Diagnosis and resolution of olmesartan-associated sprue-like enteropathy confirmed by capsule endoscopy: a case report and literature review.

Herein, we describe a case of olmesartan-associated sprue-like enteropathy, in which improvement in villous atrophy was confirmed using small bowel capsule endoscopy. The patient was a 69-year-old woman who had persistent watery diarrhea (20 bowel movements/day) for 1 year and experienced a weight loss of 10 kg in the same period. Abdominal computed tomography revealed no abnormalities, and blood test results revealed no inflammatory reactions. Upper endoscopy and colonoscopy revealed villous atrophy in the duodenum and terminal ileum. As the patient was administered olmesartan for a long time and capsule endoscopy showed villous atrophy throughout the small bowel, she was diagnosed with olmesartan-associated sprue-like disease. Following the discontinuation of the medication, symptoms of diarrhea soon improved, and repeat capsule endoscopy indicated improvement in small intestinal villous atrophy. Olmesartan-associated sprue-like enteropathy should be considered a differential diagnosis in patients with severe chronic watery diarrhea. Our report is the first in which capsule endoscopy was performed multiple times over a long period for follow-up observation of improvements in the small intestine. In addition, our literature review regarding capsule endoscopy for olmesartan-associated enteritis might aid clinicians in the early diagnosis of the condition and the assessment of treatment efficacy.

Dynamic Reconstruction Using Bilateral Lengthening Temporalis Myoplasty for Facial Palsies in Patients with Hereditary Skin Laxity.

Hereditary skin laxity is a rare condition, some cases of which are also referred to as cutis laxa, and those involving facial skin are considered a target for treatment by plastic surgery as patients present with an aged face, which can reduce their quality of life. In some of these patients, the facial nerve and muscles may be affected, and cause weakness of mimetic muscles. We performed one-stage bilateral lengthening temporalis myoplasty reanimation, followed by lower facial contouring with partial lower lip excision and hammock-shaped fascia grafting in two patients with hereditary facial skin laxity coexisting with facial palsy. The patient was a 63-year-old woman with hereditary gelsolin amyloidosis and a 64-year-old man who was diagnosed with oculopharyngeal muscular dystrophy. Postoperatively, a symmetrical facial contour was achieved in repose, and smiling with and without biting was possible. To our knowledge, there are no reports of dynamic smile reconstruction for facial weakness in patients with hereditary facial skin laxity. Although these patients may experience progressive loss of function of the trigeminal nerve and its innervating muscles, the static suspension effect of lengthening temporalis myoplasty can be expected to continue even if the temporal muscles lose their function in the future. We believe that, with careful patient selection, dynamic reconstruction is an option for progressive facial paralysis. In this article, we present the chronological history of two patients who underwent multiple plastic surgery procedures and discuss the importance of the role of plastic surgery in improving the quality of life under these conditions.

Changes in physical activity level during hospitalization in patients with stroke and those with fracture: a prospective longitudinal study.

[Purpose] To examine changes in physical activity levels between admission and discharge in patients hospitalized after stroke and fracture. [Participants and Methods] Patients with stroke (n=36) or fracture (n=41) wore an accelerometer during the daytime for three days after admission and before discharge. Physical activity was divided into sedentary behavior (SB), light-intensity (LIPA), and moderate-to-vigorous (MVPA), and then compared between hospital admission and discharge using the Wilcoxon signed-rank test. The characteristics of patients with or without changes in SB during hospitalization were compared using the Mann-Whitney U test. [Results] The median LIPA time in patients after stroke and fracture increased from 107.5 and 106.7 minutes on admission to 122.0 and 127.3 minutes at discharge, and the median MVPA time increased from 2.7 and 0.7 minutes on admission to 4.2 and 2.7 minutes at discharge, respectively. In particular, LIPA in non-therapy time increased for patients both after stroke and fracture. No differences in characteristics were observed between with or without changes in SB regardless of differences in diagnoses. [Conclusion] These findings indicate that while physical activity levels increased during hospitalization, they remained below World Health Organization recommendations for MVPA, and patient characteristics alone may not account for increased activity levels.

