A Case of Severe Lower Extremity Lymphedema Caused by Postoperative Intraperitoneal Lymphatic Leakage Treatment.

In the present study, we encountered a patient who developed intraabdominal lymphatic leakage after surgery for gastric cancer, underwent lymphangiography and lymphatic mass embolization, and developed severe lymphedema. The patient was a 55-year-old woman with gastric cancer with pancreatic invasion. Total gastrectomy and lymph node dissection were performed as conversion procedures. Six liters of ascites was detected postoperatively. Lymphangiography with Lipiodol injections into the bilateral inguinal lymph nodes was done three times, and Histoacryl embolization of the lymphatic leak was performed. However, edema of the lower extremities rapidly worsened. Lymphatic venous anastomosis was performed under general anesthesia. Anastomosis was performed at seven sites on the right and eight sites on the left. Postoperatively, the patient underwent compression therapy using the multilayer bandage method. The edema continued to improve further, and at 2 weeks postoperatively, the patient's weight had decreased by 21.4 kg from the preoperative weight, which was the same as that before the onset of edema. In this case, the patient's general condition was unstable due to cardiac insufficiency and other factors. Therefore, we aimed for an operation time of less than 3 hours. In addition, two surgeons performed the surgery to ensure an immediate therapeutic effect, and more anastomoses were performed than usual. After lymphatic venous anastomosis, not only the edema of both lower extremities but also the edema of the entire body improved promptly. One of the reasons for the improvement in general edema was thought to be due to increased intravascular protein and enhanced intravascular return of interstitial fluid.

Teaching of Microsurgery and Supermicrosurgery for Residents.

On the basis of our numerous years of experience in teaching residents without microsurgery experience and assisting in the initiation of microsurgery in clinical practice, we herein describe the general procedures and crucial aspects to consider regarding microsurgery and supermicrosurgery training for residents. The description focuses on training methods, surgical skills, and training time and effort. The target audience of the training is residents who have never performed microsurgery. We believe that any person, regardless of operative experience, can acquire the technique for microsurgery and supermicrosurgery by performing 4 to 5 hours of training per day over a total of 30 days within this program setting. Considering individual differences in learning and experience, the training can be completed in a shorter period by performing additional daily training. It is relatively simple for a well-trained microsurgeon to master the uncommon supermicrosurgery techniques. We hope that this report will help as many residents as possible in learning the art of (super)microsurgery.

Size adjustment suture technique for lymphaticovenular anastomosis.

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.

A Novel Doppler Flowmetry Shaft for Postoperative Monitoring after Head and Neck Reconstructive Surgery.

Doppler flowmetry is one of the most popular methods of monitoring Doppler signals during reconstructive surgery of the body surface. However, because of the thick and straight structure of the shaft, it is difficult to perform in areas with limited space, such as the oral cavity. We used a new type of Doppler flowmetry shaft to postoperatively monitor the flap in the oral cavity. Compared with conventional Doppler flowmetry, the new type uses a thinner metal probe shaft that can easily be inserted in narrow and limited spaces, such as the oral cavity. Additionally, the tip of the metal probe is gently bent, thereby allowing the Doppler tip to be placed perpendicular to the surface of the skin flap. We used this new type of Doppler flowmetry shaft for 30 patients after head and neck reconstruction using free flap transfer because Doppler signals were difficult to hear using conventional Doppler flowmetry. For all 30 patients, the new Doppler flowmetry shaft was able to monitor free flaps. Vascular thrombosis or vascular spasm occurred in three patients; two patients had inadequate arterial flow caused by vasospasm and arterial thrombus, and one patient had a venous thrombus. These three patients required re-exploration, and all flaps survived. This new type of Doppler flowmetry is simple and noninvasive. Furthermore, it can easily be performed by nonphysician medical personnel, and is useful for monitoring patients after head and neck reconstructive surgery.

Relationship between rib cartilage resection and postoperative chest recession deformity in breast reconstruction.

