Dynamic Indocyanine Green (ICG) lymphography for breast cancer-related arm lymphedema.

BACKGROUND: Lymph transportation capacity is a critical function maintaining fluid circulation. After breast cancer treatments, lymph obstruction at the axilla leads to abnormal lymph circulation, resulting in lymph pump dysfunction. As well as lymph circulation, lymph pump function is important for lymphedema evaluation. METHODS: We assessed and analyzed lymph transportation capacity of 15 breast cancer-related arm lymphedema patients using dynamic indocyanine green (ICG) lymphography. RESULTS: ICG velocity and transit time could evaluate lymph pump function; ICG velocity decreases and transit time increases as the lymphedema severity stage progresses. Measurement of ICG velocity required 3 minutes after the dye injection, whereas that of transit time took more than 1 hour in severe cases. CONCLUSIONS: ICG velocity can be easily obtained and is recommended for evaluation of lymph pump function. Dynamic ICG lymphography, which evaluates both lymph pump function and circulation, plays an important role in comprehensive assessment of lymphedema pathophysiology.

High-accuracy diagnosis and regional classification of lymphedema using indocyanine green fluorescent lymphography after gynecologic cancer treatment.

BACKGROUND: Secondary lymphedema is defined as swelling of the limbs caused by retention of lymph after cancer therapy. We diagnosed lymphedema using indocyanine green (ICG) fluorescent lymphography and developed a classification based on 12 regional types of edema in the lower bodies, with the goal of improved understanding of the pathology. METHODS: The subjects were 72 consecutive female patients aged 25 to 88 years (mean, 54.5 years) with secondary lymphedema of the lower extremities and abdominal area. The traditional diagnosis of lymphedema was stages 0, 1, 2, 3 and 4 in 5, 11, 19, 24, and 13 patients, respectively. All patients were examined by ICG lymphography. RESULTS: Features of dermal backflow were noted in most patients after cancer therapy, and the incidence was particularly high after radiotherapy. Regional analysis of lymphedema was classified into 12 types (A to L, definitions are given for major categories). The number of patients (number receiving radiation therapy in parentheses) in each type were A, 1 (0); B, 3 (1); C, 13 (1); D, 1 (0); E, 2 (0); F, 0 (0); G, 1 (0); H, 7 (3); I, 13 (3); J, 6 (2); K, 20 (3); and L, 5 (2). CONCLUSIONS: The ICG test permits definite diagnosis of lymphedema at a very early stage and in mild cases. The regional analysis enables establishment of policies for conservative or surgical treatment (for example, lymphaticovenous anastomosis) for individual regions, thereby facilitating more effective lymphedema treatment.

Minimally invasive multiple lymphaticovenular anastomosis at the ankle for the prevention of lower leg lymphedema.

BACKGROUND: The patients with secondary unilateral lower limb lymphedema are likely to experience lymphedema of the contralateral leg in the future. Our policy is to perform preventive lymphaticovenular anastomosis (LVA) of the contralateral limb without symptoms in these patients. In this report, we describe a minimally invasive preventive LVA procedure and present the preliminary results. METHODS: Ten patients with unilateral lower leg lymphedema underwent multiple LVA procedures through a skin incision over the ankle of the contralateral limb without symptoms. The Campisi clinical stage of these limbs without symptoms was stage 0 in five cases and stage 1A in five cases. The number of anastomoses performed through the incision over the ankle was two LVAs in five cases, three LVAs in four cases, and four LVAs in one case. RESULTS: All the multiple LVAs were completed without complications. The onset of postoperative cellulitis and edematous aggravation of the limb that received the minimally invasive preventive LVA procedure was not noted in any patient during 6-month follow-up period. CONCLUSIONS: This minimally invasive preventive LVA procedure might prevent lymphedema and improve the physical appearance of the limb with minimal scarring. Long-term follow-up will be necessary to monitor the future progression of edema in these patients.

The effect of lymphatico-venous anastomosis for an intractable ulcer at the lower leg in a marked obese patient.

