoedema is recurrent cellulitis. The aim was to determine whether lymphaticovenous anastomosis (LVA) was effective at reducing cellulitis in patients with lymphoedema.

METHODS

This was a retrospective review of patients with arm/leg lymphoedema who underwent LVA. The frequency of cellulitis was compared before and after surgery. The diagnostic criteria for cellulitis were a fever of 38·5°C or higher, and warmth/redness in the affected limb(s).

RESULTS

A total of 95 patients were included. The mean number of episodes of cellulitis in the year preceding surgery was 1·46, compared with 0·18 in the year after surgery (P < 0·001).

CONCLUSION

LVA reduced the rate of cellulitis in these patients with lymphoedema.

Navigation lymphatic supermicrosurgery for the treatment of cancer-related peripheral lymphedema

BACKGROUND

Lymphatic supermicrosurgery is becoming the treatment of choice for refractory lymphedema. Detection and anastomosis of functional lymphatic vessels are important for lymphatic supermicrosurgery.

METHODS

Navigation lymphatic supermicrosurgery was performed using an operating microscope equipped with an integrated near-infrared illumination system (OPMI Pentero Infrared 800; Carl Zeiss, Oberkochen, Germany). Eight patients with extremity lymphedema who underwent navigation lymphatic supermicrosurgery were evaluated.

RESULTS

A total of 21 lymphaticovenular anastomoses were performed on 8 limbs through 14 skin incisions. Lymphatic vessels were enhanced by intraoperative microscopic indocyanine green (ICG) lymphography in 12 of the 14 skin incisions, which resulted in early dissection of lymphatic vessels. All anastomoses showed good anastomosis patency after completion of anastomoses. Postoperative extremity lymphedema index decreased in all limbs.

CONCLUSIONS

Navigation lymphatic supermicrosurgery, in which lymphatic vessels are visualized with intraoperative microscopic ICG lymphography, allows a lymphatic supermicrosurgeon to find and dissect lymphatic vessels earlier and facilitates successful performance of lymphaticovenular anastomosis.

Near-infrared illumination system-integrated microscope for supermicrosurgical lymphaticovenular anastomosis

BACKGROUND

Lymphatic supermicrosurgery, lymphaticovenular anastomosis (LVA), is becoming a treatment option for progressive lymphedema with its effectiveness and minimal invasiveness. It is important to detect and anastomose large functional lymphatic vessels for LVA surgery. This study aimed to evaluate usefulness of a near-infrared illumination system-integrated microscope for lymphatic supermicrosurgery.

METHODS

We performed LVA on 12 lower extremity lymphedema (LEL) patients with or without intraoperative microscopic indocyanine green (ICG) lymphography guidance. An operating microscope equipped with an integrated near-infrared illumination system (OME-9000; Olympus, Tokyo, Japan) was used for intraoperative microscopic ICG lymphography guidance. Feasibility, anastomosis patency, and treatment effect of the method were evaluated.

RESULTS

Forty LVAs were performed (24 LVAs with intraoperative microscopic ICG lymphography-guidance on 7 limbs, and 16 LVAs without the guidance on 5 limbs). Lymphatic vessels were enhanced by intraoperative microscopic ICG lymphography in 11 of 12 skin incision sites. Time required for detection and dissection of lymphatic vessels in cases with intraoperative microscopic ICG lymphography guidance was significantly shorter than that in cases without the guidance (2.3 ± 1.7 min vs. 6.5 ± 4.0 min, P = 0.010). There was no statistically significant difference in LEL index reduction between cases with and without intraoperative microscopic ICG lymphography guidance (18.3 ± 5.5 vs. 15.0 ± 5.5, P = 0.337).

CONCLUSIONS

Intraoperative microscopic ICG lymphography visualized lymphatic vessels, which helps a lymphatic supermicrosurgeon to find and dissect lymphatic vessels earlier.