Efficacy of Adding Locoregional Therapy in Non-Complete Remission Hepatocellular Carcinoma Treated With Atezolizumab Plus Bevacizumab: A Preliminary Study.

BACKGROUND/AIM: Atezolizumab plus bevacizumab (Atez/Bev) therapy is extremely effective and has a high response rate in hepatocellular carcinoma (HCC) treatment. This study investigated the efficacy of adding locoregional therapy with Atez/Bev for non-complete response (CR) HCC cases. PATIENTS AND METHODS: Twenty-eight HCC patients without CR during Atez/Bev therapy received locoregional therapy, and treatment efficacy was evaluated based on the modified RECIST criteria. RESULTS: The study included 23 male and five female participants with a mean age of 73.5 years. In the Atez/Bev and locoregional combination therapy effective group, both transcatheter arterial chemoembolization (TACE) and radiofrequency ablation (RFA) were combined in all patients. A significant reduction in neutrophil-to-lymphocyte ratio (NLR) was observed after adding locoregional therapy (p=0.039). Moreover, a combination of TACE and RFA was performed in all patients of the CR group. When assessing the add-on effect of the combination of TACE and RFA in the progressive disease (PD) group, seven patients were found to achieve non-PD. For patients who did not achieve PD, a significant NLR reduction was noted after the addition of locoregional therapy. CONCLUSION: Adding locoregional therapy such as TACE/RFA was found to exert an effect even in non-CR patients who had received Atez/Bev therapy. A reduction in NLR after locoregional therapy was noted. Even when a response is not obtained during Atez/Bev therapy, it is important to avail the option to add locoregional therapy, as it may contribute to improved prognosis via immune modulation with tolerable adverse reactions.

Effects of body composition and liver function after long-term pemafibrate treatment on dyslipidemia-associated non-alcoholic fatty liver disease.

Aim of the study: Owing to the association between non-alcoholic fatty liver disease (NAFLD) and dyslipidemia, there is a need for new treatment strategies to manage both conditions concomitantly. Our aim in this study was to evaluate the effectiveness of pemafibrate in alleviating dyslipidemia-associated NAFLD, including the evaluation of its effects on liver function and body composition. Material and methods: The study sample included 67 patients with dyslipidemia-associated NAFLD (29 males, mean age 65.7 years [range, 58.4-73.7]) who were administered pemafibrate continuously for a period of at least 12 months, between June 2019 and January 2022. Outcomes were the change in body composition indices (visceral adipose tissue index - VATI, subcutaneous adipose tissue index - SATI, and skeletal muscle index - SMI), lipid biochemistry, and liver function, reserve, and fibrosis score, from baseline to the 12-month time point of pemafibrate treatment. Results: Pemafibrate treatment improved liver function (alanine aminotransferase, aspartate aminotransferase, g-glutamyl transpeptidase, and alkaline phosphatase), and lipid biochemistry (triglycerides and total cholesterol). Improvements in ferritin and hepatic reserve (Mac-2 binding protein, albumin-to-bilirubin score, and NAFLD fibrosis score) were also observed, as well as a decrease in SATI. Conclusions: Pemafibrate improved dyslipidemia, liver function, and hepatic reserve. The positive effects of pemafibrate on body composition likely contributed to the improvements in liver function. Longer-term treatment may be necessary to influence VATI and thus to further evaluate the relationship between improved body composition and NAFLD with pemafibrate treatment.

Comparison of Ablation Volume Between Emprint® and Mimapro® Systems for Hepatocellular Carcinoma -A Preliminary Study.

