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Background: Immediate lymphatic reconstruction (ILR) has been proposed to decrease lymphedema rates. The primary aim of our study was to determine whether ILR decreased the incidence of lymphedema in patients undergoing axillary lymph node dissection (ALND). Methods: We conducted a two-site pragmatic study of ALND with or without ILR, employing surgeon-level cohort assignment, based on breast surgeons' preferred standard practice. Lymphedema was assessed by limb volume measurements, patient self-reporting, provider documentation, and International Classification of Diseases, Tenth Revision (ICD-10) codes. Results: Overall, 230 patients with breast cancer were enrolled; on an intention-to-treat basis, 99 underwent ALND and 131 underwent ALND with ILR. Of the 131 patients preoperatively planned for ILR, 115 (87.8%) underwent ILR; 72 (62.6%) were performed by one breast surgical oncologist and 43 (37.4%) by fellowship-trained microvascular plastic surgeons. ILR was associated with an increased risk of lymphedema when defined as ≥10% limb volume change on univariable analysis, but not on multivariable analysis, after propensity score adjustment. We did not find a statistically significant difference in limb volume measurements between the two cohorts when including subclinical lymphedema (≥5% inter-limb volume change), nor did we see a difference in grade between the two cohorts on an intent-to-treat or treatment received basis. For all patients, considering ascertainment strategies of patient self-reporting, provider documentation, and ICD-10 codes, as a single binary outcome measure, there was no significant difference in lymphedema rates between those undergoing ILR or not. Conclusion: We found no significant difference in lymphedema rates between patients undergoing ALND with or without ILR. [ABSTRACT FROM AUTHOR]

Intestinal lymphangiectasia (IL) is a protein-losing enteropathy (PLE) that occasionally leads to gastrointestinal bleeding (GIB). We encountered a 41-year-old female with a 9-year history of duodenal IL with PLE and GIB that progressively worsened. Despite a diet, supplemented with medium-chain triglycerides, antiplasmin therapy, oral corticosteroids, octreotides, sirolimus, and repeated endoscopic hemostasis, her symptoms remained uncontrolled, leading to blood transfusion dependence. Lymphangiography revealed significant leakage from abnormal abdominal lymph vessels into the duodenal lumen. The patient subsequently underwent an abdominal-level lymphaticovenous anastomosis combined with local venous ligation. This approach resulted in a dramatic improvement and sustained resolution of both the PLE and GIB. More than 6 months after surgery, the patient remained free of symptoms and blood transfusion dependence. [ABSTRACT FROM AUTHOR]

Polypropylene is a material recognized for its tensile properties, as well as for the stability of its chemical structure, an important element that has allowed the use of this material on a large scale, in a wide range of fields of activity, especially in the medical field. This study aims to highlight the structural properties of polypropylene, which contribute to improving the prognosis of vascular microsutures, through the comparative analysis of the results obtained after performing lymphaticovenous anastomosis in lymphedema patients. The research was focused on analyzing the importance of the diameter of the polypropylene thread and its tensile properties on the patency of the lymphatic anastomosis, through the comparative analysis of two groups of patients who benefited from microvascular sutures. The database was made up of a group of 82 patients divided into two groups who benefited from supermicrosurgical interventions by using polypropylene thread 11.0 (37 cases involving 148 anastomoses), respectively 12.0 (45 cases involving 180 anastomoses). The results of the research revealed that the group of patients who benefited from microvascular anastomoses using 12.0 polypropylene thread recorded both better anastomosis patency rates and a significantly reduced rate of complications due to the rejection reaction of the suture material, under the conditions a significantly reduced tensile strength. [ABSTRACT FROM AUTHOR]

Although the usefulness of lymphaticovenous anasotmosis (LVA) for lymphedema has been reported, it is difficult to determine where the LVA is to be performed, especially for inexperienced surgeons. This study aimed to establish a map of the LVA site. A total of 105 limbs from 64 patients who underwent lower limb LVA were retrospectively reviewed. Multi-lymphosome indocyanine green (ICG) lymphography (in 35 patients) and lymphatic ultrasound (in all patients) were performed preoperatively and the incision site was determined where dilated lymph vessels and appropriate veins were located in close proximity. The LVA location was identified using a post-operative photograph. Additionally, the degree of lymphatic degeneration at the LVA site was recorded based on the normal, ectasis, contraction, and sclerosis type (NECST) classification. A total of 206 skin incisions were analyzed. Among them, 161 (75.9%) were medial and 45 (21.2%) were lateral. Among the 85 sites on the calf, 52 (61.2%) were medial and 33 (38.8%) were lateral. Among the 117 sites on the thigh, 106 (90.6%) were medial and 11 (9.4%) were lateral. As the severity of lymphedema progressed, the probability of performing LVA on the lateral calf increased. Among the 202 locations where LVA was performed on the thigh and lower leg, ectasis type was found in 164 sites (81.2%). We established an LVA map of the legs based on multi-lymphosome ICG lymphography and lymphatic ultrasound data. Using this LVA map, surgeons can easily predict the location of lymph vessels, thereby improving the success rate of LVA. [ABSTRACT FROM AUTHOR]

Background Lymphaticovenular anastomosis (LVA) requires special supermicrosurgery techniques designed for vessels less than 0.8 mm in size. While preparing the field for LVA, it is often difficult to handle the lymphatic vessel directly without injuring it or fracturing it entirely.