Secondary lymphedema occurs after trauma, cancer surgery, or obesity, and wounds in lymphedema can easily become intractable. We report positive results using lymphatico-venous anastomosis (LVA) to treat a post-traumatic lymph fistula and an intractable ulcer in a severely obese patient. A 41-year-old male (BMI 51.8), one year prior, had a traffic injury, and had an 18-cm contusion in his right leg. Six months later, lymph leakage in a 14 cm × 8 cm region and a 5 cm × 3 cm skin ulcer occurred in the center of the wound. We made a diagnosis of lymphedema resulting from obesity, accompanied with lymphorrhea and intractable ulcer. He was unable to reach his legs owing to obesity, making complex physical therapy impossible. We performed LVA under local anesthesia. The lymphorrhea healed 2 weeks after the operation and had not recurred 3 months after the operation. The leg lymphedema improved after the surgery without the compression therapy. In cases of intractable ulcers, suspected of being caused by lymphostasis, treatments indicated for lymphedema, for example LVA, may possibly allow satisfactory wound healing. © 2013 Wiley Periodicals, Inc. Microsurgery 34:64-67, 2014.

Effective treatment of pelvic lymphocele by lymphaticovenular anastomosis.

OBJECTIVE: Pelvic lymphocele can be a severe complication associated with surgical procedures such as pelvic lymphadenectomy. Lymphaticovenular anastomosis (LVA) is increasing in popularity as a surgical treatment for lymphedema. The aim of this study was to evaluate whether LVA is an effective treatment for lymphocele, which is caused by an obstruction of the lymphatic flow in a manner similar to the development of lymphedema. METHODS: Eleven female patients, who presented with lymphocele, were treated with LVA. Before the operation, 3 of them were treated with a percutaneous catheter. Lymphocele size and the volume of daily drainage were measured before and after LVA. RESULTS: The lymphocele was completely resolved in 6 patients and partially resolved in the remaining 5 patients. The mean size of the pelvic lymphocele changed from 400 ml (range 50-1050 ml) to 43 ml (range 0-120 ml) (P<0.01). In the 3 patients who had percutaneous drainage catheters, the volume of fluid drained decreased from 340 ml/day to 20 ml/day after LVA. CONCLUSIONS: Our technique is minimally invasive and is performed under local anesthesia. LVA is effective regardless of the size of the lymphocele. Therefore, LVA should be considered as a therapy for lymphocele because of its low invasiveness and its effectiveness in re-establishing circulation of lymphatic flow. Further studies should be performed to compare LVA with other minimally invasive techniques, such as percutaneous catheter and sclerotherapy.

Dynamic reconstruction of full-thickness abdominal wall defects using free innervated vastus lateralis muscle flap combined with free anterolateral thigh flap.

Reconstruction of full-thickness abdominal wall defects remains a difficult surgical challenge. Although various reconstructive methods, including artificial mesh, pedicled and free flaps, have been reported, most reported reconstruction of only the fascia layer, leaving the resected rectus abdominis muscle unreconstructed. However, recent studies suggested the importance of dynamic reconstruction with functional muscle in preventing abdominal hernia in the long-term. According to the principle of reconstructive surgery, "replace lost tissue with similar tissue," a functionally and aesthetically ideal reconstruction is to reconstruct all components of the abdominal wall structure, including skin, subcutaneous fat, fascia, and muscle. We present 2 cases with full-thickness abdominal wall defects in the upper abdominal region, which we reconstructed with a free innervated vastus lateralis muscle flap combined with a free anterolateral thigh flap. The motor nerve of the vastus lateralis muscle was sutured with the intercostal nerve, and reinnervation was confirmed by electromyography. This method allows reconstruction of all components of the abdominal wall with a single flap, and dynamic reconstruction is achieved which will reduce the risk of postoperative hernia. We believe this method can be a good option for reconstruction of full-thickness abdominal wall defects with long-term stability.

Indocyanine green velocity: lymph transportation capacity deterioration with progression of lymphedema.