Background: Microwave ablation (MWA) is a standard percutaneous local therapy for hepatocellular carcinoma (HCC). Next-generation MWA is reported to create a more spherical ablation zone than radiofrequency ablation (RFA). We compared the ablation zone and aspect ratio of two 2.45 GHz MWA ablation probes; Emprint® (13G) and Mimapro® (17G). We compared the ablation zone to the applied energy after MWA in patients with hepatocellular carcinoma (HCC). Furthermore, we investigated local recurrence. Materials and Methods: We included 20 patients with HCC, with an average tumour diameter of 33.2 ± 12.2 mm, who underwent MWA using Emprint®, and 9 patients who underwent MWA using Mimapro® with an average tumour diameter of 31.1 ± 10.5 mm. Both groups underwent the same ablation protocol using the same power settings. The images obtained after MWA showed the treatment ablation zone and aspect ratio, which were measured and compared using three-dimensional image analysis software. Results: The aspect ratios in the Emprint® and Mimapro® groups were 0.786 ± 0.105 and 0.808 ± 0.122, respectively, with no significant difference (p = 0.604). The ablation time was significantly shorter in the Mimapro® group than in the Emprint® group, and there was no significant difference in the frequency of popping or the ablation volume. There were no significant differences in local recurrence between the two groups. Conclusion: There was no significant difference in the aspect ratios of the ablation diameter, and the ablation zone was almost spherical in both cases. Mimapro® at 17G was less invasive than Emprint® at 13G.

Ex Vivo Experimental Study of the Ablation Area of Bovine Liver Using STARmed Radiofrequency Ablation.

BACKGROUND/AIM: Ablating a spherical area during hepatocellular carcinoma ablation therapy is a very important issue. We aimed to determine the ablation area of bovine liver using various radiofrequency ablation (RFA) protocols. MATERIALS AND METHODS: Bovine liver (1-2 kg) was placed in an aluminum tray, which was punctured with STARmed VIVA 2.0 17-gauge (G) and 15-G electrodes using a current-carrying tip. Under the step-up or linear method, with an ablation time up to one break and RFA output stop, the size of the color change area (representing the thermally coagulated area) of the bovine liver was measured along the vertical and horizontal axes, and the ablated volume and total heat generated were calculated. RESULTS: 5-W per minute increases protocol resulted in greater horizontal and vertical diameters of the ablated area than 10-W per minute increases protocol under the step-up method. For 5-W and 10-W per minute increases under the step-up method, the aspect ratio was 0.81 and 0.67 with a 17-G electrode, and 0.73 and 0.69 with a 15-G electrode, respectively. For 5-W and 10-W increases under the linear method, the aspect ratio was 0.89 and 0.82, respectively. Sufficient ablation was obtained, with vertical and horizontal diameters of 50 mm and 43.50 mm, respectively. Although the ablation time was long, the watt output value at the break and average watt value were low. CONCLUSION: Gradual increase in output (5 W) using the step-up method yielded a more spherical ablation area, and longer ablation time in the linear method with a 15-G electrode could result in a more spherical ablation area in real clinical practice in humans. Future studies should examine concerns regarding long ablation times.

An Investigation of Popping During Radiofrequency Ablation After Lenvatinib Administration for Hepatocellular Carcinoma.

BACKGROUND/AIM: Lenvatinib is available as a molecular target agent for hepatocellular carcinoma (HCC). In this study, we investigated the popping phenomena in patients with HCC who underwent radiofrequency ablation (RFA) after taking lenvatinib. PATIENTS AND METHODS: Fifty-nine patients with HCC between 21-30 mm in diameter and no history of systemic treatment were enrolled in the study. The patients underwent RFA using a VIVA RFA SYSTEM with an ablation tip of 30 mm in length. For the initial lenvatinib administration, 16 patients had an adequate course of treatment and were treated with RFA as add-on therapy (combination group). The other 43 patients were treated by RFA monotherapy (monotherapy group). The popping frequency during RFA was recorded and compared. RESULTS: Popping frequency in the combination group (RFA combined with lenvatinib) was significantly higher than that in the monotherapy group. There was no significant difference between the combination group and the monotherapy group in ablation time, maximum output level, tumour temperature after ablation, or initial resistance value. CONCLUSION: Popping frequency was significantly higher in the combination group. It is possible that the intra-tumour temperature increased rapidly during RFA in the combination group due to the inhibitory effect of lenvatinib on tumour angiogenesis, leading to the occurrence of popping. Further studies are needed to investigate popping after RFA, and precise protocols need to be developed.