AIM: The most versatile recipient vessels for breast reconstruction are the internal mammary artery and vein. For microvascular anastomosis, one or two costal cartilages are often dissected to increase the length of the vessel and the degree of freedom. In some cases, the resection of the rib cartilage causes long-term depression at the dissected site, compromising its cosmetic appearance. PATIENTS AND METHODS: A total of 101 patients were examined, with 111 sides in which the internal mammary artery and vein were used as the recipient vessels. The patients were followed up for at least 6 months. RESULTS: A total of 37 of 38 patients with complete rib cartilage preservation had no depression, and 1 patient had a slight depression. In the case of partial resection of the rib cartilage, 37 of the 46 sides had no depression, 8 sides had mild depression, and 1 side had an obvious depression. When more than one rib cartilage was removed, 11 of the 27 sides had no depression, 11 had mild depression, and 5 had an obvious depression. The Spearman rank correlation coefficient was 0.4911936. CONCLUSION: This study reported the relationship between rib cartilage resection and postoperative concave deformity in breast reconstruction surgery using free flap transfer and the internal mammary artery and vein as the recipient vessels. A strong correlation was found between the extent of rib cartilage resected and the degree of depression. Minimizing rib cartilage resection when using the internal mammary artery and veins may minimize postoperative chest recession deformity and provide a well-dressed breast reconstruction.

Efficacy of Lymphaticovenular Anastomosis for Secondary Upper Extremity Lymphedema: Treatment Strategies with Effects of Compression Therapy Discontinuation and Site-Specific Evaluation of the Upper Extremity.

Background: Lymphaticovenular anastomosis (LVA) has recently become a mainstream surgical treatment for lymphedema and is a useful treatment option in addition to conservative therapies such as compression therapy, exercise therapy, and lymphatic drainage. We performed LVA with the goal of stopping compression therapy and report the effect of LVA on secondary lymphedema of the upper extremities. Methods and Results: The participants were 20 patients with secondary lymphedema of the upper extremities categorized as stage 2 or 3 according to the International Society of Lymphology classification. We measured and compared the upper limb circumference at six locations before and 6 months after LVA. Significant decreases in circumference after surgery were observed at 8 cm proximal to the elbow, the elbow joint, 5 cm distal to the elbow, and the wrist joints, but not at 2 cm distal to the axilla or the dorsum of the hand. At more than 6 months postoperatively, eight patients who had been wearing compression gloves were no longer required to wear them, and three patients who had been wearing both sleeves and gloves were no longer required to wear them. Conclusions: LVA is effective in the treatment of secondary lymphedema of the upper extremities, particularly in improving elbow circumference, and is one of the treatments that contributes significantly to the improvement of quality of life. For severe cases with limited range of motion of the elbow joint, LVA should be performed first. Based on these results, we present an algorithm for upper extremity lymphedema treatment.

Synthesis of Carlactone Derivatives to Develop a Novel Inhibitor of Strigolactone Biosynthesis.

Strigolactones (SLs), phytohormones that inhibit shoot branching in plants, promote the germination of root-parasitic plants, such as Striga spp. and Orobanche spp., which drastically reduces the crop yield. Therefore, reducing SL production via chemical treatment may increase the crop yield. To design specific inhibitors, it is valid to utilize the substrate structure of the target proteins as lead compounds. In this study, we focused on Os900, a rice enzyme that oxidizes the SL precursor carlactone (CL) to 4-deoxyorobanchol (4DO), and synthesized 10 CL derivatives. The effects of the synthesized CL derivatives on SL biosynthesis were evaluated by the Os900 enzyme assay in vitro and by measuring 4DO levels in rice root exudates. We identified some CL derivatives that inhibited SL biosynthesis in vitro and in vivo.

Combined Volume Reduction Surgery and Lymphaticovenular Anastomosis for Treatment of Lower Leg Lymphedema.

Much has been reported in the past regarding obesity as a risk factor for the origin of lymphedema. There are also reports of surgical treatments for obesity-related lymphedema. We have previously reported on the effectiveness of lymphaticovenular anastomosis in reducing chronic inflammation, and we believe that lymphaticovenular anastomosis is a very useful surgical approach in patients with recurrent cellulitis. In this report, we describe a case of a severely obese patient with a body mass index over 50 who developed lymphedema in both lower extremities due to pressure from sagging abdominal fat accompanied by frequent episodes of cellulitis.

Super-microsurgery technique for lymphaticovenular anastomosis.

