The lymphatic circulation in lymphedema

Lymphatic vessel mapping in the upper extremities of a healthy Korean population

Background

Intraoperative indocyanine green (ICG) lymphography can effectively detect functioning lymph vessels in edematous limbs. However, it is sometimes difficult to clearly identify their course in later-stage edematous limbs. For this reason, many surgeons rely on experience when they decide where to make the skin incision to locate the lymphatic vessels. The purpose of this study was to elucidate lymphatic vessel flow patterns in healthy upper extremities in a Korean population and to use these findings as a reference for lymphedema treatment.

Methods

ICG fluorescence lymphography was performed by injecting 1 mL of ICG into the second web space of the hand. After 4 hours, fluorescence images of lymphatic vessels were obtained with a near-infrared camera, and the lymphatic vessels were marked. Three landmarks were designated: the radial styloid process, the mid-portion of the cubital fossa, and the lower border of the deltopectoral groove. A straight line connecting the points was drawn, and the distance between the connected lines and the marked lymphatic vessels was measured at 8 points.

Results

There were 30 healthy upper extremities (15 right and 15 left). The average course of the main lymph vessels passed 26.0±11.6 mm dorsal to the styloid process, 5.7±40.7 mm medial to the mid-cubital fossa, and 31.3±26.1 mm medial to the three-quarters point of the upper landmark line.

Conclusions

The main functioning lymphatic vessel follows the course of the cephalic vein at the forearm level, crosses the mid-cubital point, and travels medially toward the mid-axilla.

Retroperitoneal lymphocele after anterior spinal surgery

STUDY DESIGN

Case report; Review of Literature.

OBJECTIVE

To present an uncommon complication after anterior lumbar surgery as well as a treatment option and a review of the literature.

SUMMARY OF BACKGROUND DATA

A number of complications have been reported after anterior lumbar surgery. Common complications include vascular, ureteral, and neurologic injuries. The development of a retroperitoneal lymphocele has been previously been described, but details regarding evaluation, diagnosis, and treatment options are lacking in the literature.

METHODS

The case of a single patient with a postoperative retroperitoneal lymphocele was identified and retrospectively reviewed. Permission was obtained from the patient to review and publish this information. A review of literature on lymphoceles and anterior lumbar complications was also performed using PubMed and Ovid databases.

RESULTS

A 76-year-old woman underwent anterior interbody fusion from L2-L3-L4-L5, followed by posterior T11-L5 fusion for degenerative scoliosis and spinal stenosis. Six weeks after surgery, she presented with severe abdominal pain, nausea, and emesis. Examination revealed a retroperitoneal lymphocele, which was confirmed after aspiration. The patient was treated with a laparoscopic marsupialization procedure without recurrence. At 12 months, the patient had no further abdominal symptoms, noted improvements in back and leg pain scores, and had stable radiographic findings.

CONCLUSION

Retroperitoneal lymphocele is a rare complication after anterior lumbar interbody fusion. The different diagnosis should include infectious abscess, ureteral injury with urinoma, pancreatic injury with pseudocyst formation, and spinal fluid leak with pseudomeningocele. Diagnosis can be guided by serum and cyst fluid analysis. Although treatment options exist, surgical treatment may provide the most reliable results.

Novel lymphography using indocyanine green dye for near-infrared fluorescence labeling

Lymphedema is known to be caused by many pathologic conditions; however, its diagnostic and therapeutic strategies remain to be unestablished. In this study, we investigated the usefulness of a novel lymphographic method based on fluorometric sensing using indocyanine green (ICG) dye for imaging lymphatic vessels using rat models. The real-time imaging system enabled visualization of superficial lymphatic vessels with a diameter of 0.1 mm in 33 frames/second. In addition, morphologic changes in lymphatic vessels in a radiation-induced lymphedema model were detected even at the latent stage. These results suggest that this imaging technique is acceptable as an evaluation method for the lymphatic system.

MR lymphangiography in infants, children, and young adults

OBJECTIVE

Our objective was to offer a preliminary description of MR lymphangiography; its uses and limitations; and its findings in infants, children, and young adults.

SUBJECTS AND METHODS

Twenty-nine patients underwent 32 MR lymphangiographic examinations for evaluation of vascular malformations, other masses, soft-tissue swelling, gigantism, fluid accumulation, or pain. MR lymphangiography was based on a heavily T2-weighted fast spin-echo sequence and a maximum-intensity-projection algorithm. We assessed the axial and off-axial lymphatic channels in conjunction with MR venography to help differentiate veins from lymphatics. Correlation was made with published lymphangiograms and anatomic diagrams to assist interpretation and (when available) with histologic specimens (n = 11) for validation.

RESULTS

Presumed lymphatic channels were seen universally, although 14 examinations showed incomplete venous signal suppression. Lymphatic channels appeared normal in eight children and in 20 of the 21 asymptomatic contralateral limbs. Ten patients had an increased number and size of off-axial channels, including seven children with large, diffuse low-flow vascular malformations. Enlarged axial and off-axial channels were seen in five patients, four of whom had Klippel-Trénaunay syndrome. Six patients, each with an extensive hemangioendothelioma, Klippel-Trénaunay syndrome, Gorham syndrome, or unilateral body edema, showed absence or interruption of axial channels.