Two Cases of Gastric Varices with Left-sided Portal Hypertension Due to Essential Thrombocythemia Treated with Gastric Devascularization or Partial Splenic Embolization.

Left-sided portal hypertension (LSPH) is a condition of extrahepatic portal hypertension that often results in bleeding from isolated gastric varices (GVs). LSPH is sometimes caused by myeloproliferative diseases, such as essential thrombocythemia (ET). We herein report two cases of GVs with LSPH due to ET that were successfully controlled by gastric devascularization (GDS) or partial splenic embolization (PSE). Since each patient with LSPH due to ET has a different pathology, optimal treatment should be performed depending on the patient's condition, such as platelet counts, hemodynamics, or the prognosis. We believe that these cases will serve as a reference for future cases.

Two cases of portal-systemic encephalopathy caused by multiple portosystemic shunts successfully treated with percutaneous transhepatic obliteration.

BACKGROUND: Portal-systemic encephalopathy is a hepatic encephalopathy caused by portosystemic shunts and is a poor prognostic factor for cirrhotic patients. Percutaneous transhepatic obliteration is an option for controlling portal-systemic encephalopathy. We report two cases of portal-systemic encephalopathy that were successfully controlled with percutaneous transhepatic obliteration. CASE PRESENTATION: (Case 1) A 70-year-old woman experienced repeated portal-systemic encephalopathy due to a mesocaval shunt and a paraumbilical vein. She underwent percutaneous transhepatic obliteration with coils and 5% ethanolamine oleate-iopamidol. After treatment, portal-systemic encephalopathy became controllable. (Case 2) A 60-year-old man experienced repeated portal-systemic encephalopathy due to a left gastric vein shunt, a shunt from the posterior branch of the intrahepatic portal vein to the inferior phrenic vein, and a paraumbilical vein. He underwent percutaneous transhepatic obliteration of three portosystemic shunts with coils, 5% ethanolamine oleate-iopamidol, and N-butyl-2-cyanoacrylate. After treatment, the portal-systemic encephalopathy became controllable. CONCLUSIONS: Percutaneous transhepatic obliteration is particularly effective in cases involving multiple and complex portosystemic shunt pathways; however, percutaneous transhepatic obliteration is an invasive treatment, and its indications should be carefully considered. These cases will serve as a reference for successful treatment in the future cases.

Resection and Abdominal Wall Reconstruction for Cesarean Scar Endometriosis.

Introduction: Currently, there are few reports describing the use of reconstructive techniques in the treatment of cesarean scar endometriosis (CSE). Here, we report a case of CSE, a rare form of endometriosis caused by scars from obstetric and gynecological surgeries. Case Report. A 50-year-old woman became aware of a painful, deep scar mass in her lower abdomen during her menstrual period 10 years after her second cesarean section. This was diagnosed as CSE after the biopsy. Under general anesthesia, the mass, a portion of the rectus abdominis, and a 1 cm tumor-free margin were resected as a whole, and the abdominal wall was reconstructed with a soft artificial mesh. Results: No obvious recurrence or subjective symptoms were observed postoperatively or reported in the 1-year follow-up period. Discussion. Endometriosis appearing in a cesarean scar is rare; it is chiefly triggered by intraoperative mechanical implantation. In cases of surgical scar masses with a history of gynecological surgery and associated menstrual symptoms, this syndrome should be considered during diagnosis and treatment.

New Method for Umbilicoplasty with Bilateral Square Flap and Caudal Deep Inferior Epigastric Artery Perforator Flap.