BACKGROUND: In super-microsurgery, such as lymphaticovenular anastomosis (LVA), the diameter of the target vessel can be small and difficult to manage, and the basic surgical technique of microsurgery, such as inserting a forceps into the lumen and applying countertraction, can be difficult. In addition, it can be difficult to confirm the success or failure of the postoperative anastomosis, unlike with normal free-flap transfer, or to learn the technique by reviewing the results. METHODS: We have described a safe, quick, and accurate technique for LVA based on our experience performing several hundred such cases at our institution. RESULTS: Before LVA, the location of the significant lymphatic vessels and veins proximal to the lymphatic vessels should be marked using indocyanine green fluorescence angiography and a vein viewer to help determine the skin incision site. We used super-microsurgical titanium needles and surgical scissors and an end-to-end anastomosis. The lymphatic vessels should be dissected as far as possible from the skin incision to the center, and the veins should be dissected as far as possible from the periphery. First, a stay suture should be applied to the upper and lower ends of the anastomosis at 180°. Next, the anterior wall should be sutured. In some cases, countertraction can be applied by inserting the tip of a forceps into the vascular vessel. However, because its insertion could damage the lymphatic vessel wall, it would be more appropriate to perform the anastomosis using the involved stitch technique. After anastomosis of the anterior wall, the vessel should be inverted and the posterior wall anastomosed using the same technique. CONCLUSIONS: We have reported the key points necessary to perform LVA quickly and accurately and the precautions necessary to maintain long-term patency. This sophisticated LVA technique can be applied to improve the outcomes for patients with lymphedema.

A 47-Year-Old Man with Advanced Distal Pancreatic Carcinoma and an Initial Partial Response to Chemotherapy Requiring Celiac Axis Reconstruction of the Common Hepatic Artery and Left Gastric Artery.

BACKGROUND Distal pancreatectomy with en bloc celiac artery resection (DP-CAR) is a curative surgical method for locally advanced pancreatic body cancer; however, arterial reconstruction remains controversial in this procedure. This report presents the case of a 47-year-old man with advanced distal pancreatic carcinoma and initial partial response to chemotherapy who required celiac axis reconstruction of the common hepatic artery and left gastric artery. CASE REPORT A 47-year-old man had loss of appetite. He had a 40-mm hypovascular tumor extending from the pancreatic body to the tail, invading around the celiac artery, common hepatic artery, left gastric artery, and splenic artery. We initiated chemotherapy concurrent with chemo-radiotherapy with S-1 administration. After chemo-radiotherapy, computed tomography (CT) showed tumor shrinkage, indicating partial response, but soft tissue CT density surrounding the celiac axis arteries persisted. We conducted conversion surgery. When the common hepatic artery was clamped during surgery, the intrahepatic arterial blood flow reduced; thus, we reconstructed the middle hepatic artery to the common hepatic artery. The left gastric artery was also reconstructed using the second jejunal artery to prevent ischemic gastropathy. Histopathologic examination showed no tumor cells in the specimen; thus, R0 resection was achieved. CONCLUSIONS Arterial reconstruction can be an option for R0 resection in DP-CAR when hepatic arterial blood flow is reduced due to an intraoperative common hepatic artery clamping test.

Stacked deep inferior epigastric perforator with sequential lumbar artery perforator flaps for bilateral breast reconstruction: A case report.

Breast size that can be reconstructed with a single flap is limited in thin patients who need bilateral autologous large-volume breast reconstruction. We present the case of a 39-year-old female with bilateral heterogeneous breast cancer. The patient underwent total mastectomy and radiation therapy on the left side and nipple sparing mastectomy on the right. We planned to use the stacked deep inferior epigastric perforator (DIEP) with sequential lumbar artery perforator (LAP) flaps because the patient's thigh was too thin and she refused using gluteal tissue. The flap was 10 cm wide at the abdomen, 5 cm wide at the waist, and 72 cm long overall. The DIEP and LAP flaps were harvested as one continuous flap and were folded onto each other to create a breast mound. The lumbar artery and vein were anastomosed to the distal stump of the deep inferior epigastric artery and vein (DIEA/V) intraflaps, and then, the proximal stump of the DIEA/V was anastomosed to the internal mammary artery and vein. The LAP flaps were placed deeply, whereas the DIEP flaps were placed superficially. Whole skin was de-epithelialized on the right side, and skin damaged by radiotherapy was released and replaced with abdominal skin on the left side. The flap survived fully, the shape of the reconstructed breasts was good, and the body line on the donor side was well maintained. We present the stacked DIEP with sequential LAP flaps as one of the options for bilateral breast reconstruction in thin patients with larger breast size.

Double-pedicle unaffected split-breast flap for unilateral breast reconstruction.