Lymphaticovenous anastomosis is widely used in lymphedema management. Although its effectiveness in reducing edema in patients can be clinically observed, evaluating the long-term outcomes of this technique can be complex. This study established an animal model to assess the outcomes of lymphaticovenous anastomosis technique at 15 and 30-days post-surgery using indocyanine green lymphography, Patent Blue V dye injection, and histopathological examination. An experimental model was established in the hindlimbs of 10 rabbits using the popliteal vein and afferent lymphatic vessels in the popliteal area. The subjects were divided into two groups: the first group (n = 5) underwent patency assessment at 0 and 15 days, and the second group (n = 5) at 0 and 30-days, resulting in 20 anastomoses. Patency was verified at 0, 15, and 30-days using indocyanine green lymphography and Patent Blue V injection. Histopathological examinations were performed on the collected anastomosis samples. The patency rate was 90% (19/20) initially, 60% (6/10) at 15 days post-surgery, and 80% (8/10) at 30-days. The average diameter of lymphatic vessels and veins was 1.0 mm and 0.8 mm, respectively. The median number of collateral veins was 3; the median surgical time was 65.8 min. Histopathology revealed minimal endothelial damage and inflammatory responses due to the surgical sutures, with vascular inflammation and thrombosis in a single case. Local vascular neoformations were observed. This study highlights the reliability and reproducibility of using rabbits as experimental models for training in lymphaticovenous anastomosis technique owing to the accessibility of the surgical site and dimensions of their popliteal vasculature. [ABSTRACT FROM AUTHOR]

Background Lymphaticovenular anastomosis (LVA) requires special supermicrosurgery techniques designed for vessels less than 0.8 mm in size. While preparing the field for LVA, it is often difficult to handle the lymphatic vessel directly without injuring it or fracturing it entirely. Method We propose a novel technique, which is used in LVA for tagging of lymphatic vessels, with the use of a nylon 6–0 suture and micro-ligaclip. Results We have successfully performed 78 LVAs in 26 cases with this method. The average lymphatic vessel size was 0.3 mm (0.15–0.8 mm). Conclusion This novel technique to implement the use of a nylon suture with a micro-ligaclip to use as a vessel loop for lymphatics has not been previously described in the literature. It is a useful technique that we find beneficial to lymphatic identification through tagging of the lymphatic channels, contributing to greater success in each anastomosis. [ABSTRACT FROM AUTHOR]

Background: Contraction-type lymphatic vessels (LV) are considered suboptimal for lymphaticovenous anastomosis (LVA). However, despite these pathological changes, their functionality and link to outcomes have not been fully elucidated. The aim of this study was to determine the impact on outcomes when contraction-type LVs were used for LVA compared to the noncontractiontype (normal + ectatic) counterpart for treating lower limb lymphedema. Study design: Eighty-three patients with gynecologic cancer-related unilateral lower-limb lymphedema who underwent LVA as their primary treatment were enrolled in this study. The study group included 20 patients who used only contraction-type LVs. An additional 63 patients (control group) received noncontraction-type LVs only. Patients with a history of LVA, liposuction, or excisional therapy were excluded. Patient characteristics, intraoperative findings, functional parameters, and pre-LVA and post-LVA volume changes were recorded and matched using propensity scores. The primary endpoint was the volume change at 6/12 months after LVA. Results: After matching, 20 patients were included in each group. All parameters were matched, except that the study group still had a significantly inferior indocyanine green (ICG)-positive ratio, lymph flow-positive ratio, and washout-positive ratios (P< 0.001, P =0.003, and P<0.001, respectively) when compared to the control group after matching. However, at 1-year follow-up, the postoperative percentage volume reduction was comparable between the groups (P =0.619). Conclusion: The use of contraction-type LVs for LVA is encouraged when no other LVs are available. [ABSTRACT FROM AUTHOR]

Lymphaticovenous anastomosis (LVA) is a critical surgical approach for managing limb lymphedema, proving particularly effective in mild cases where lymphatic vessels are visible via indocyanine green (ICG) imaging. However, in advanced cases, substantial lymphatic obstructions manifest as stardust patterns in ICG images, posing diagnostic challenges. Traditionally, surgeons have relied on manually extrapolating the position and orientation of lymphatic vessels from the unaffected limb to the affected one based on the assumption of bodily symmetry. To streamline this process and enhance accuracy, we developed the LVA detection model (LVADet), which employs computer vision-based artificial intelligence techniques to automate the detection of lymphatic vessels. LVADet uses a segmentation algorithm to identify lymphatic vessels on ICG images of the unaffected limb and performs keypoint detection on both limbs. Through Procrustes analysis, keypoints from both limbs are used to construct an affine transformation matrix, enabling the projection of segmented vessels from the unaffected limb onto the image of the affected limb. We tested the model using a dataset of 52 lymphedema cases, with 42 used for training and 10 for testing. This included high-quality annotations of segmentations, keypoints, and incisional wounds. Our findings, supported by rigorous evaluation and ablation studies, validate the model’s design choices. Furthermore, we integrated LVADet into a prototype system using Microsoft HoloLens, facilitating real-time identification of lymphatic vessels during LVA procedures. This integration significantly reduces labor and time in the preparatory phases of surgery and shows the potential to mark a substantial advancement in surgical treatments for lymphedema.