Background: The navel is an important cosmetic feature of the abdomen. A vertically long navel with a deep caudal side has recently been preferred by patients. Currently, there is no plastic surgery technique for complete umbilical repositioning or plasty after umbilical keloid resection. This study aimed to examine the effect of a new umbilicoplasty by combining a bilateral square flap with a triangular flap that utilizes the excess caudal skin nourished by the deep inferior epigastric artery perforator. Methods: A total of 23 patients underwent umbilical keloid resection and new umbilicoplasty between April 2018 and March 2020. The mean patient age was 48.2 (range: 36-68) years, and mean body mass index was 23.1 (range: 18.5-33.4). Satisfaction with umbilical morphology was evaluated on a 5-point scale through interviews. Results: The surgery resulted in forming a vertically elongated deep caudal umbilical fossa. All patients were satisfied with their umbilical morphology (mean score, 4.6). In one case involving a woman who underwent breast reconstruction with a deep inferior epigastric artery perforator flap, superficial necrosis of the triangular flap was observed. However, no other complications were observed. Conclusions: Creating a flap with stable blood circulation using the tissue originally excised during umbilical surgery allowed for the reproduction of a desirable umbilical morphology with adequate verticality and caudal depth.

Balloon-occluded retrograde transvenous obliteration for gastric varices improves hepatic functional reserve in long-term follow-up.

BACKGROUND AND AIM: Balloon-occluded retrograde transvenous obliteration (BRTO) has been widely adopted for the management of gastric fundal varices (GVs). There are a few reports that BRTO leads to the improvement of mid-term and long-term hepatic functional reserve (HFR). We retrospectively investigated the long-term effect on HFR and prognosis among patients who had undergone BRTO for GVs. METHODS: This single-center, retrospective study included 57successful patients out of 60 patients who underwent BRTO for GVs from December 2005 to September 2018. We examined the indicators of HFR (e.g., encephalopathy and ascites statuses, serum total bilirubin and albumin levels, % prothrombin time, and Child-Pugh and albumin-bilirubin [ALBI] scores) during 3 years of follow-up after BRTO. We analyzed survival using the Kaplan-Meier method and identified the independent prognostic factors via multivariate analyses. RESULTS: GVs disappeared in all patients who were successfully treated by BRTO. At 3 years after BRTO, serum albumin levels were significantly elevated (from 3.3 to 4.0 g/dL, P = 0.008), while Child-Pugh and ALBI scores were significantly decreased (from 7.0 to 5.7, P = 0.043, and from -1.94 to -2.60, P = 0.006, respectively). The median survival time among all patients was 2207 days; the survival rates after BRTO were 87.0% at 1 year, 81.8% at 3 years, 67.3% at 5 years, and 44.1% at 10 years. Multivariate analyses revealed that ascites, hepatic encephalopathy, and malignant neoplasms were independently associated with poor prognosis. CONCLUSION: BRTO for GVs has a favorable effect on long-term HFR.

A Rare Case of Recurrent Generalized Peritonitis Caused by Spontaneous Urinary Bladder Rupture after Radiotherapy: A Case Report and Literature Review.

Since generalized peritonitis is a fatal disease, accurate diagnosis and treatment are important. In this paper, we report a case of recurrent generalized peritonitis associated with spontaneous urinary bladder rupture (SBR). A 65 year old woman, who underwent radiotherapy 21 years prior, was diagnosed with generalized peritonitis. Although the cause of the generalized peritonitis could not be identified, the patient recovered with conservative treatment in short period. However, recurrent episodes of generalized peritonitis occurred four times. We diagnosed the patient with urinary ascites due to SBR, based on a history of radiotherapy and dysuria. No recurrence of generalized peritonitis had occurred after accurate diagnosis and treatment with long-term bladder catheter placement. Since SBR often occurs as a late complication after radiotherapy, it is difficult to diagnose SBR, which leads to delayed treatment. This case and literature review of similar cases suggest that the information of the following might be helpful in the diagnosis of SBR: (i) history of recurrent generalized peritonitis, (ii) pseudo-renal failure, (iii) history of radiotherapy, (iv) dysuria, and (v) increase or decrease of ascites in a short period. It is important to list SBR in the differential diagnosis by knowing the disease and understanding its clinical features. This case and literature review will serve as a reference for future practices.

Defining the functionally sufficient regulatory region and liver-specific roles of the erythropoietin gene by transgene complementation.