CONCLUSION

MR lymphangiography appears to be a useful noninvasive technique to study superficial and deep lymphatic channels in children with local or diffuse vascular lesions or swelling of extremities. Its limitations notwithstanding, the technique may offer further insight into the nature of vascular anomalies, may direct therapy, and may predict prognosis.

LYMPHOGRAPHY IN METASTATIC LYMPH NODE DISEASE

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Measurement of lymphatic flow variation by noninvasive method cases of lymphedema

The purpose of this study was to measure the variations of lymphatic flow. A noninvasive isotopic method was used to achieve a functional exploration of lymphatic circulation. Fifteen subjects were used in the study: 10 healthy subjects and 5 patients with lower extremity lymphedema. A first subcutaneous injection of technetium 99m rhenium sulfate (99mTc) was performed in the first interdigital space of both feet. The radioactivity was recorded in two places: the first one on the inguinal site by a gamma camera; the second, below the first, on the precordial site by a multichannel analyzer. With the two types of recording procedures, it was possible to obtain a curve that showed the amount of radioactivity in relation to time. In order to obtain a muscular activity fifty-five minutes after the injection, each subject or patient spent ten minutes on an ergometric bike. A second subcutaneous injection was performed one week later, but prior to the injection, the subject or patient took orally 1800 mg of heptaminol adenosine phosphate (HAP) per day for three days. The radioactivity recording was made under the same conditions as with the muscular activity. The statistical results of the experiment without treatment on the two types of recording show that in the healthy subjects the amount of radioactivity increased during muscular activity. Moreover, the treatment indicated higher radioactivity values, which remained at a higher level. However, the muscular activity performed by a patient was unable to increase the radioactivity. On the other hand, the drug gave radioactivity values that were higher than the previous values of the first curve.(ABSTRACT TRUNCATED AT 250 WORDS)

Chyloperitoneum with collateral lymphatic drainage involving abdominal skin

A 58-year-old man with poorly differentiated lymphoma and chyloperitoneum, who developed periumbilical white vesicular skin lesions, is presented. These skin lesions represent collateral lymphatic drainage pathways for the chyloperitonium as evidenced by drainage of chylous fluid from these lesions and communication with the peritoneum as demonstrated by intraperitoneal 99mTc sulfur colloid injection.

Selection of patients with lymphedema for compression therapy

Seventeen patients with lymphedema were treated with intermittent external pneumatic compression. Two patients with hemodynamically significant venous obstruction showed no response to therapy. The response of the remaining fifteen patients varied with the degree of subcutaneous tissue fibrosis. Xeroradiographic estimates of tissue compressibility provided valuable prognostic information. Intermittent external pneumatic compression is an effective nonsurgical method of treatment in patients selected by xeroradiography.

Post-thrombotic leg ulcer and its surgical treatment

The post-thrombotic syndrome is a complex disease to whose development at least three factors contribute: (1) incompetence of the venous valvular system; (2) opening of the local arteriovenous shunts; and (3) disturbances in the lymphatic system. Our surgical treatment considers all three factors by providing: (1) stripping of the saphenous veins; (2) wide excision of the ulcerated region with the fascia, followed by immediate skin graft; and (3) large excision of subcutaneous tissue and fascia. Of fifty-one patients with chronic post-thrombic leg ulcers operated on according to these principles, only one had recurrence, a recurrence rate of only 0.5%. This compares favorably with other published results.

Lymphovenous shunts in man

Lymphovenous shunts have been detected in patients by lymphography with Ultrafluid Lipiodol. No shunts were found in patients with normal lymphatic systems. They were found in patients with lymphoedema, with lymph nodes involved by malignant disease, and in patients who had had surgical interruption of lymphatic pathways, either vessels or nodes. The total incidence of lymphovenous shunts in 700 lymphographic studies was 2.3%. The incidence in the various pathological groups was highest in those with obvious lymph node involvement.In certain situations, particularly primary lymphoedema, the role of a lymphovenous shunt appears favourable to prognosis. In other situations a deleterious effect may be produced.

Malignant melanoma: treatment by endolymphatic radio-isotope infusion

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Chylous reflux in the lungs and pleurae

Lymphangiectasis of varying extent may be present in some cases of chronic pulmonary disease. Often the dilated lymphatic channels are not identified because pulmonary fibrosis and emphysema together with secondary inflammatory changes obscure the lymph vessel pathology. When chylothorax is associated with such chronic pulmonary pathology, attention may be drawn to the lymphatic system. The presence of a chylothorax is usually attributed to obstruction or injury of the thoracic duct, whereas in some cases chylous reflux into the lungs and pleurae via abnormal lymph channels in the lungs and pleurae as well as in the mediastinum may cause the chylothorax. In rare instances a patient may actually expectorate chylous fluid which seeps into the bronchi from the abnormal peribronchial lymphatics. A detailed analysis of reported cases together with some personal experience has demonstrated that pathological changes in the pulmonary and pleural lymphatic vessels are more common than is usually appreciated. The normal remarkable regenerative potential which is usually evident after experimental interruption of the lymphatics apparently is lacking in some humans due to genetic and other factors. Thus pathological changes, difficult to simulate experimentally, may be encountered. Lymphangiectasis is often found not to be limited to a single organ if complete studies of the lymphatic system are made.

Rheumatoid lymphadenopathy

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Primary lymphoedema of the lower limb

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