Background: Lymphovenous anastomosis (LVA) enables lymphatic fluid to drain into the venous system. However, no study has investigated the association between LVA and heart failure (HF) caused by fluid overload in the blood circulating system. The purpose of our study was to determine whether LVA increases the risk of HF and mortality. Material and methods: This nationwide retrospective study evaluated a total of 1400 lymphedema patients who underwent LVA and two control cohorts with 28 000 lymphedema who did not undergo LVA and 70 000 age-matched and sex-matched participants from the Korean National Health Insurance database were included. Blood pressure, body mass index (BMI), glucose and cholesterol levels, smoking history, and comorbidities were obtained during National Health Insurance Service - Health Screening (NHIS-HealS). The incidence, adjusted risk for HF, and mortality were evaluated. Results: Adjusted HRs for HF were 1.20 (confidence interval [CI], 1.03-1.40) and 1.30 (CI, 1.12-1.50), referenced by the general population control cohort and patients with lymphedema without LVA, respectively. In age, sex, BMI, and smoking status-stratified analyses, heightened risk of HF was evident across all sexes, spanning both young and old age groups, encompassing individuals with various smoking statuses, and those with a BMI of 18.5 or higher. Among these groups, the risk was notably greater in males compared to females, higher in younger individuals as opposed to older ones, and further elevated within the BMI range of 18.5-25. Conclusions: LVA is associated with an increased HF risk, independent of cardiovascular risk factors and associated comorbidities. This association is prominent in participants aged <50 years, in males, and in the normal-to-obese (BMI = 18.5 kg/m2) group. Among patients with lymphedema, LVA did not significantly affect mortality. [ABSTRACT FROM AUTHOR]

BACKGROUND: The use of dyes like Indocyanine green (ICG) and Patent blue facilitates the identification of lymphatic vessels during lymphaticovenous anastomosis (LVA) surgery. However, some patients experience "staining failure". In these cases, no stained lymphatic vessels can be detected, making supermicrosurgical LVA even more complex. OBJECTIVE: This study aims to investigate patient-related factors that may interfere with lymphatic vessel staining during LVA. METHODS: A retrospective study was conducted on 30 patient charts, focusing on patient characteristics and the staining quality of ICG and Patent blue dye. Statistical analyses were performed to identify correlations between variables. RESULTS: Significant correlations were found between higher age and secondary lymphedema, longer duration of lymphedema in male patients until surgery and reoccurring cellulitis and Patent blue staining. Notably, recurrent infections to the lymphatic system resulted in inferior staining ability during LVA surgery. CONCLUSIONS: Due to staining failure the detection of functional lymphatic vessels remains challenging in LVA surgery. A more extensive preoperative workup is recommended for patients with recurrent cellulitis to optimize surgical feasibility and procedure quality in LVA treatment for lymphedema. [ABSTRACT FROM AUTHOR]

Lymphedema is a chronic and debilitating disease that affects up to 250 million patients worldwide. Recent advances in understanding its pathophysiology, along with improved diagnosis and microsurgical techniques, have enhanced our ability to cope with the challenging task of treating this disease. This review provides an overview of the disease from a surgeon's point of view, including existing imaging modalities used for preoperative assessment, as well as surgical procedures used in its treatment. The advantages and drawbacks of various existing modalities used for the pre- or intraoperative assessment of lymphatic vessels are discussed. Lymphedema treatment has shifted from palliative debulking procedures (liposuction and direct excision) to those aimed at restoring lymphatic flow and countering the pathophysiology of the disease (lymphaticovenous anastomosis and vascularized lymph node transfer). A combination of both approaches can result in a synergistic benefit for patients and is discussed in this review. Despite recent advances, some controversies persist, and further studies are needed to better define surgical treatment algorithms. [ABSTRACT FROM AUTHOR]

Purpose of Review: Breast cancer-related lymphedema (BCRL) is a major contributor to morbidity in breast cancer survivors. Immediate lymphatic reconstruction (ILR) has emerged as a promising surgical option for prevention of BCRL. The purpose of this review is to critically evaluate recent literature on ILR in breast cancer patients. Recent Findings: Short-term outcomes of ILR at most centers have shown low BCRL rates similar to those seen with sentinel lymph node biopsy. Some centers reporting more than 4-year follow-up have demonstrated up to 50–75% BCRL risk reduction following axillary lymph node dissection (ALND). Others have demonstrated equivocal results from ILR. ILR appears to be surgically and oncologically safe. Summary: ILR continues to be a promising surgical technique to reduce the risk of BCRL following ALND. Ongoing evaluation is needed to characterize the extent of protective effect conferred by ILR. [ABSTRACT FROM AUTHOR]