BACKGROUND: Erythropoietin (EPO) is an essential growth factor for erythroid cells and is mainly secreted from the kidneys and subsidiarily from the livers of adult mammals in an anemia/hypoxia-inducible manner. AIM AND METHOD: To elucidate the regulatory mechanisms of stress-inducible and cell type-specific Epo gene transcription, the rate-limiting step of EPO production, we investigated the sufficiency of a 180-kb genomic fragment flanking the mouse Epo gene locus for recapitulating endogenous Epo gene function by a transgene complementation strategy. KEY FINDINGS: While Epo gene-deficient mice exhibited lethal anemia in utero with defects in erythroblast proliferation and maturation, Epo-knockout mice integrated with the 180-kb Epo transgene showed normal erythropoiesis throughout life. In the transgene-rescued mice, liver-specific deletion of the transgene by the Cre-loxP recombination system caused neonatal anemia with erythropoietic defects in the liver but not in the spleen, indicating the essential function of hepatic EPO on normal erythropoiesis in the liver, which is the major erythropoietic site in late embryonic and neonatal stages. SIGNIFICANCE: These results demonstrate that the 180 kb Epo gene flanking region contains the fully functional Epo gene unit and that EPO from the liver dominantly stimulates hepatic erythropoiesis but contributes less to erythropoiesis in other organs.

JDP2 is directly regulated by ATF4 and modulates TRAIL sensitivity by suppressing the ATF4-DR5 axis.

Jun dimerization protein 2 (JDP2) is a bZip-type transcription factor, which acts as a repressor or activator of several cellular processes, including cell differentiation and chromatin remodeling. Previously, we found that a stress-responsive transcription factor, known as activating transcription factor 4 (ATF4), enhances JDP2 gene expression in human astrocytoma U373MG and cervical cancer HeLa cells; however, the role of JDP2 in the ATF4-mediated stress response remained unclear. Here, we reported that siRNA-mediated JDP2 knockdown enhances the expression of several ATF4 target genes, including ASNS, and death receptors 4 and 5 (DR4 and DR5) in HeLa cells. In addition, the results of a transient reporter assay indicate that JDP2 overexpression represses ER stress-mediated DR5 promoter activation suggesting that JDP2 negatively regulates ATF4-mediated gene expression. Curiously, knockdown of JDP2 increases the sensitivity of cells to TNF-related apoptosis-inducing ligand (TRAIL), which induces apoptosis in cancer cells through DR4 and DR5. These results indicate that JDP2 functions as a negative feedback regulator of the ATF4 pathway and contributes to TRAIL resistance in cancer cells.

Indocyanine green fluorescence videoangiography for reliable variations of supraclavicular artery flaps.

BACKGROUND: Pedicled flaps are useful for reconstructive surgery. Previously, we often used vascularized supraclavicular flaps, especially for head and neck reconstruction, but then shifted to using thoracic branch of the supraclavicular artery (TBSA) flaps. However, limited research exists on the anatomy of TBSA flaps and on the use of indocyanine green (ICG) fluorescence videoangiography for supraclavicular artery flaps. We utilized ICG fluorescence videoangiography to harvest reliable flaps in reconstructive operations, and describe the results herein. METHODS: Data were retrospectively reviewed from six patients (five men and one woman: average age, 54 years; range, 48-60 years) for whom ICG videoangiography was performed to observe the skin perfusion of a supraclavicular flap after it was raised. Areas where the flap showed good enhancement were considered to be favorable for flap survival. The observation of ICG dye indicated good skin perfusion, which is predictive of flap survival; therefore, we trimmed any areas without dye filling and used the remaining viable part of the flap. RESULTS: The flaps ranged in size from 13×5.5 cm to 17×6.5 cm. One patient received a conventional supraclavicular flap, four patients received a TBSA flap, and one patient received a flap that was considered to be intermediate between a supraclavicular flap and a TBSA flap. The flaps completely survived in all cases, and no flap necrosis was observed. CONCLUSIONS: The TBSA flap is very useful in reconstructive surgery, and reliable flaps could be obtained by using ICG fluorescence videoangiography intraoperatively.