BACKGROUND: In some breast cancer patients with a contralateral unaffected hypertrophic and ptotic breast, autologous small-breast reconstruction with contralateral breast reduction is a good option. The current study is aimed to assess the efficacy of the double-pedicle unaffected split-breast (USB) flap harvested from the central half of the unaffected breast for unilateral breast reconstruction with contralateral transverse scar reduction mammoplasty. METHODS: Between February 2003 and May 2020, 14 patients underwent breast reconstruction using the USB flap. The mean patient age was 59.1 (range: 48-76) years, and the mean body mass index was 24.2 (range: 19.5-33.3) kg/m2 . This flap comprised half of the contralateral breast tissues with the 3rd or 4th internal mammary perforator (IMAP) and the lateral thoracic vessel (LTA/V). After USB flap elevation and LTA/V resection, flap perfusion from the IMAP was evaluated on indocyanine green (ICG) angiography. The medial pedicle USB flap was rotated 180° and was transferred to the affected site via the midline. The LTA/V was anastomosed to the recipient vessel to supercharge the distal part of the USB flap, which was then used for breast reconstruction. Then, the remaining contralateral upper and lower breast poles were used for transverse scar reduction mammoplasty. RESULTS: The mean flap size was 13.3 × 26.9 (range: 9.5 × 22 to 16 × 29) cm. All flaps and reduced breasts survived without serious complications such as flap necrosis, although there was one patient with hematoma and one patient with hypertrophic scar. ICG revealed poor perfusion in the distal, lateral part of the flap, ranging from 22.0% to 48.5% of the overall flap area. Final aesthetic evaluation was high, with 11 cases (78.6%) being "good" or "excellent" and 3 cases (21.4%) that were either poor or fair. The mean follow-up period for the patients was 53.8 (range: 15-84) months, with none of the patients presenting second primary breast cancer or recurrence in both breasts. CONCLUSION: USB flap breast reconstruction with contralateral reduction mammoplasty is a valuable option in breast cancer patients with a hypertrophic and ptotic breast.

Relationship Between Lymphaticovenular Anastomosis Outcomes and the Number and Types of Anastomoses.

BACKGROUND: Lymphaticovenular anastomosis (LVA) is the first-line treatment for lymphedema in many hospitals. However, many aspects of its effects remain unclear. This study aimed to analyze problems with regard to the relationship between lymphaticovenular anastomosis and outcomes of surgery for lymphedema in the upper and lower extremities. METHODS: Eighteen articles were selected for review. The following information was extracted from these articles as factors associated with LVA for lymphedema in the upper and lower extremities: number of cases, average patient age, mean number of bypasses, lymphedema stage, duration and type of lymphedema, anastomotic technique, follow-up period, type of scale, and treatment outcomes. RESULTS: Upper extremity lymphedema: The average age of patients was 54.2 (range: 41.3-60.1) years. The mean number of anastomoses was 3.91 (range: 1.0-7.2). Six of nine articles provided data for volume change, and the mean volume change was 29% (-5%-50%). Lower extremity lymphedema: The average age of patients was 50.3 (range: 34-64 years). The mean number of anastomoses was 4.6 (range: 2.1-9.3). Comparison was difficult as different methods were used for postoperative evaluation (lower extremity lymphedema index in three patients, limb circumference in one, volume change in two, and restaging in three). CONCLUSIONS: We obtained useful information with regard to the effects of LVA in this review. An increased number of anastomoses between the lymphatic ducts and veins did not seem to improve the effectiveness of LVA. With regard to the stage of lymphedema, LVA may be useful for both early and advanced stages.

Morphological Changes and Durability of Skin and Mucosal Flaps in Intraoral and Pharyngeal Reconstructions: Long-term Follow-up and Literature Review for Potential Second Carcinomas.

The long-term changes in tissues implanted in the oral cavity and pharynx after head and neck reconstruction have not been fully evaluated. This study aimed to clarify the morphological changes, long-term durability, and potential for secondary carcinogenesis in such tissues. In our single-center study, the rough morphological changes in 54 cases of intraoral and pharyngeal skin and mucosal flaps were evaluated more than 10 years after flap transfer. In addition, the literature on the development of second carcinomas from skin flaps was reviewed. The mean follow-up period for transferred flaps was 148 months. The reconstruction areas and the probability of morphological changes were significantly correlated (p=0.006), especially in cases with tongue, lower gingiva, and buccal mucosal reconstruction. Free jejunal flap surfaces were well maintained, whereas tubed skin flaps showed severe morphological changes in cases with pharyngeal reconstruction. None of the flaps in our series developed second primary carcinomas. Skin flaps generally had good durability for > 10 years in intraoral environments, while mucosal flaps had better durability for pharyngeal reconstruction. Second squamous carcinomas arising from skin flaps are extremely rare; however, surgeons should take this possibility into consideration and conduct meticulous and long-term follow-up.