Free concha flap for sensitive nasal reconstruction using the infraorbital artery and nerve as a recipient vessel and a recipient nerve

Free auricular flap transplantation is one of the treatments for nasal reconstruction. This report presents a case of nasal reconstruction where the infraorbital artery was used as a recipient vessel, and the infraorbital nerve as a recipient sensory nerve. A 75-year-old female underwent resection of malignant melanoma of the right nasal ala. A free ear concha flap was used for the reconstruction. The facial artery could not be found intraoperatively; instead, the infraorbital artery was identified and anastomosed with the posterior auricular artery. The great auricular nerve was coapted with the infraorbital nerve. The results of the sensory examination were the same as those of the unaffected side. This procedure not only achieves a good aesthetic outcome, but also restores sufficient sensory function.

Side-to-end Lymphaticovenular anastomosis through temporary lymphatic expansion

OBJECTIVE

The number of bypasses is the most important factor in lymphaticovenular anastomosis (LVA) for lymphedema treatment. Side-to-end (S-E) LVA, which can bypass bidirectional lymph flows via one anastomosis, is considered to be the most efficient bypass, but creation of lateral window to a small lymphatic vessel is technically demanding. To overcome the difficulty, we introduced S-E anastomosis through temporary lymphatic expansion (SEATTLE) procedure in S-E LVA.

METHODS

This was a retrospective observational study set in a teaching hospital. Forty eight lower extremity lymphedema (LEL) patients underwent LVA. S-E LVAs were performed with (SEATTLE group) or without (non-SEATTLE group) temporary lymphatic expansion. S-E LVAs were evaluated to compare anastomosis result in SEATTLE and non-SEATTLE groups.

RESULTS

S-E LVAs resulted in 44 anastomoses in SEATTLE group (n = 25) and 37 anastomoses in non-SEATTLE group (n = 23). LEL index reduction in SEATTLE group was significantly greater than that in non-SEATTLE group (16.5±14.5 vs. 10.9±11.8, P = 0.041). Success rate of S-E LVA in SEATTLE group was significantly higher than that in non-SEATTLE group (95.5% vs 81.1%, P = 0.040). Thirty seven of 44 (84.1%) lymph vessels in SEATTLE group were successfully dilated by temporary lymphatic expansion maneuver. All of 9 failed S-E LVAs used a lymphatic vessel with diameter of 0.35 mm or smaller.

CONCLUSIONS

The SEATTLE procedure facilitates S-E LVA by a simple and easy maneuver. When the diameter of the lymphatic vessel is 0.35 mm or smaller even after the temporary lymphatic expansion maneuver, S-E LVA is not recommended due to relatively high failure rate.

Low-invasive lymphatic surgery and lymphatic imaging for completely healed intractable pudendal lymphorrhea after gynecologic cancer treatment

Lower limb lymphedema and an accompanying lymphatic fistula (lymphorrhea) occur as complications after gynecologic surgery to treat cancer. Herein, we report the case of a 68-year-old woman who underwent resection and radiotherapy because of uterine cervical cancer (stage 2a) 20 years previously. Left lower limb and pudendal lymphedema and continuous lymphorrhea developed soon after surgery. Conservative treatment was administered; however, the edema increased, and a pudendal lymphatic fistula and cellulitis developed repeatedly. Lymphovascular anastomosis (LVA) and lymph vessel ligation were performed after preoperative evaluation via lymphoscintigraphy and indocyanine green (ICG) lymphography. A radioisotope injected into the first interdigit pedal region flowed into the pudendal region via the inguinal lymph nodes at preoperative lymphoscintigraphy. Linear patterns were observed up to the half level of the crus, and stardust patterns occurred over the lower abdominal and pudendal regions at ICG lymphography. During surgery, ICG lymphography was also used to identify the site of the fistula. With the patient under local anesthesia, LVA was applied in the half crus and left inguinal regions, followed by ligation and division of lymph vessels flowing into the fistula. The region around the fistula was excised as a 1 × 3-cm tissue block. As of 5 months after surgery, no recurrence of lymphatic fistula or exacerbation of lymphedema has occurred. This case shows the effectiveness of preoperative ICG lymphography and lymphoscintigraphy followed by treatment via lymph vessel ligation and LVA for curative resolution of a lymphatic fistula.