Highly efficient induction of primate iPS cells by combining RNA transfection and chemical compounds.

Induced pluripotent stem (iPS) cells hold great promise for regenerative medicine and the treatment of various diseases. Before proceeding to clinical trials, it is important to test the efficacy and safety of iPS cell-based treatments using experimental animals. The common marmoset is a new world monkey widely used in biomedical studies. However, efficient methods that could generate iPS cells from a variety of cells have not been established. Here, we report that marmoset cells are efficiently reprogrammed into iPS cells by combining RNA transfection and chemical compounds. Using this novel combination, we generate transgene integration-free marmoset iPS cells from a variety of cells that are difficult to reprogram using conventional RNA transfection method. Furthermore, we show this is similarly effective for human and cynomolgus monkey iPS cell generation. Thus, the addition of chemical compounds during RNA transfection greatly facilitates reprogramming and efficient generation of completely integration-free safe iPS cells in primates, particularly from difficult-to-reprogram cells.

Comparison of patency rates of lymphaticovenous anastomoses at different sites for lower extremity lymphedema.

OBJECTIVE: Lymphaticovenous anastomosis (LVA) is one of the surgical treatments of lymphedema. However, only a few reports have evaluated LVA directly. This study aimed to evaluate the patency of LVA using indocyanine green fluorescence lymphography and to determine the optimal anastomosis site in patients with lower extremity lymphedema. METHODS: Thirty-six patients, with a total of 123 anastomoses for lower extremity lymphedema including 3 cases of idiopathic lymphedema, who underwent LVA for the first time between March 2014 and March 2017 were selected for enrollment in this study. The patency of the anastomoses was evaluated using PDE-neo (Hamamatsu Photonics, Hamakita, Japan) by injecting indocyanine green into the subcutaneous tissue at 6 months postoperatively. The site of anastomosis was the intersection point of the lymphatic vessel and vein, which was identified preoperatively. To determine the best surgical location, the anastomosis site was classified into the joint area (ankle and knee) and nonjoint area (dorsum and lower leg). The anastomosis was evaluated as either patent or nonpatent. RESULTS: Patency was confirmed in 37 of the 76 (49%) anastomoses at the joint area and 12 of the 47 (26%) at nonjoint areas (P = .01). CONCLUSIONS: The patency rate was significantly higher around the joint area than at the nonjoint areas. LVA around the joint area is recommended to ensure favorable technical and surgical outcomes for patients with lower extremity lymphedema.

Evaluation of patency rates of different lymphaticovenous anastomosis techniques and risk factors for obstruction in secondary upper extremity lymphedema.

OBJECTIVE: Lymphaticovenous anastomosis (LVA) is one of the surgical treatments for lymphedema. Lymphaticovenous side-to-end anastomosis (LVSEA) and lymphaticovenous end-to-end anastomosis (LVEEA) are the most commonly used procedures; however, only a few reports have evaluated direct anastomosis. We used indocyanine green fluorescence lymphography to evaluate and to compare both techniques. METHODS: Eighteen patients (67 anastomoses) with secondary upper extremity lymphedema were evaluated 6 months postoperatively. After injection of indocyanine green, anastomoses that were obviously patent were considered patent, and the others were considered unpatent. In addition, we evaluated the risk factors for obstruction using the following five points: dyeing of the lymphatic vessel by patent blue, lymphatic flow, venous regurgitation, lymphatic vessel degeneration, and runoff after the anastomosis. RESULTS: There were 44 LVSEAs and 23 LVEEAs performed, of which 14 (32%) and 8 (35%) were patent, respectively. Risk factors for obstruction in these 67 anastomoses were evaluated. However, no significant difference was found. CONCLUSIONS: Patency of an LVA anastomosis is not high and not different between LVSEA and LVEEA. However, if anastomotic occlusion occurs, lymphatic obstruction is more likely with LVEEA than with LVSEA. Therefore, when LVA is performed, we recommend LVSEA principally and LVEEA only when the potential for consequences and risk of obstruction are low.