Multi-site lymphatic venous anastomosis using echography to detect suitable subcutaneous vein in severe lymphedema patients

Surgical Treatment of Lymphedema in the Upper Extremity

The advent of supermicrosurgery has led to an increasing interest in the surgical management of lymphedema through the reconstruction of the lymphatic network, that is, the physiologic approach. Broadly, this can be divided into 2 main techniques: lymphaticovenous anastomosis and lymph node transfer. In the United Kingdom, the British Lymphology Society does not provide any recommendations on surgical management. Moreover, surgical treatment of lymphedema is not widely practiced within the National Health Service due to low-certainty evidence. Herein, we discuss our experience in physiologic reconstruction for lymphedema.

Surgical options for lymphedema after gynecological cancer treatment: current trends and advances

Lower leg lymphedema is an important complication after gynecological treatment that can severely affect the quality of life of long-term survivors of these malignancies. As a chronic and progressive disease, affected patients will require life-long therapy centered on compression. Although conventional compressive treatments can be effective, they are extremely burdensome and time-consuming for most patients and adherence is challenging. With advances in the field of reconstructive microsurgery, new procedures have been developed in the past decades to help these patients in their continuous care and have been offered at many oncological centers around the world as a first line of treatment. We performed a PubMed search using the Mesh terms 'Lymphedema/surgery' and 'Lower extremity' yielding a total of 508 articles. Of these, 35 articles were included for analysis. Articles that failed to provide a comprehensive analysis of outcomes following surgical treatment, studies examining treatment for upper limb lymphedema, primary lymphedema, or lower extremity lymphedema resulting from non-gynecologic etiologies, and studies that failed to have a minimum of 6 months follow-up were excluded. A comprehensive review of these 35 articles including over 1200 patients demonstrated large variability on the outcomes reported; however, an overall benefit from these procedures was found. Surgical options including lymphovenous anastomosis, vascularized lymph node transfers, and excisional procedures can be performed in patients with lower leg lymphedema, depending on staging and findings in indocyanine green lymphography. Surgical treatment of lymphedema is an effective option that can improve symptoms and quality of life of patients suffering from lymphedema following gynecologic cancers.

Usefulness of 33 MHz Linear Probe in Lymphatic Ultrasound for Lymphedema Patients

Background: Lymphatic ultrasound has recently been reported useful in the treatment of lymphedema. However, no conclusions have been reached regarding the best probe for lymphatic ultrasound. Methods: This was a retrospective study. Fifteen limbs of 13 patients with lymphedema in whom we could not find dilated lymphatic vessels on lymphatic ultrasound with an 18 MHz probe but later could find them with 33 MHz probe were included. All patients were women, and the mean age was 59.5 years. We performed lymphatic ultrasound in four areas per limb by applying an index of D-CUPS, as we previously reported. We measured the depth and diameter of the lumen of the lymphatic vessels. We also diagnosed the degree of lymphatic degeneration based on the normal, ectasis, contraction, and sclerosis type (NECST) classification. Results: We found lymphatic vessels in 22/24 (91.7%) areas in the upper limbs and 26/36 (72.2%) areas in the lower limbs. The mean depth and diameter of the lymphatic vessels were 5.2 ± 0.28 mm and 0.33 ± 0.029 mm, respectively. Based on the NECST classification, 68.2% of the upper limbs and 56.0% of the lower limbs were of the ectasis type. We found functional lymphatic vessels in 6/6 (100%) of the upper limbs and 5/7 (71.4%) of the lower limbs, which indicated lymphaticovenous anastomosis (LVA) in these 11 patients. Conclusion: Using 33 MHz probe, we could detect functional lymphatic vessels in most patients. Even if lymphatic vessels were not found with the 18 MHz probe, LVA could be performed using a higher frequency probe.

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.

Outcomes of Lymphovenous Anastomosis for Lower Extremity Lymphedema: A Systematic Review

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.

The accuracy of lymphatic ultrasound in measuring the lymphatic vessel size in lower limb lymphedema patients

BACKGROUND

Lymphatic ultrasound is a newly developed method to observe the lymphatic vessels. In this study, we compared the diameter of lymphatic vessels observed on preoperative ultrasound with the actual lymphatic diameter (LD) of lymphatic vessels observed intraoperatively.