Recent advancement on surgical treatments for lymphedema

Treatment for limb lymphedema is challenging. The recent development of the super-microsurgical technique has made lymphaticovenular (LV) anastomosis an easier and more accurate surgical method for lymphedema. A summary of our experience as well as recent developments in surgical treatments for lymphedema are described.

METHODS AND RESULTS

Ultra-microstructural analysis demonstrated that dysfunction of the lymphatics in lymphedema was caused by the degeneration and incomplete regeneration of smooth muscle cells and valve insufficiency in the lymphatic channel. ICG and infrared ray examinations have been proposed as new means of assessment of lymphatic function. LV anastomosis is suitable for genital edema, arm edema with severe phlegmone with leg edema, and early stage leg edema. Although pre- and postoperative compression therapy is generally required for limb edema, some cases do not require postoperative compression due to remaining or regenerated smooth muscle cells. As new methods of treatment, the vascularized lymphadiposal flap has been effective for progressive cases with LV anastomosis. LV anastomosis is also effective for congenital chyloabdomen. (*English Translation of J Jpn Coll Angiol 2008; 48: 173-178.).

Pathological steps of cancer-related lymphedema: histological changes in the collecting lymphatic vessels after lymphadenectomy

Introduction

To date, an electron microscopy study of the collecting lymphatic vessels has not been conducted to examine the early stages of lymphedema. However, such histological studies could be useful for elucidating the mechanism of lymphedema onset. The aim of this study was to clarify the changes occurring in collecting lymphatic vessels after lymphadenectomy.

Methods

The study was conducted on 114 specimens from 37 patients who developed lymphedema of the lower limbs after receiving surgical treatment for gynecologic cancers and who consulted the University of Tokyo Hospital and affiliated hospitals from April 2009 to March 2011. Lymphatic vessels that were not needed for lymphatico venous anastomosis surgery were trimmed and subsequently examined using electron microscopy and light microscopy.

Results

Based on macroscopic findings, the histochemical changes in the collecting lymphatic vessels were defined as follows: normal, ectasis, contraction, and sclerosis type (NECST). In the ectasis type, an increase in endolymphatic pressure was accompanied by a flattening of the lymphatic vessel endothelial cells. In the contraction type, smooth muscle cells were transformed into synthetic cells and promoted the growth of collagen fibers. In the sclerosis type, fibrous elements accounted for the majority of the components, the lymphatic vessels lost their transport and concentrating abilities, and the lumen was either narrowed or completely obstructed.

Conclusions

The increase in pressure inside the collecting lymphatic vessels after lymphadenectomy was accompanied by histological changes that began before the onset of lymphedema.

Indocyanine green (ICG) lymphography is superior to lymphoscintigraphy for diagnostic imaging of early lymphedema of the upper limbs

BACKGROUND

Secondary lymphedema causes swelling in limbs due to lymph retention following lymph node dissection in cancer therapy. Initiation of treatment soon after appearance of edema is very important, but there is no method for early diagnosis of lymphedema. In this study, we compared the utility of four diagnostic imaging methods: magnetic resonance imaging (MRI), computed tomography (CT), lymphoscintigraphy, and Indocyanine Green (ICG) lymphography.

PATIENTS AND METHODS

Between April 2010 and November 2011, we examined 21 female patients (42 arms) with unilateral mild upper limb lymphedema using the four methods. The mean age of the patients was 60.4 years old (35-81 years old). Biopsies of skin and collecting lymphatic vessels were performed in 7 patients who underwent lymphaticovenous anastomosis.

