BACKGROUND:Supermicrosurgical lymphaticovenular anastomosis is becoming a useful treatment option for progressive lower extremity lymphedema because of its minimal invasiveness. Finding a lymphatic ...vessel is a minimum requirement for lymphaticovenular anastomosis surgery, but no study has reported comprehensive analysis on factors associated with lymphatic vessel detection.
METHODS:One hundred thirty-four female secondary lower extremity lymphedema patients who underwent indocyanine green lymphography and lymphaticovenular anastomosis without a history of lymphedema surgery were included. Medical charts were reviewed to obtain clinical, indocyanine green lymphographic, and intraoperative findings. Lymphatic vessel detection was defined as positive when one or more lymphatic vessels were found in a surgical field of lymphaticovenular anastomosis. Logistic regression analysis was used to identify independent factors associated with lymphatic vessel detection.
RESULTS:Patient age ranged from 36 to 81 years, duration of edema ranged from 3 to 324 months, and body mass index ranged from 16.2 to 33.3 kg/m. Forty-eight patients (35.8 percent) had a history of radiation therapy, and 76 patients (56.7 percent) had a history of cellulitis. Lymphaticovenular anastomoses were performed in 840 surgical fields, among which lymphatic vessel detection was positive in 807 fields; the overall lymphatic vessel detection rate was 96.1 percent. Multivariate analysis revealed inverse associations in higher body mass index (OR, 0.323; p = 0.008) and the S-region/D-region on indocyanine green lymphography compared with the L-region (OR, 1.049 × 10/1.724 × 10; p < 0.001/p < 0.001).
CONCLUSIONS:Independent factors associated with lymphatic vessel detection were clarified. Lower body mass index and L-region on indocyanine green lymphography are favorable conditions for finding lymphatic vessels in lower extremity lymphedema patients.
CLINICAL QUESTION/LEVEL OF EVIDENCE:Risk, III.
Background
Lymphaticovenular anastomosis (LVA) has become one of the useful surgical treatments for compression‐refractory lower extremity lymphedema (LEL). It is important to anastomose larger ...lymphatic vessels with abundant lymph flows in LVA surgery. This study aimed to clarify factors associated with lymphatic vessel diameter.
Methods
One hundred thirty‐four LEL patients who underwent pre‐operative indocyanine green (ICG) lymphography and LVA from June 2009 to August 2014 in a single institution were included in this retrospective observational study. Clinical, ICG lymphography, and intraoperative findings were collected from medical charts. A lymphatic vessel with external diameters of 0.5 mm or larger was defined as a large lymphatic vessel (LLV). Independent factors associated with LLV were identified using logistic regression analysis.
Results
Nine hundred sixty‐two lymphatic vessels were identified, among which 438 (45.5%) were LLVs. Independent factors associated with LLV were older age (odds ration OR, 1.408; 95% confidence interval CI, 1.026‐1.931; P = 0.034), positive history of radiation (OR, 1.634; 95%CI 1.228‐2.173; P = 0.001), incision site in the thigh/lower leg compared with in the groin (OR, 1.617/1.685; 95%CI 1.076‐2.432/1.148‐2.473; P = 0.021/0.008). Inverse associations were observed in S‐region/D‐region on ICG lymphography compared with L‐region (OR, 0.537/0.048; 95%CI, 0.397‐0.726/0.006‐0.371; P < 0.001/0.004).
Conclusions
D‐region on ICG lymphography had the lowest OR to find LLV, representing that lymphatic vessels found in D‐region on ICG lymphography would be significantly smaller than those in L‐region. In LVA surgery, D‐region should be avoided.
Indocyanine green lymphography has been a highly useful modality in the clinical examination and surgical management of patients with lymphedema. No formal classification system of indocyanine green ...imaging findings according to the severity of lymphedema exists, however. The purpose of this study was to describe, analyze, and classify characteristic indocyanine green lymphography findings to uniformly guide surgical management of lymphedema using this modality.
Forty-five patients (78 limbs) with lower extremity lymphedema underwent indocyanine green lymphography. All lymphography images were recorded in photographs and videos. Images were reviewed and analyzed to classify characteristic findings according to clinical severity as determined by Campisi clinical lymphedema staging.
Lymphography findings were classifiable into two patterns. Mild cases of lymphedema were characterized by a linear lymphatic channel pattern (linear pattern). In more severe cases, lymphatic channels demonstrated retrograde lymphatic flow (dermal backflow pattern) and diminution or absence of linear channel patterning. Three dermal backflow patterns, splash, stardust, and diffuse, were identified and correlated with the progression of lymphedema severity. These findings supported the generation of a novel anatomical lymphedema severity staging system, the dermal backflow staging system.
Indocyanine green lymphography is a safe, minimally invasive, and useful tool for the surgical evaluation of extremity lymphedema. Characteristic indocyanine green lymphography patterns are consistent and correlate with clinical severity. The dermal backflow staging system can facilitate patient stratification, discussion between referring parties, and surgical planning.