METHODS

The study included 32 lower limbs in 17 patients with lower limb lymphedema. Lymphatic ultrasound was performed using a commonly used ultrasound device, Noblus ultrasound system, with an 18 MHz linear probe on preoperative day 1. We tracked the lymphatic vessels along the great saphenous vein, at the lateral calf, and at the lateral thigh, based on the lymphosome principle. We measured the cross-sectional height (CSH) and the cross-sectional width (CSW) of lymphatic vessels using ultrasound at the incision sites. Intraoperatively, we measured the diameter of the lymphatic vessel. Based on lymphatic degeneration, lymphatic vessels were categorized into four types using the normal-, ectasis-, contraction-, and sclerosis-type (NECST) classification.

RESULTS

We evaluated 68 lymphatic vessels. The mean CSH, CSW, and LD were 0.65 ± 0.35 mm, 1.3 ± 0.41 mm, and 0.79 ± 0.35 mm, respectively. The correlation coefficient between the CSH and the LD was 0.36 and that between the CSW and LD was 0.24. A significant difference was observed in CSH between the ectasis and contraction types (p = 0.0025).

CONCLUSIONS

We can somehow predict the size of the lymphatic vessels with CSH in the lymphatic ultrasound, whereas CSW is not reliable.

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.

Surgical Management of Postmastectomy Lymphedema and Review of the Literature

ABSTRACT

Upper limb lymphedema is one of the most common complications after breast cancer surgery and radiotherapy. At present, physical methods and surgical methods can be used for treatment. Surgical operations are mainly based on lymphovenous anastomosis and vascularized lymph node transfer. For these 2 surgical methods, we analyzed and compared the literature review and our own clinical experience. We summarized the differences between the 2 surgical techniques and the selection methods. We hope to help more young plastic surgeons and breast doctors understand how to treat upper limb lymphedema through surgical methods and help patients improve their quality of life.

Diagnosis of Lymphatic Dysfunction by Evaluation of Lymphatic Degeneration with Lymphatic Ultrasound

Background: The standard examination for diagnosing lymphedema is lymphoscintigraphy, which has a disadvantage in versatility and radiation exposure. We have reported the usefulness of echography in observing the lymphatic degeneration. The purpose of this study was to investigate the usefulness of lymphatic ultrasound in diagnosing lymphedema. Methods and Results: The study included 14 patients (28 lower limbs) who underwent lymphaticovenous anastomosis for lower limb lymphedema. Preoperative echography with a common 18-MHz linear probe was used to detect lymphatic vessels. We evaluated abnormal expansion or sclerosis of lymphatic vessels in the medial legs, which indicated the presence of lymphedema. We proposed the method "D-CUPS" on how to detect and observe the lymphatic vessels. We then performed indocyanine green (ICG) lymphography to diagnose lymphedema. The results of examination were compared. Stage 1 lymphedema was diagnosed in 9 limbs, Stage 2a in 7, Stage 2b in 8, and Stage 3 in 4. Lymphatic vessel detection was possible in all 28 medial thighs and in 27 medial lower legs. The sensitivity and specificity for diagnosis of lymphedema based on echography of the medial leg were 95.0% and 100.0%, respectively. The accuracy rate was 94.6%. We could detect lymphatic vessels with echography in 39 of 54 areas that failed detection using lymphoscintigraphy or ICG lymphography (72.2%). Conclusion: The location and degeneration of lymphatic vessels in lymphedematous limbs can be evaluated with a commonly used ultrasound device. Although exclusion of comorbidities is still necessary, lymphatic ultrasound has potential for use in diagnosis of lymphedema or lymphatic dysfunction.

Lymphaticovenous anastomosis for advanced-stage lower limb lymphedema

BACKGROUND

Early-stage lymphedema patients are said to be candidates for lymphaticovenous anastomosis (LVA). The progressions in the preoperative examinations have made it possible to find the suitable lymphatic vessels even in advanced-stage lymphedema. The aim of this study was to elucidate the surgical effect of LVA in cases of advanced-stage lymphedema.