RESULTS

The specificity was 1 for all four methods. The sensitivity was 1 in ICG lymphography and MRI, 0.62 in lymphoscintigraphy, and 0.33 in CT. These results show that MRI and ICG lymphography are superior to lymphoscintigraphy or CT for diagnosis of lymphedema. In some cases, biopsy findings suggested abnormalities in skin and lymphatic vessels for which lymphoscintigraphy showed no abnormal findings. ICG lymphography showed a dermal backflow pattern in these cases.

CONCLUSIONS

Our findings suggest the importance of dual diagnosis by examination of the lymphatic system using ICG lymphography and evaluation of edema in subcutaneous fat tissue using MRI.

Idiopathic portal hypertension and lower limb lymphedema

Idiopathic lymphedema is a condition where lymph accumulates in subcutaneous tissue without a clear cause. Likewise, idiopathic portal hypertension is a syndrome where intrahepatic peripheral portal branch obstruction causes portal hypertension without a clear cause. We encountered a 37-year-old man with both idiopathic lymphedema and idiopathic portal hypertension. He had a history of right lower limb edema and epigastric varices since childhood with repeated cellulitis in the affected limb. Lymph accumulation and dilation of collateral lymph pathways in the right lower limb were observed by indocyanine green and lymphoscintigraphy, and a serpentine thoracic duct was observed using MRI. Idiopathic portal hypertension and idiopathic lymphedema were diagnosed, and peripheral lymphaticovenous anastomosis was performed for treatment of lymphedema. The limb circumference improved, and the frequency of cellulitis decreased. It is postulated that an abnormality in the embryonic cardinal vein before lymph vessel differentiation could be a possible mechanism of the dual pathologic conditions.

A new device expanding operability of fingertip replantation: subzone 1 fingertip replantation assisted by non-enhanced angiography in a 2-year-old boy

Fingertip replantation in young children is difficult, especially in cases with amputation at subzone 1. Replantation is preferred whenever possible, but the identification of vessels of operative size can be very challenging. Non-enhanced angiography (NEA; Genial Viewer; Genial Light, Shizuoka, Japan) emits infrared light with the wavelength of 850 nm, which is exclusively absorbed by haemoglobin. The light penetrates the bones and other soft tissues, effectively visualising vessels containing blood, and the image is shown in real time on the screen of a laptop computer. We present a case in which preoperative NEA visualised vessels in the amputated fingertip, allowing a successful replantation in a 2-year-old boy. By taking the guesswork out of vessel localisation, NEA can be useful in expanding operability of replantation surgery in fingertip amputations.

Preexcisional artery reconstruction: a new strategy in multiple hepatic artery reconstruction for reducing ischemic injury of the liver

Multiple reconstructions of the hepatic arteries (HA) after cancer resection presents a surgical challenge, not only because it is technically demanding, but also because attention must be paid to potential ischemic injury to the liver caused by the prolonged ischemia. We present a novel "preexcisional artery reconstruction" method for minimizing ischemic injury of the liver. A 65-year-old woman presented with cholangiocarcinoma invading the HA. Pancreatoduodenectomy, resection, and multiple reconstruction of the HA were performed. First, the left hepatic artery (LHA) was reconstructed prior to the tumor resection. During this procedure, blood supply was maintained to most of the liver via the right hepatic artery (RHA). Then, resection of the tumor en bloc with the HA was performed, followed by reconstruction of the RHA. During this procedure, blood supply was maintained via the already-reconstructed LHA, thereby limiting the ischemic area. Use of this method allowed the ischemia time and region to be divided and minimized, thereby leading to a reduced risk of ischemia-related complications. We believe that this method may be one of the useful approaches in multiple HA reconstruction.