Indocyanine green (ICG) lymphography is widely used to localize functional lymphatic vessels for lymphaticovenous anastomosis (LVA); however, flow velocity is rarely assessed. We aimed to evaluate the correlation between lymphatic flow velocity and the presence of functional lymphatic vessels. Data of a total of 924 lymphatic vessels from 273 lymphedema patients who underwent LVA between July 2018 and December 2020 were retrospectively reviewed. Lymph flow velocity was defined by considering the most proximal anatomic location enhanced by ICG at 30 min after injection and categorized into four groups; grade 1 (foot or hand), grade 2 (below knee or elbow), grade 3 (at/above knee or eblow), or grade 4 (axilla or groin). The presence of functional lymphatic vessels, which showed lymphatic fluid flow when the vessels were cut for anastomosis, was compared between the four groups. A higher rate of functional lymphatic vessels was observed among lymphatic vessels with grade 3 or 4 flow velocity compared with those with grade 1 or 2 flow velocity (67.5% vs. 44.5%; p < 0.001). These findings were consistent with the observations for lymphatic vessels with a non-linear pattern in ICG lymphography (59.4% vs. 26.5%; p < 0.001). The rate of completion of LVA at surgical sites in extremities with grade 3 or 4 flow velocity was 88.1% compared with 65.8% in extremities with grade 1 or 2 velocity (p < 0.001). Lymph flow velocity grading can be a simple and easy adjunctive method to determine indication for LVA in extremities with lymphedema. [ABSTRACT FROM AUTHOR]

In this report, we describe a super microsurgical technique that enables rapid and accurate anastomosis while adjusting for caliber differences when anastomosing a small-caliber lymphatic vessel and a vein with a larger caliber, which is frequently encountered in surgeries such as lymphaticovenous anastomosis (LVA). The suture size adjustment technique was performed in 30 anastomoses of lymphatic vessels and veins, whose diameter of lymph duct was at least two times smaller than that of the vein. The type of lymphedema, caliber of lymphatic vessels and veins anastomosed, caliber ratio, vein wall thickness, modified caliber ratio after vein wall thickness subtracted, presence of additional anastomosis, and anastomosis time were examined. On average, the lymphatic vessels had a diameter of 0.61 mm, while the veins were 1.43 mm in diameter. The mean caliber ratio of vein to lymphatic vessel was 2.3, while the modified caliber ratio of vein-to-lymphatic vessel was 1.5 on average. The average venous wall thickness was 0.51. The average anastomosis time was 9.1 min and no additional anastomosis due to leakage was necessary in any case. We successfully performed an anastomosis of lymphatic vessels and veins with different calibers, which can maintain long-term patency while adjusting the caliber difference and suppressing leakage at the anastomosis site. Finally, the caliber of the vein is commonly larger than that of the lymphatic vessel to be anastomosed in many cases of LVA surgery, indicating that the proposed anastomosis method could be of therapeutic use in many cases. [ABSTRACT FROM AUTHOR]

Secondary lymphedema following inguinal lymph node dissection in lower extremities skin cancer reduce the patients' quality of life. Immediate lymphaticovenous anastomosis (LVA) at groin is a procedure intended to prevent secondary lymphedema. The data regarding the long-term efficacy and safety of this procedure was limited. Therefore, we evaluated the long-term outcomes of immediate LVA in patients with melanoma and non-melanoma skin cancer of the lower extremities. The retrospective data review of patients with melanoma or squamous cell carcinoma of the lower extremities underwent oncologic tumor resection with groin node dissection between December 2013 and December 2016 was performed. Seven patients underwent immediate LVA (intervention) at groin after node dissection and 22 acted as controls. The occurrence of lymphedema and oncologic outcomes were followed up to 7 years. Fifteen patients (51.7%) developed postoperative lymphedema, which were three patients in the intervention group and twelve patients in the control group (p = 0.68). The intervention group had significant lower 2-year (57.1% versus 77.3%) and 5-year overall survival (14.3% versus 54.5%) (p = 0.035). The intervention group had reduced 2-year (28.6% versus 86.4%) and 5-year (28.6% versus 68.2%) Recurrence Free Survival (RFS) (p = 0.013). The intervention group also had reduced 2-year (0% versus 90%) and 5-year (0% versus 70%) Metastasis Free Survival (MFS) (p = 0.003). Immediate inguinal LVA following groin node dissection in lower extremity skin cancer patients did not reduce the incidence of lymphedema. Unfortunately, it was associated with lower overall survival and an increase in tumor recurrence and metastasis. [ABSTRACT FROM AUTHOR]

Background and Objectives: Neurogenic bladder (NB), a complication of gynecological cancer treatment, entails significant symptoms such as loss of urinary urgency, incontinence, and renal dysfunction. To investigate whether lymphatic fluid stagnation at the pelvis causes NB, we investigated the effectiveness of lymphaticovenular anastomosis (LVA) for NB., Methods: In this retrospective study between 2014 and April 2024, LVA was performed on 52 patients complaining of preoperative urinary dysfunction with lower extremity lymphedema following pelvic lymphadenectomy in gynecologic cancer treatment. Pre- and postoperative assessments evaluated NB symptoms and volume reduction of lower extremities., Results: With an average follow-up period of 35.0 months, the volume of the affected limbs was reduced in all patients. Symptoms of urinary function were improved in 44 out of 52 patients, as improved urinary urgency, disappearance of incontinence, and independence from self-catheterization. Among 15 patients who underwent pre- and postoperative questionnaire assessment of NB, the mean score of NB severity decreased significantly from 16.9 ± 7.1 points preoperatively to 4.3 ± 3.6 points postoperatively (p < 0.01)., Conclusions: The specific reason for NB following gynecologic cancer treatment remains unclear. Our study results suggest that lymphatic fluid stagnation itself might be a reason for NB and LVA could reduce these symptoms., (© 2024 Wiley Periodicals LLC.)