Lymph transportation capacity is a critical function maintaining fluid circulation. After pelvic cancer treatments, lymph obstruction at the pelvic region leads to abnormal lymph circulation, resulting in lymph pump dysfunction. Besides lymph circulation, lymph pump function is important for lymphedema evaluation. We assessed and analyzed lymph transportation capacity of secondary lower extremity lymphedema patients using indocyanine green (ICG) lymphography according to corresponding severity stage. Indocyanine green velocity and transit time could evaluate lymph pump function; ICG velocity decreases and transit time increases as the lymphedema severity stage progresses. Measurement of ICG velocity required 5 minutes after the dye injection, whereas that of transit time took more than 1 hour in severe cases. Indocyanine green velocity can be easily obtained and is recommended for evaluation of lymph pump function compared with transit time. Dynamic ICG lymphography, which evaluates both lymph pump function and circulation, plays an important role in comprehensive assessment of lymphedema pathophysiology.

Free concha flap for sensitive nasal reconstruction using the infraorbital artery and nerve as a recipient vessel and a recipient nerve.

Free auricular flap transplantation is one of the treatments for nasal reconstruction. This report presents a case of nasal reconstruction where the infraorbital artery was used as a recipient vessel, and the infraorbital nerve as a recipient sensory nerve. A 75-year-old female underwent resection of malignant melanoma of the right nasal ala. A free ear concha flap was used for the reconstruction. The facial artery could not be found intraoperatively; instead, the infraorbital artery was identified and anastomosed with the posterior auricular artery. The great auricular nerve was coapted with the infraorbital nerve. The results of the sensory examination were the same as those of the unaffected side. This procedure not only achieves a good aesthetic outcome, but also restores sufficient sensory function.

Necrotizing Fasciitis Occurred in the Lymphedematous leg.

Lymphedema is a chronic edema that sometimes occurs after treatment of gynecologic cancer, and cellulitis often occurs concomitantly with lymphedema. On the other hand, necrotizing fasciitis (NF) is a relatively rare, but life-threatening disease. The symptoms in cellulitis and NF are very similar. In this case report, we describe a case in which the diagnosis of NF in a lymphedematous limb was difficult. A 70-year-old woman had secondary lymphedema in bilateral legs and consulted our department. On the first day of lymphedema therapy, the patient complained of vomiting, diarrhea, and fever (37.7 °C) without local fever in the legs. She was diagnosed with acute gastroenteritis. On the next day, swelling and pain in her left leg occurred and her blood pressure was 59/44 mmHg. She was diagnosed with cellulitis accompanied by lower limb lymphedema and septic shock. On the second day, blisters appeared on the left leg, and computed tomography showed NF. We performed debridement under general anesthesia and her vital signs improved postoperatively. Streptococcus agalactiae (B) was detected in blood culture, and we administered bixillin and clindamycin. Postoperatively, necrosis in the skin and fat around the left ankle gradually spread, and it took 5 months to complete epithelialization. The diagnosis was more difficult than usual NF because patients with lymphedema often experience cellulitis. Clinicians should always think of NF to avoid mortality due to delayed treatment. This case report was approved by the institutional ethics committee.

Using indocyanine green fluorescent lymphography and lymphatic-venous anastomosis for cancer-related lymphedema.

Advances in cancer therapy have increased the importance of improvement of quality of life after cancer survival. Cancer-related lymphedema or secondary lymphedema that occurs after lymph node dissection in resection of tumors of abdominal visceral organs can impair quality of life. However, standard curative treatment for secondary lymphedema has not been established. This may be due to the lack of a method for early diagnosis of lymphedema, and because of selection of conservative treatment such as compression therapy to delay edema progression in many cases. To develop a curative approach, we have performed definite diagnosis of early-stage lymphedema using magnetic resonance imaging and an indocyanine green fluorescent lymphography, followed by surgical treatment with lymphatic-venous anastomosis using supermicrosurgery. Herein, we report the first case of secondary lymphedema in which we performed early diagnosis and surgery using these techniques and achieved an almost complete cure of lymphedema. We suggest that early diagnostic imaging and early microsurgery is the key of lymphedema treatment.