Lower limb lymphedema treated with lymphatico-venous anastomosis based on pre- and intraoperative icg lymphography and non-contact vein visualization: A case report

Lymphatico-venous anastomosis (LVA) is used to resolve lymph retention in lymphedema. However, the postoperative outcome of lower limb lymphedema is poorer than that for upper limb lymphedema, because of the location lower than the heart level. Improvement of the therapeutic outcome requires application of as many anastomoses as possible in a limited operation time, particularly since there is a positive correlation between the number of anastomoses and the therapeutic effect of LVA. In this case, we described a method to increase the efficiency of lymphatico-venous anastomosis for bilateral severe lower limb lymphedema through efficient identification of lymph vessels and veins suitable for anastomosis using indocyanine green (ICG) contrast imaging and AccuVein, a noncontact vein visualization system, respectively. Ten LVAs were succeeded at seven incisions, and the operation time was 3 hours and 5 minutes. Accuvein can be used for identification of subcutaneous venules with a diameter of about 0.5-1.0 mm. We used this approach in surgery for a case of bilateral lower limb lymphedema, with a resultant improvement in the surgical outcome.

Severe lymphedema caused by repeated self-injury

Lymphedema is divided into primary and secondary forms. Primary lymphedema often develops in young people and may be caused by lymphvascular aplasia, hypoplasia, and hyperplasia. The most frequent cause of secondary lymphedema after lymphatic filariasis is regional lymph node dissection for treatment of a malignant tumor, and this complication occurs most frequently in middle aged or older patients. Here, we describe a relatively young patient (27 years old) in whom collecting lymph vessels in the upper limb were disrupted by repeated self-injury, with resultant lymphedema. There have been very few reports on lymphedema caused by self-induced trauma. This case report illustrates that secondary lymphedema should also be considered and evaluated appropriately when diagnosed in a relatively young patient without a history of cancer or infection.

Pure skin perforator flap for microtia and congenital aural atresia using supermicrosurgical techniques

Microtia or pinna deformities with congenital aural atresia are severe conditions that significantly affect the quality of life. Although several surgical treatments have been proposed for aural atresia, revision surgery is often required to address complications associated with the initial procedure, which include external auditory canal stenosis, lateralization of the tympanic membrane and chronic recurrent otorrhea. However, such problems may be addressed by using vascularized skin. We herein report a new method of reconstruction for congenital aural atresia in three cases using the superficial circumflex iliac artery as a pure skin perforator flap.

MATERIALS & METHODS

The branch of the superficial circumflex iliac artery perforator was traced distally to a point where it penetrated the dermis. After identifying the branch of the perforator penetrating the dermis (termed the "pure skin perforator"), the pure skin perforator flap was elevated. A new external auditory canal was then created by drilling through the mastoid air cells and atresia plate. The pure skin perforator flap was folded into a 1.5×3 cm sac, which was placed into the external auditory canal. The superficial circumflex iliac artery and the superficial circumflex iliac vein were anastomosed to the superficial temporal artery and the superficial temporal vein, respectively.

RESULTS

All of the pure skin perforator flaps survived. The flap sizes varied from 10×2.5 to 10×4 cm (average area of 32.5 cm2). These skin perforator flaps were all 2 mm thick.

CONCLUSION

Pure skin perforator flaps fed only by the dermal subpapillary plexus survived, regardless of the presence of the subdermal plexus. The pure skin perforator flap can be as thin as a skin graft and it has the possibility to reduce the complications that frequently occur when the previously reported procedures are used.

Flap salvage following postoperative venous thrombosis diagnosed by blood glucose measurement in the flaps

OBJECTIVE

This is the first paper to report the measurement of blood glucose in flaps to detect early flap congestion and flap salvage following immediate flap exploration.

METHODS

We performed blood glucose measurement in a superficial circumflex iliac artery perforator flap and an anterolateral thigh flap postoperatively using Medisafe-Mini (Terumo, Japan), a regular capillary blood glucose-monitoring device.

RESULTS

The blood glucose measurements were low when in early venous thrombosis. Low capillary blood glucose levels were detected early, even before flap discoloration occurred.

CONCLUSIONS

Low capillary blood glucose level in congested flaps is an early sign of venous thrombosis. The incorporation of blood glucose measurement in addition to clinical monitoring aids in early detection and possible reduction postoperative complications due to venous thrombosis.