Summary Background Lymphorrhea can occur after surgical intervention to the lymphatic system. Most cases with lymphorrhea can be treated conservatively, but some cases are refractory to conservative ...treatments and require further surgical treatments. Methods Eight patients developed inguinal lymphorrhea after surgical intervention in the groin region. Navigation lymphatic supermicrosurgery (NLS) was performed for the treatment of iatrogenic lymphorrhea refractory to conservative treatments. Lymphatic vessels ruptured in a lymphorrhea lesion were identified under intraoperative indocyanine green (ICG) lymphography navigation and were anastomosed to a recipient vessel; an intact lymphatic vessel or a vein was selected as a recipient. Feasibility and efficacy of the method were evaluated. Results Among eight inguinal lymphorrhea patients, four patients with refractory lymphorrhea underwent NLS under local anesthesia. In all cases, a lymphatic vessel that caused an intractable lymphorrhea was successfully anastomosed to a recipient vessel (to an intact lymphatic vessel in one case, and to a venule in three cases), and the lymphorrhea was completely cured without lymphorrhea recurrence or lymphedema development. Treatment duration in NLS was significantly shorter than that in conservative treatments (5.0 ± 2.4 vs. 30.0 ± 8.1 days, P = 0.006). Conclusions Intraoperative ICG lymphography helps a surgeon to find lymphatic vessels in and near a lymphorrhea lesion, which allows secure and easier treatment for an intractable lymphorrhea with preservation of lymph drainage function.
BACKGROUND:Recently, a superthin “pure skin perforator” flap without any subcutaneous tissue was proposed, but the vascularity is still unclear. The authors therefore investigated the vascularity of ...the proposed superficial circumflex iliac artery–pure skin perforator along with its clinical applications and findings on indocyanine green imaging.
METHODS:The locations and dimension of 70 pure skin perforators on 40 flaps were investigated and classified into central-peripheral and mediolateral parts. Indocyanine green angiography was used to analyze the patterns of the vascular anatomy.
RESULTS:Twenty-seven of 29 cases (93.1 percent) presented with pure skin perforator vessels within the area 5 cm above and 1 cm below the inguinal ligament and 4 cm medial and 2 cm lateral from the anterior superior iliac spine. The total flap size averaged 39 ± 22 cm (range, 3 to 90 cm). A subanalysis of the relationship between the flap size and location of pure skin perforators within the single, double, and triple pure skin perforator flap subgroups did not reveal any significance. Indocyanine green angiography revealed three interesting perfusion patterns of pure skin perforator flapa radial diffusion pattern, direct linking vessels in the intradermal layer, and intradermal arteriovenous shunts.
CONCLUSIONS:The location number of the pure skin perforators within the flap was not considered to be a crucial factor in the flap design and size in this study. This new knowledge regarding the pure skin perforator concept will allow surgeons to elevate a full-thickness skin flap safely.
The anatomical variations in accessory lymphatic pathways around the axillary region may work as a drainage route for excess lymphatic fluid accumulation in secondary upper extremity lymphedema. In ...this report, accessory lymphatic pathways extending to the shoulder, neck, and breast regions in secondary upper extremity lymphedema patients are shown using indocyanine green (ICG) lymphography.
Between January 2012 and May 2015, 30 limbs of 29 patients with upper extremity lymphedema after malignant tumor resection were evaluated. ICG lymphography was performed after chronic lymphedema formation.
Of the 30 limbs, accessory lymphatic pathways were identified across the axillary region in 3 patients using ICG lymphography. In 2 of these 3 patients, accessory drainage lymphatics were connected to the cervical lymph nodes. In regard to the distribution of dermal backflow patterns, dermal backflow appeared in 26 patients-in the forearm in 26 patients and in the upper arm in 20 patients.
Accessory lymphatic pathways are thought to be the drainage routes in the affected arm, which may prevent edema progression to the terminal stage. Variations in the lymphatic system are easily visualized using ICG lymphography. Understanding of accessory lymphatic routes in lymphedema patients may provide new insight for further understanding the pathophysiology of lymphedema.
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.
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.
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.
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.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
BACKGROUND:Lymphedema can be classified as either primary or secondary. In the present study, the authors investigated the efficacy of lymphaticovenous anastomosis for correcting primary lower limb ...lymphedema and to determine its indications and contraindications.
METHODS:The authors retrospectively examined patients with primary lower limb lymphedema who underwent lymphaticovenous anastomosis between April of 2009 and September of 2013. Anastomosis efficacy was evaluated using lower limb circumference measurements at five anatomical locations. Lymphedema staging was determined using modified leg dermal backflow stage. The authors added two categories to the standard leg dermal backflow staging systemno backflow and distal backflow. Lymphaticovenous anastomosis was performed under local anesthesia, except in pediatric cases.
RESULTS:The authors evaluated 62 patients (79 lower limbs). Lower limb circumference increased after lymphaticovenous anastomosis in patients with an onset age of 1 year or later and before age 11 years, but it significantly decreased in patients with an onset age older than 11 years. The presence of lymphedema for a longer period did not negatively impact lymphaticovenous anastomosis efficacy. In particular, lymphaticovenous anastomosis was effective in the leg dermal backflow stage 2 and no backflow group.
CONCLUSIONS:For patients developing lymphedema before 11 years of age, the indications should be considered carefully. However, lymphaticovenous anastomosis was effective in patients developing lymphedema after the age of 11 years. Regardless, due to its low level of invasiveness, lymphaticovenous anastomosis may be considered for patients who are refractory to conservative treatment, even if they have early-onset lymphedema.
CLINICAL QUESTION/LEVEL OF EVIDENCE:Therapeutic, IV.
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.
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.
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.
The increase in pressure inside the collecting lymphatic vessels after lymphadenectomy was accompanied by histological changes that began before the onset of lymphedema.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
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