Lymphatic-venous anastomosis for the radical cure of a large pelvic lymphocyst.

Therapeutic efficacy of lymphatic-venous anastomosis (LVA) has been shown, but expansion of the indication is desirable because LVA is a procedure with low invasiveness and is applicable over a wide area. This is the first reported case of intractable pelvic lymphocyst for which LVA was effective. LVA may be useful for pelvic lymphocyst at an early stage after cancer resection and lymph node dissection.

Assessment of configuration of thoracic duct using magnetic resonance thoracic ductography in idiopathic lymphedema.

The structure and the function of the peripheral lymph channels have been investigated, but the thoracic duct has not. This study used magnetic resonance thoracic ductography for 2 patients with idiopathic lymphedema to evaluate the configuration of the thoracic duct in these patients. Anomalies of the thoracic duct were detected in both cases. This result suggests that deformity of the thoracic duct is one of the causes of idiopathic lymphedema. Characterization of the etiology could lead to a breakthrough in resolving the occurrence of idiopathic lymphedema and developing a treatment procedure for it. In addition, visualization of the thoracic duct may assist in selecting the optimal therapy for each idiopathic lymphedema patient.

Reconstruction of the larynx and aryepiglottic fold using a free radial forearm tendocutaneous flap after partial laryngopharyngectomy: a case report.

The patient was a 62-year-old man with chief complaints of pharyngeal pain and dysphagia. He was diagnosed with pyriform sinus poorly differentiated squamous cell carcinoma T3N0M0 (Stage II) and underwent partial laryngopharyngectomy, lymphadenectomy in the right neck, tracheostomy, and reconstruction of the larynx and aryepiglottic fold with a free radial forearm flap and the associated vascularized palmaris longus tendon. No particular problems occurred after surgery, and swallowing and articulation functions were successfully recovered. A free jejunum transfer is the first choice for reconstruction of a defect after partial hypopharyngectomy, but reconstruction of the supracricoid complex structure of the larynx using a free jejunum transfer after partial laryngopharyngectomy may lead to aspiration of intestinal fluids. In this case, we performed functional reconstruction of the laryngopharyngeal defect using a free radial forearm flap including a vascularized tendon of the palmaris longus, and satisfactory postoperative function was achieved. We believe that the key to successful functional recovery after partial laryngopharyngectomy is establishment of the three-dimensional complex structure of the arytenoid and aryepiglottic fold.

Antegrade and retrograde lymphatico-venous anastomosis for cancer-related lymphedema with lymphatic valve dysfuction and lymphatic varix.

In healthy people, no retrograde lymph flow occurs because of valves in collecting lymph vessels. However, in secondary lymphedema after lymph node dissection, lymph retention and lymphatic hypertension occurs and valvular dysfunction induces retrograde lymph flow. In this case reported, we focused on retrograde lymph flow and performed retrograde lymphatico-venous anastomosis (LVA) simultaneously with antegrade LVA. A 67-year-old Japanese woman had worsening edema in her right thigh and hip area for 3 years. She had previously undergone extended hysterectomy with lymph node dissection for endometrial cancer 8 years before. Indocyanine green test showed antegrade and retrograde lymph flow. Four LVAs were made in the right medial thigh and right lower abdominal area under local anesthesia. Lymphedema showed rapid improvement within 12 months and compression therapy was not required at 24 months after LVA. Retrograde LVA has a possibility of a more efficacy for secondary lymphedema.

Upper-limb lymphedema treated aesthetically with lymphaticovenous anastomosis using indocyanine green lymphography and noncontact vein visualization.

