Treating and preventing recurrence of recurrent genital acquired lymphangiectasia using lymphaticovenous anastomosis at genital area: A case report

Necrotizing Fasciitis Occurred in the Lymphedematous leg

Lymphedema is a chronic edema that sometimes occurs after treatment of gynecologic cancer, and cellulitis often occurs concomitantly with lymphedema. On the other hand, necrotizing fasciitis (NF) is a relatively rare, but life-threatening disease. The symptoms in cellulitis and NF are very similar. In this case report, we describe a case in which the diagnosis of NF in a lymphedematous limb was difficult. A 70-year-old woman had secondary lymphedema in bilateral legs and consulted our department. On the first day of lymphedema therapy, the patient complained of vomiting, diarrhea, and fever (37.7 °C) without local fever in the legs. She was diagnosed with acute gastroenteritis. On the next day, swelling and pain in her left leg occurred and her blood pressure was 59/44 mmHg. She was diagnosed with cellulitis accompanied by lower limb lymphedema and septic shock. On the second day, blisters appeared on the left leg, and computed tomography showed NF. We performed debridement under general anesthesia and her vital signs improved postoperatively. Streptococcus agalactiae (B) was detected in blood culture, and we administered bixillin and clindamycin. Postoperatively, necrosis in the skin and fat around the left ankle gradually spread, and it took 5 months to complete epithelialization. The diagnosis was more difficult than usual NF because patients with lymphedema often experience cellulitis. Clinicians should always think of NF to avoid mortality due to delayed treatment. This case report was approved by the institutional ethics committee.

Ultrasound-guided lymphaticovenous anastomosis without indocyanine green lymphography mapping: A preliminary report

BACKGROUND

Although indocyanine green (ICG) lymphography is the standard preoperative examination for lymphaticovenous anastomosis (LVA), it cannot be performed in patients allergic to ICG. This report aimed to clarify the effects of LVA with lymphatic ultrasound and without ICG lymphography.

METHOD

Lymphatic ultrasound was performed preoperatively on six limbs of four patients with lower limb lymphedema who were allergic to ICG to detect the lymphatic vessels. All patients were women and had secondary lymphedema after uterine cancer treatment, with a mean age of 57.0 years (range; 47-68 years). The severity of lymphedema was stage 2a in two limbs, stage 2b in three limbs, and stage 3 in one limb. During the preoperative lymphatic ultrasound, we searched for the dilated lymphatic vessels in the saphenous, lateral calf, and lateral thigh lymphosomes. The incision sites were determined based on the ultrasonographic findings, and LVA was performed under local anesthesia. The surgical results were evaluated based on the limb volume calculated from the circumferences.

RESULT

Totally, 13 skin incisions were made, and the lymphatic vessels consistent with the ultrasonographic findings were found in all locations. The mean number of the lymphatic vessels anastomosed per limb was 2.2 (range; 1-4). The mean diameter of the lymphatic vessel was 0.69 mm (range; 0.3-1.0 mm). No complications were observed in the perioperative period. The mean follow-up period was 386.8 days. The mean preoperative and postoperative limb volumes were 5468 ml (range; 4552-6378 ml) and 5027.4 ml (range; 4353-5561 ml). Limb volume decreased in all six limbs.

CONCLUSION

The effectiveness of performing LVA by identifying the lymphatic vessels using lymphatic ultrasound was demonstrated. More medical institutions will be able to perform LVA in the future, even without ICG devices.

Lymphatic refill in ultrasound and lymphatic washout after lymphaticovenous anastomosis

BACKGROUND

Lymphaticovenous anastomosis (LVA) drains lymph accumulated in the lymphatic vessels into the veins (lymphatic washout). A method to identify the ideal lymphatic vessels to achieve washout has not been established. This study examined the relationship between lymphatic washout, lymphatic ultrasonographic findings, and surgical outcomes.

METHODS

We reviewed consecutive patients who underwent LVA for lower limb lymphedema between September 2020 and March 2021. Patients who lacked data were excluded. Preoperative ultrasonography was performed to measure the lymphatic diameter. After the probe was pressed against the skin and released, the reaction of the lymphatic vessels was classified as either refilled, crushed, undecidable, or solid. Intraoperatively, whether lymphatic washout was observed or not, was recorded and compared to preoperative findings using the chi-square test. In 54 limbs from 32 patients, the total number of LVA, number of anastomoses with washout, number of refills detected by ultrasound, and severity of lymphedema were compared with the surgical result (postoperative limb volume change) by multiple regression analysis (49 limbs whose pre-or postoperative circumference data were lacking or who underwent intensive compression therapy postoperatively were excluded).

RESULTS

Sixty-five patients were reviewed. After excluding six patients with missing data, 59 patients (103 limbs) were included. The median patient age was 63 years (interquartile range, 51-76 years). We performed LVA at 217 sites (mean, 2.1 anastomoses per limb). "Refilled" lymphatics were observed at 156 sites (71.6%) and significantly thicker than those classified as "undecidable" (p = .020 in the lower leg and p < .001 in the thigh). In the thigh, "refilled" lymphatics had a higher rate of a washout than those classified as "undecidable." In Pearson's correlation coefficient for the surgical result, as the number of washout positive LVA increased, the limb volume tended to decrease postoperatively (correlation coefficient: -0.25). However, multiple regression analysis did not identify any factors that significantly affected the surgical outcomes.

CONCLUSION

"Refilled" lymphatic vessels had a higher rate of intraoperative lymphatic washout after anastomosis.

Genital lymphaticovenous anastomosis (LVA) and leg LVA to prevent the recurrence of genital acquired lymphangiectasia

BACKGROUND

Genital acquired lymphangiectasia (GAL) commonly recurs after simple resection. This study aimed to elucidate the efficacy of lymphaticovenous anastomosis (LVA) in the genital region or legs for preventing GAL recurrence after resection.

METHODS

We retrospectively investigated 25 female patients who underwent GAL resection and LVA, lymphoscintigraphy, and indocyanine green (ICG) lymphography. Isotope or ICG was injected into the leg. Medicine accumulating in the genitals indicates lymphatic flow from the legs to the genitals (type 1). In some cases, we injected ICG into the anus to detect lymphatic flow from the anus to the genitals (type 2). Based on the findings, we selected LVA site (genital or leg).

RESULTS

The mean patient age was 61.4 (range, 42-81) years. Seventeen patients underwent leg LVA only, while eight patients underwent genital LVA. The mean follow-up period was 285 (range, 87-365) days. GAL recurrence was observed in 10 patients (40.0%): three of eight (37.5%) who underwent genital LVA versus seven of 17 (41.2%) who underwent leg LVA. Among patients with type 2 lymphatic vessels, GAL recurrence was observed in two of six (33.3%) who underwent genital LVA versus five of nine (55.6%) who underwent leg LVA.

CONCLUSION

Genital LVA prevented GAL recurrence in patients with type 2 lymphatic flow. Detecting the direction of lymphatic flow around GAL is essential to its successful treatment.