Lymphedema is a chronic disabling condition affecting a growing number of patients worldwide. Although lymphedema is not life-threatening, several reports underlined detrimental consequences in terms of distress, pain, functional impairment, and infections with a relevant decrease in quality of life. Currently, there is no cure, and the therapeutic management of this condition aims at slowing down the disease progression and preventing secondary complications. Early diagnosis is paramount to enhance the effects of rehabilitation or surgical treatments. On the other hand, a multidisciplinary treatment should be truly integrated, the combination of microsurgical and reductive procedures should be considered a valid strategy to manage extremity lymphedema, and rehabilitation should be considered the cornerstone of the multidisciplinary treatment not only for patients not suitable for surgical interventions but also before and after surgical procedures. Therefore, a specialized management of Plastic Reconstructive Surgeons and Physical and Rehabilitative Medicine physicians should be mandatory to address patients' needs and optimize the treatment of this disabling and detrimental condition. Therefore, the aim of this review was to characterize the comprehensive management of lymphedema, providing a broad overview of the potential therapy available in the current literature to optimize the comprehensive management of lymphedema and minimize complications. [ABSTRACT FROM AUTHOR]

In order to provide a physiological solution for patients with breast cancer-related lymphedema (BCRL), the surgeon must understand where and how the pathology of lymphedema occurred. Based on each patient’s pathology, the treatment plan should be carefully decided and individualized. At the authors’ institution, the treatment plan is made individually based on each patient’s symptoms and relative factors. Most early-stage patients first undergo decongestive therapy and then, depending on the efficacy of the treatment, a surgical approach is suggested. If the patient is indicated for surgery, all the points of lymphatic flow obstruction are carefully examined. Thus a BCRL patient can be considered for lymphaticovenous anastomosis (LVA), a lymph node flap, scar resection, or a combination thereof. LVA targets ectatic superficial collecting lymphatics, which are located within the deep fat layer, and preoperative mapping using ultrasonography is critical. If there is contracture on the axilla, axillary scar removal is indicated to relieve the vein pressure and allow better drainage. Furthermore, removing the scars and reconstructing the fat layer will allow a better chance for the lymphatics to regenerate. After complete removal of scar tissue, a regional fat flap or a superficial circumflex iliac artery perforator flap with lymph node transfer is performed. By deciding the surgical planning for BCRL based on each patient’s pathophysiology, optimal outcomes can be achieved. Depending on each patient’s pathophysiology, LVA, scar removal, vascularized lymph node transfer with a sufficient adipocutaneous flap, and simultaneous breast reconstruction should be planned.

Despite an increased incidence of secondary lower limb lymphedema (LLL) and severity of comorbidities with age, the impact of age on the effectiveness of lymphaticovenous anastomosis (LVA) in the older patients remains unclear. Methods: This retrospective cohort study enrolled older patients (age > 65 years) with secondary unilateral LLL. All patients underwent supermicrosurgical LVA. Demographic data and intraoperative findings including lymphatic vessel (LV) diameter, LV functionality (indocyanine green-enhanced and Flow positivity), and lymphosclerosis classification were recorded. Magnetic resonance volumetry was used for measuring preoperative and postoperative volume changes at 6 months and one year after LVA as primary and secondary endpoints. Results: Thirty-two patients (29 females/3 males) with a median age of 71.0 years [range, 68.0 to 76.3] were enrolled. The median duration of lymphedema was 6.4 [1.0 to 11.7] years. The median LV diameter was 0.7 [0.5 to 0.8] mm. The percentage of ICG-enhanced and Flow-positive LVs were 89.5% and 85.8%, respectively. The total percentage of suitable LVs (s0 and s1) for LVA based on lymphosclerosis classification was 75.9%. There were significant six-month and one-year post-LVA percentage volume reductions compared to pre-LVA volume (both p < 0.001). A significant reduction in cellulitis incidence was also noted after LVA (p < 0.001). No surgical or postoperative complications were found. Conclusion: Relief of secondary LLL was achievable through LVA in older patients who still possessed favorable LV characteristics, including larger LV diameters as well as a high proportion of functional LVs with a low grade of lymphosclerosis. [ABSTRACT FROM AUTHOR]