We have described a procedure to minimize surgical wounds, in which lymph vessels and skin venules are identified by indocyanine green (ICG) lymphography and the AV300 noncontact visualization system (AccuVein, Cold Spring Harbor, NY), respectively. This approach allows accurate decisions regarding sites of incision for lymphatic venous anastomosis (LVA). This method was applied in a patient with right upper-limb lymphedema after breast cancer therapy. The low-invasive procedure can be used before and during surgery. The incision size is minimal, and the incision site is at the joint area. Thus, we aim to establish this approach as a standard method for identifying lymph vessels and veins that are suitable for LVA. This innovative vascular-imaging machine makes LVA less invasive and more effective without side effects.

Lower extremity lymphedema index: a simple method for severity evaluation of lower extremity lymphedema.

Measurement of the circumference is the most commonly used method for evaluating extremity lymphedema. However, comparison between different patients is difficult with this measurement. To resolve this problem, we have formulated a new index, lower extremity lymphedema (LEL) index, which can be easily obtained from measurements of the body. We evaluated correlation between lower LEL index and clinical stage in patients with LEL. The LEL indices were significantly correlated with clinical stages and could be used as a severity scale. The LEL index makes objective assessment of the severity of lymphedema through a numerical rating, regardless of the body type. This numerical rating makes the index useful for evaluation of lymphedema severities between different cases.

Resection and Reconstruction of Giant Abdominoscrotal Arteriovenous Malformation.

Genital arteriovenous malformations are rare and present unique surgical challenges in preserving urogenital function, abdominal wall integrity, and lower limb perfusion. A 32-year-old man with a giant abdominoscrotal arteriovenous malformation presented with recurrent heavy bleeding. Due to the high risk of rebleeding and fatal hemorrhage, surgery with curative intent was proposed and the patient was counseled on the risks of ischemia to the lower limb, testes, and penis. Preoperative embolization of the feeding vessels was performed. Three days later, surgical excision of the mass with the affected scrotum, left rectus muscle, sheath, and overlying abdominal skin followed. The testes were dissected from the malformation and preserved along with the right internal pudendal artery. The left thigh skin was advanced to the scrotal remnants and a neoscrotum created. The resulting large abdominal wall defect was reconstructed in layers with a pedicled anterolateral thigh flap, including innervated vastus lateralis muscle, to prevent herniation. Recovery was uneventful, and a 4-year follow-up revealed no significant clinical or radiological recurrence with recovery of flap sensation, retained erectile function, and no herniation. We report this case due to rarity of giant abdominoscrotal arteriovenous malformations and present preoperative embolization, surgical resection, and functional anterolateral thigh flap reconstruction as a valuable treatment option of this life-threatening illness.

Comparison of indocyanine green lymphographic findings with the conditions of collecting lymphatic vessels of limbs in patients with lymphedema.

BACKGROUND: The authors investigated the relationship between findings from indocyanine green lymphography and the condition of lymphatics according to the Normal, Ectasis, Contraction, Sclerosis Type classifications observed in each area during surgery. METHODS: The authors examined 43 limbs of 25 patients who had undergone lymphaticovenous anastomosis from April to July of 2012 at the Department of Plastic and Reconstructive Surgery, University of Tokyo Hospital. After the injection of indocyanine green, linear, splash, stardust, and diffuse patterns were determined. Visual findings of the collecting lymph vessels during the anastomosis at each incision site were evaluated using the Normal, Ectasis, Contraction, Sclerosis Type classifications. RESULTS: Lymphaticovenous anastomosis was conducted on 164 collecting lymph vessels within 43 limbs of 25 people. Normal-type lymph vessels were observed in 36, ectasis type in 43, contraction type in 52, and sclerosis type in 33. Many normal vessels were found in the linear region, but the proportion of this type declined in the more severe stardust and diffuse regions. In contrast, no sclerosis-type vessels were found in the linear region, while the proportion of this type increased with lymphedema severity. CONCLUSIONS: Indocyanine green lymphography findings and the Normal, Ectasis, Contraction, Sclerosis Type classification of collecting lymph vessels seem to have a relationship. An increase in the severity of lymphedema according to the indocyanine green lymphography findings indicated an increase in the stage of lymphedema according to the Normal, Ectasis, Contraction, Sclerosis Type classification. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, IV.