METHODS

We evaluated 42 limbs of 34 patients with lymphoscintigraphic type 4 or 5. A mean disease duration was 7.5 ± 6.5 years. We performed multi-lymphosome indocyanine green (ICG) lymphography preoperatively to detect the saphenous lymphatics, the lateral calf lymphatics, and the lateral thigh lymphatics. We also performed ultrasound to detect the subcutaneous veins and the dilated lymphatic vessels. The pre- and postoperative evaluation was made by the sum of circumference measurements at 6 points per limb.

RESULTS

The mean number of anastomosis per limb was 2.8 (range, 1-5). Of the 41 limbs for which we performed ICG lymphography, we found the saphenous lymphatics in 29 limbs (70.7%), lateral calf lymphatics in 28 limbs (68.3%), and lateral thigh lymphatics in 21 limbs (51.2%). We found at least 1 linear pattern in ICG lymphography for 39 limbs (95.1%). The mean pre- and postoperative circumference (sum of 6 points) were 221.7 ± 4.9 cm and 215.9 ± 4.9 cm, which was significantly reduced (p < .01).

CONCLUSIONS

LVA was effective for advanced-stage lymphedema patients. An adequate preoperative examination with plural imaging methods seems helpful for achieving a successful surgical result.

Postoperative Changes in Lymphoscintigraphic Findings After Lymphaticovenous Anastomosis

BACKGROUND

The surgical result of lymphaticovenous anastomosis (LVA) is usually evaluated using the volume or circumference measurement. The purpose of this study was to elucidate the changes in lymphoscintigraphic findings after LVA.

METHODS

We conducted a retrospective study on patients who underwent LVA and preoperative and postoperative lymphoscintigraphy from August 2014 to September 2017. In lymphoscintigraphy, albumin labeled with Tc (222 MBq) was injected to the first web space of the foot or the second web of the hands. We evaluated the findings and diagnosed them as "improved" if the extent of dermal backflow was decreased. The clinical symptom was evaluated using circumference measurement and subjective symptoms.

RESULTS

A total of 56 patients (107 limbs) were included. The mean age was 59.1 years. The mean period between LVA and postoperative lymphoscintigraphy was 437.0 days. The difference between preoperative and postoperative lymphoscintigraphic types in Maegawa classification was not found to be statistically significant on the χ test (P = 0.36). The lymphoscintigraphic findings were improved in 26 limbs (24.3%), did not change in 43 limbs (40.2%), and were aggravated in 38 limbs (35.5%). Among the 22 limbs whose lymphoscintigram improved postoperatively, 9 limbs (40.9%) improved in clinical symptoms.

CONCLUSIONS

The changes in clinical symptoms and the postoperative lymphoscintigraphic changes did not always correspond. However, there was a tendency for the percentage of lymphoscintigraphic aggravation to be higher in the group with clinical aggravation.

Change of the Lymphatic Diameter in Different Body Positions

Background: Until now, lymphatic ultrasound was performed with the patients in the prone position. The aim of this study was to evaluate the change in the lymphatic diameter in different body positions. Methods: We performed a retrospective study. We performed indocyanine green (ICG) lymphography and lymphatic ultrasound as a pre-operative examination for lymphaticovenous anastomosis (LVA). ICG was injected at three lymphosomes per limb (the saphenous lymphatics, lateral thigh lymphatics, and lateral calf lymphatics). For the lymphatic ultrasound, a commonly used ultrasound device with an 18 MHz linear probe was employed. We measured the lymphatic diameter in the designed LVA sites in prone, sitting, and upright position. Results: We investigated 61 limbs of 31 female patients with lower limb lymphedema. The mean age was 62.0 (range: 42-86) years. We measured the lymphatic diameter at 78 sites in the thigh and 76 sites in the lower leg. In the thigh, the mean lymphatic diameters in the supine and upright positions were 0.43 ± 0.02 mm and 0.40 ± 0.02 mm, respectively, with no significant difference (p = 0.10). In the lower leg, the mean lymphatic diameters in the supine, sitting, and upright positions were 0.68 ± 0.04 mm, 0.63 ± 0.04 mm, and 0.63 ± 0.04, respectively. A significant decrease was noted between the supine and sitting positions (p = 0.02). Conclusions: The lymphatic diameter in the lymphedematous lower limbs tended to decrease when the patients changed their body position from supine to the sitting or upright positions.