Lymphedema is defined as the abnormal accumulation of interstitial fluid in subcutaneous tissues resulting from cancer, cancer treatment (surgery and/or radiotherapy), infection, inflammatory disorders, obesity, and hereditary syndromes. Surgical management of lymphedema can be broadly classified into two categories, reductive surgical techniques such as direct excision, suction assisted protein lipectomy (SAPL) or radical reduction with perforator preservation (RRPP); and physiological surgical procedures such as lymphaticovenous anastomosis (LVA) and vascularised lymph node transfer (VLNT). These techniques and their various combinations were evaluated. The results revealed patients with reversible lymphedema (ISL stage I, mild severity) benefit most from physiological procedures (LVA or VLNT) which can reduce the chance of disease progression to the chronic, solid phase. Reductive techniques such as SAPL, RPPP, or direct excision procedures should be reserved for patients with advanced – severe lymphedema (ISL stages II and especially stage III) as the surgical treatment of choice. In this study, current literature on the surgical treatment of lower extremity lymphedema is reviewed and discussed in conjunction with authors’ clinical experiences. An algorithm is presented, based on clinical evidence and experience which aims to provide a structured approach to managing lower limb lymphedema.

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.

Background: Lymphovenous anastomosis (LVA) has become an increasingly common treatment for patients with secondary extremity lymphedema. The objective of this study was to optimize strategies for lower secondary extremity lymphedema using LVA techniques, with the aim of enhancing patient outcomes., Methods: We conducted a retrospective analysis of 121 patients who underwent LVA at Taizhou Hospital of Zhejiang Province from January 2020 to December 2023. Preoperative and postoperative assessments included intraoperative observations, functional parameters, and clinical outcomes. The efficacy of LVA was evaluated based on circumferential reduction, quality of life improvements (Lymphoedema Quality of Life Questionnaire), and postoperative complications., Results: This study enrolled 121 patients with lower secondary extremity lymphedema, with an average age of 58.19 years. The results revealed significant associations between incision depth, lymphatic vessel size, the number of LVAs performed, and the number of incisions per patient, all of which correlated with postoperative volume reduction. The resulted analysis that identified optimal incision depths of 10 to 15 mm, lymphatic vessel size of 0.4 to 0.6 mm, and a recommended number of 6 to 8 LVAs. After LVA, there was a marked improvement in patient quality of life, with particularly notable enhancements in functionality and appearance., Conclusions: This study's findings optimizing the strategy for LVA surgery recommend the depth of incision, the size of lymphatic vessels, and the number of anastomoses to improve the quality of life and limb volume in patients with secondary lymphedema of the lower limbs., Competing Interests: Disclosures None., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Lower extremity lymphedema is a common complication following treatment for gynecological malignancies. Its incidence rate can reach up to 70%, affecting ~20 million people worldwide. However, specialized treatment centers are scarce, and there is a lack of consensus on treatment approaches. Furthermore, there are even fewer reports on the systematic and effective treatment of severe lymphedema with malformations. Effective management of this condition remains a significant challenge for clinicians., Case Summary: A 40-year-old woman developed bilateral leg swelling 6 years after receiving treatment for endometrial cancer. Since August 2018, she experienced > 30 episodes of lymphangitis. Upon presentation, she exhibited bilateral leg swelling and deformation, with four large swellings in the posterior thigh that impeded movement, and pain in the limbs. Skin manifestations included lichenoid lesions and features of deep sclerosis. Radionuclide lymphoscintigraphy confirmed the diagnosis of lower limb lymphedema. After 6 mo of complex decongestive therapy (CDT) and three lymphaticovenous anastomosis (LVA) treatments, the patient lost 49 kg in weight. She also experienced a maximum circumference reduction of 35.2 cm in the left lower limb and 37.5 cm in the right lower limb. The leg pain disappeared, her swelling significantly decreased, and she regained the ability to walk, cycle, and run normally., Conclusion: The combined application of CDT and LVA therapy demonstrates significant positive effects in the treatment of severe, deformed stage III lymphedema., Competing Interests: Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article., (©The Author(s) 2024. Published by Baishideng Publishing Group Inc. All rights reserved.)

In this report, we discuss the postoperative protocol for patients undergoing lymphaticovenous anastomosis (LVA) in our unit. Immediately after LVA, the incision site is closed over a small Penrose drain and a simple gauze dressing is applied without compression. In the first 5 days, ambulation is allowed, but limb elevation is actively encouraged to promote lymphatic flow across the newly formed anastomosis. Prophylactic antibiotics are routinely given to prevent infection because this patient group is susceptible to infections, which could trigger thrombosis in the anastomosis.

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Abstract Background Lymphedema in lower limb is one of major postoperative complications followed by a total hysterectomy with lymph node dissection. The objective of this report is to examine a long-term result of lymphaticovenous anastomosis procedure as a preventive surgery. Methods Sixteen patients with endometrial cancer underwent an abdominal hysterectomy with a bilateral salpingo-oophorectomy. Just after pelvic lymph node dissection, either end-to-end or sleeve anastomosis utilizing venules and suprainguinal lymph vessels was performed. During the observation period from 4 to 13 years, the symptom of lymphedema in lower extremities has been assessed. Results Among 16 patients, 1 presented postoperative lymphedema grade 3 (CTCAE (Common Terminology Criteria for Adverse Events) Ver. 4.0, 10025233) in lower limb, and a second surgery at 7 years after the first one was required. Other 6 patients showed non-severe symptoms of lymphedema, diagnosed as grade 1. The rest 9 patients did not show any symptoms of postoperative lymphedema in a long term (up to 13 years). Conclusion From the long term outcomes of our 16 cases, we propose that a direct lymphaticovenous microsurgery immediately after a hysterectomy with lymphadenectomy of external inguinal lymph node is one of the appropriate therapeutic choices to prevent severe lymphedema in lower limb.