Controversies in Surgical Management of Lymphedema

Surgical treatment of lymphedema has expanded in recent years. Lymphovenous bypass and vascularized lymph node transfer are both modern techniques to address the physiologic dysfunction associated with secondary lymphedema. While efficacy of both techniques has been demonstrated in numerous studies, there are several questions that remain. Here, the authors discuss the most pertinent controversies in our practice as well as the current state of surgical management of lymphedema.

Lymphaticovenous Anastomosis for Lower Extremity Lymphedema: A Systematic Review

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.

Multilymphosome injection indocyanine green lymphography can detect more lymphatic vessels than lymphoscintigraphy in lymphedematous limbs

BACKGROUND

Sometimes, injecting indocyanine green (ICG) or isotope at distal limbs is insufficient especially in cases with low lymphatic function. The purpose of this study was to elucidate the usefulness of multi-lymphosome injection ICG lymphography.

METHODS

Two hundred and six lower limbs of 103 patients were included. ICG lymphography was performed by injecting ICG in three lymphosomes per limb: dorsum of foot (saphenous lymphatics), the proximal side of the lateral condyle (lateral calf lymphatics), and the lateral side of the superior edge of the knee (lateral thigh lymphatics). We observed the presence or absence of a linear pattern at each injection site with a near-infrared camera. Lymphoscintigraphy was performed by injecting an isotope in the first web space, conventionally. Whole body scintigrams were taken 60 min after injection.

RESULTS

In multi-lymphosome ICG lymphography, the lateral thigh lymphatics were observed as a linear pattern in 75.2% of patients, the lateral calf lymphatics in 72.8%, and the saphenous lymphatics in 84.5% of patients. There was not a significant difference between secondary and primary lymphedema (p = 0.57, 0.77, and 0.56 in the lateral thigh, the lateral calf, and the saphenous lymphatics, respectively). Among the 12 limbs classified as Type 5, at least one linear pattern was found in 10 limbs (83.3%).

CONCLUSIONS

We observed a linear pattern in 83.3% of the limbs that were lymphoscintigraphic Type 5 by using multi-lymphosome ICG lymphography. There is a possibility that the results of this study can increase the number of patients eligible for lymphatico-venous anastomosis (LVA) and increase the success rate of LVA.

Preoperative Assessment of Upper Extremity Secondary Lymphedema

Introduction: The purpose of this study was to evaluate the most commonly used preoperative assessment tools for patients undergoing surgical treatment for secondary upper extremity lymphedema. Methods: This was a prospective cohort study performed at a tertiary cancer center specializing in the treatment of secondary lymphedema. Lymphedema evaluation included limb volume measurements, bio-impedance, indocyanine green lymphography, lymphoscintigraphy, magnetic resonance angiography, lymphedema life impact scale (LLIS) and upper limb lymphedema 27 (ULL-27) questionnaires. Results: 118 patients were evaluated. Limb circumference underestimated lymphedema compared to limb volume. Bioimpedance (L-Dex) scores highly correlated with limb volume excess (r2 = 0.714, p < 0.001). L-Dex scores were highly sensitive and had a high positive predictive value for diagnosing lymphedema in patients with a volume excess of 10% or more. ICG was highly sensitive in identifying lymphedema. Lymphoscintigraphy had an overall low sensitivity and specificity for the diagnosis of lymphedema. MRA was highly sensitive in diagnosing lymphedema and adipose hypertrophy as well as useful in identifying axillary vein obstruction and occult metastasis. Patients with minimal limb volume difference still demonstrated significantly impaired quality of life. Conclusion: Preoperative assessment of lymphedema is complex and requires multimodal assessment. MRA, L-Dex, ICG, and PROMs are all valuable components of preoperative assessment.

Lymphovenous Anastomosis Bypass Surgery

The field of lymphedema surgery has witnessed tremendous advancements over the years and has been coupled to the rapid growth of supermicrosurgical techniques. A lymphovenous bypass or lymphaticovenular anastomosis is a new technique that requires identification of patent, residual lymphatic channels and performing an anastomosis to a recipient venule, thereby allowing outflow of lymphatic fluid and improvement in a patient's lymphedema. This article provides a summary of the maturation of the technique, as well as the technical aspects of the approach and the current outcomes in the treatment of postmastectomy lymphedema.