Lymphedema can cause by a congenital anomaly, an infectious disease, chronic inflammation, connective tissue disease, and cancer. The most common presenting symptoms are swelling of the affected limb, difficulty wearing clothes, and disturbances to daily life activities. Most of the time, patients have a high chance of developing a soft tissue infection that will jeopardize the quality of their life and socioeconomic status. As to management of the disease, it necessary to make a precise diagnosis and clinico-pathological staging in order to guide the treatment plan and yield optimum results. Currently, surgical management for lymphedema is based on the use of 1) physiological treatment, and 2) reductive or ablative procedures. Conservative treatment (especially for complete decongestive therapy) is still the mainstay for the management of lymphedema.

Lymphedema is defined as the abnormal accumulation of interstitial fluid in subcutaneous tissues resulting from cancer, cancer treatment (surgery and/or radiotherapy), infection, inflammatory disorders, obesity, and hereditary syndromes. Surgical management of lymphedema can be broadly classified into two categories, reductive surgical techniques such as direct excision, suction assisted protein lipectomy (SAPL) or radical reduction with perforator preservation (RRPP); and physiological surgical procedures such as lymphaticovenous anastomosis (LVA) and vascularised lymph node transfer (VLNT). These techniques and their various combinations were evaluated. The results revealed patients with reversible lymphedema (ISL stage I, mild severity) benefit most from physiological procedures (LVA or VLNT) which can reduce the chance of disease progression to the chronic, solid phase. Reductive techniques such as SAPL, RPPP, or direct excision procedures should be reserved for patients with advanced – severe lymphedema (ISL stages II and especially stage III) as the surgical treatment of choice. In this study, current literature on the surgical treatment of lower extremity lymphedema is reviewed and discussed in conjunction with authors' clinical experiences. An algorithm is presented, based on clinical evidence and experience which aims to provide a structured approach to managing lower limb lymphedema. [ABSTRACT FROM AUTHOR]

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., Competing Interests: Disclosure D Furniss performs lymphedema surgery as codirector of the Oxford Lymphoedema Practice (https://olp.surgery/) at the Manor Hospital, Oxford, United Kingdom. Z Y. Ng and X Chalhoub have nothing to disclose., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background and Objectives: Indocyanine green (ICG) lymphography is the reference standard for evaluating lymphedema stage and identifying lymphatic vessels. However, the penetration depth was limited to 1-2 cm from the skin surface. This prospective study compares clinical outcomes following lymphaticovenous anastomoses (LVA) in patients with upper and lower limb lymphedema using contrast-enhanced ultrasonography (CEUS) with ICG as a preoperative imaging modality., Methods: Under general anesthesia, Sonazoid® was injected subcutaneously to visualize functional lymphatic channels via CEUS. We analyzed the changes in limb circumference and inter-limb ratio (ILR) using bioimpedance to measure electrical resistance between the CEUS plus ICG group and the ICG-only group to see the effect of CEUS-assisted LVA., Results: No significant demographic differences existed between the two groups (CEUS plus ICG group vs. ICG-only group). The ILR decrease of the Z 1 value measured using bioimpedance was statistically significant (p = 0.042 for the upper limb, p = 0.002 for the lower limb)- CONCLUSIONS: CEUS allowed us to identify deep-lying, functional, and large lymphatic channels. In conclusion, the combination of CEUS and ICG for identifying lymphatic channels has the potential to lead to a more functional lymphovenous anastomosis., (© 2024 Wiley Periodicals LLC.)

Background: Lymphedema is characterized by an accumulation of interstitial fluids due to inefficient lymphatic drainage. Primary lymphedema is a rare condition, including congenital and idiopathic forms. Secondary lymphedema is a common complication of lymph node ablation in cancer treatment. Previous studies on secondary lymphedema lymphatic vessels have shown that after an initial phase of ectasia, worsening of the disease is associated with wall thickening accompanied by a progressive loss of the endothelial marker podoplanin. Methods and Results: We enrolled 17 patients with primary and 29 patients with secondary lymphedema who underwent lymphaticovenous anastomoses surgery. Histological sections were stained with Masson's trichrome, and immunohistochemistry was performed with antibodies to podoplanin, smooth muscle α-actin (α-SMA), and myosin heavy chain 11 (MyH11). In secondary lymphedema, we found ectasis, contraction, and sclerosis vessel types. In primary lymphedema, the majority of vessels were of the sclerosis type, with no contraction vessels. In both primary and secondary lymphedema, not all α-SMA-positive cells were also positive for MyH11, suggesting transformation into myofibroblasts. The endothelial marker podoplanin had a variable expression unrelatedly with the morphological vessel type. Conclusions: Secondary lymphedema collecting vessels included all the three types described in literature, that is, ectasis, contraction, and sclerosis, whereas in primary lymphedema, we found the ectasis and the sclerosis but not the contraction type. Some cells in the media stained positively for α-SMA but not for MyH11. These cells, possibly myofibroblasts, may contribute to collagen deposition. [ABSTRACT FROM AUTHOR]

Introduction: Supermicrosurgical lymphaticovenous anastomosis (LVA) can be performed in different configuration such as end-to-end (LVEEA), end-to-side (LVESA), and side-to-end (LVSEA). Each configuration has its own advantages and disadvantages. However, it has remained ambiguous as to which anastomotic o configuration to choose. The aim of this study is to analyze and compare the relative sizes of lymphatic vessel (LV) and recipient vein (RV), in attempts to provide the basis for proper selections of the anastomotic configuration.Methods: From March 2016 to October 2018, 100 lymphedema patients with 103 lymphedematous lower limbs (stage I-III) were included. All patients underwent supermicrosurgical LVA. Demographic data and intraoperative findings, including the number and size of the LV/RV, the size discrepancies, and the numbers of LVA performed were recorded. The severity of LVs were classified based on the lymphosclerosis classification (s0, s1, s2, and s3). One-way ANOVA test and post hoc analysis with Bonferroni's correction were performed for size discrepancy analysis.Results: A total 730 LVA were performed with 621 LVs and 468 RVs, averaging 7.1 LVA per limb. Of these, 367 (50.3%) were LVEEA, 333 (45.6%) were LVESA, and 30 (4.1%) were LVSEA. The average LV and RV size was 0.61 ± 0.35 mm and 0.87 ± 0.43 mm, respectively (p < 0.001). The average LV size in different configuration: LVEEA = LVESA < LVSEA (p < 0.001); The average RV size: LVEEA = LVSEA < LVESA (p < 0.001); The size discrepancy: LVESA > LVSEA > LVEEA (p < 0.001).The LVSEA group has more s1 lymphatic vessels as opposed to LVEEA and LVESA (p = 0.004).Conclusion: The size and the comparative discrepancy between the LVs and RVs are the determining factors for proper anastomotic configuration selection during LVA. LVESA was more frequently performed when vessel size discrepancy was larger. The efficacy of each anastomotic configuration has yet to be determined. [ABSTRACT FROM AUTHOR]

Lymphaticovenous anastomoses are mainly used in secondary limbs lymphedema. They also can be used to treat iatrogenic seroma. This technique was used to treat a patient with a painful breast seroma that appeared after a mastectomy with axillary dissection, resistant to multiple ponctions and persistent 8 months after. Pre operative both lymphoscintigraphy and lympho-MRI have been performed and we identified lymphatic ducts responsible for the seroma. The one involved in the seroma was also the preferential drainage network of the arm. Innoperative, we performed an indocyanine green angiography to map those lymphatic ducts. A total capsulectomy of the breast seroma has been performed. An incision was made in front of lymphatics selected for lymphaticovenous anastomoses on the anterior axilla face. We performed two microscopic lymphaticovenous anastomoses. The patient was followed up at one, three, six months and one year post operative. No recurrence occurred during the follow-up. At six month the arm perimeter reduced of two centimeters. Lymphoscintigraphy and lympho-MRI were performed at six month showing a disappearance of the drainage asymmetry and collateralities of the upper limb; and no measurable volume in projection of the right breast area. Lymphaticovenous anastomoses may be an effective therapeutic solution for resistant seroma after node dissection. Lymphoscintigraphy and lympho IRM are very useful in those cases. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Purpose: Breast cancer-related lymphedema (BCRL) is caused by an interruption of the lymphatic system after breast cancer treatment. Lymphaticovenous anastomosis (LVA), by which one or more patent lymphatic collecting vessels are connected to subcutaneous veins, shows promising results. Postoperatively, the patency of these anastomosis can be evaluated; however, little is known concerning the long-term patency after LVA in patients with BCRL. The aim of this study was to analyse the long-term patency, quality of life (QoL) and arm circumference after LVA, and to explore differences between patent and non-patent anastomosis and its correlation with clinical improvement. Methods: Twenty-five patients underwent indocyanine green (ICG) lymphography, lymph ICF-questionnaire, and arm circumference measurement preoperatively and 12 months after the LVA procedure. Results: Seventy-six percent of the patients showed at least one patent anastomosis after 12 months. Quality of life according to the Lymph-ICF increased significantly (p < 0.000); however, arm circumference showed no significant decrease. Sixty-five percent discontinued wearing compression stockings. The patent anastomosis group, compared with the non-patent anastomosis group showed, without significance, more improvement in QoL, arm circumference, and discontinuation of compression stockings, as well as a lower rate of infections both pre- and postoperatively, a shorter duration of lymphedema preoperatively, and a higher rate of early lymphedema and ICG stage. Conclusions: LVA showed an acceptable patency and positive correlation between a patent anastomosis and clinical improvement after 12 months. Further research with a larger study population is required to determine whether outcomes or patient characteristics significantly correlate with a patent anastomosis after LVA operation. [ABSTRACT FROM AUTHOR]