The utility of surgical and conservative combination therapy for advanced stage lymphedema.

BACKGROUND: In the treatment of lymphedema, a plastic surgeon carries out only surgical treatment, whereas a therapist performs only complex physical therapy. Therefore, a combination treatment strategy is not performed in most cases. Our institution combines a lymphaticovenular anastomosis (LVA) operation with complex physical therapy during the same hospitalization. METHODS: From advanced cases of lymphedema of stage II or higher, we included patients who were hospitalized for 2 weeks or more for combined LVA and complex physical therapy. Of the 28 cases studied, 26 were secondary lymphedema and two were primary lymphedema. There were seven upper limb cases and 21 lower limb cases. The mean length of hospital stay was 12 days (7-14 days). We performed a multisite LVA in all 28 patients. The mean number of anastomoses in each case (the side with the most edema for bilateral cases) was 3.96 (2-6). During hospitalization, lymphatic therapists who were familiar with complex physical therapy for lymphedema were trained to provide total care for lymphedema. The content of the education was applied according to the individual patient's status, and an emphasis was placed on development of a treatment regimen that patients could perform continuously by themselves after discharge. RESULTS: The average volume reduction in seven patients with upper limb lymphedema was 15.1%; the average in 18 patients with lymphedema of the lower limbs was 13.1%. The average volume reduction in eight patients at stage II was 14.1%; stage II late was 13.0%, and stage III was 14.7%. The other three cases had suffered an exacerbation, and the mean exacerbation was 3.2%. Among the 12 patients who had cellulitis preoperatively, an episode of cellulitis was detected in only two patients during follow-up postoperatively. These two patients were those at late stage II and stage III. The frequency of onset decreased in these two cases. CONCLUSIONS: In this study, combination therapy was administrated for lymphedema. We obtained good results in the diseased limbs, including volume reduction and prevention of cellulitis. Therefore, combination therapy might be useful for lymphedema cases at advanced stages.

Erratum: Relationship between the Incidence of Postoperative Fistula or Dysphagia and Resection Style, Gastric Tube Formation, and Irradiation following Free Jejunum Transfer: Erratum.

[This corrects the article DOI: 10.1097/GOX.0000000000002663.].

Investigation of Free-Flap Transfer Reconstruction in Elderly Patients and Oral Intake Function.

The authors retrospectively examined 39 patients with head and neck reconstruction using a free-flap transfer with microsurgery in elderly patients aged over 80 years in our hospital. They investigated postoperative local complications, postoperative systemic complications, day of ambulation, the presence of delirium, the postoperative oral intake ratio, and the reconstructive method in mandibular reconstruction patients. There were 12 postoperative local complications. And postoperative systemic complications were detected in 19 patients; however, 17 of these were respiratory disorders due to pneumonia. There were 17 patients with postoperative delirium. Oral intake was resumed after an average of 14.9 days. Of these, 34 patients were eventually able to eat some kind of food. The incidence of local complications in elderly free-flap reconstruction patients was similar to that in young people. However, the rate of systemic complications was much higher in elderly patients. The authors suggest that free-flap reconstruction can be performed relatively safely in elderly people when a detailed preoperative surgical plan.

Relationship between the Incidence of Postoperative Fistula or Dysphagia and Resection Style, Gastric Tube Formation, and Irradiation following Free Jejunal Flap Transfer.

BACKGROUND: The purpose of this study was to examine the relationship between the incidence of dysphagia or fistula formation in an anastomotic region and factors such as extent of resection, gastric tube formation, and irradiation among patients who underwent free jejunal flap transfer. METHODS: We retrospectively examined 100 cases (88 men and 12 women; average age, 65.8 years; range, 46-88 years) in whom the evaluation of postoperative oral intake was possible after undergoing total pharyngo-laryngo-esophagectomy (TPLE) and free jejunal flap transfer. Chi-square test (with Fisher transformation, if necessary) was performed to analyze the relationship among resection styles (the resection margin extended to the oropharynx or to the cervical esophagus and gastric tube elevation), radiation therapy history, and incidence of dysphagia or fistula formation. RESULTS: One hundred patients were analyzed, and complications such as postoperative fistula and dysphagia occurred in 8 (8.0%) and 20 patients (20.0%), respectively. However, no significant correlation was found between various resection factors and fistula formation or adverse events. At the reconstruction site, other complications such as postoperative lymphorrhea (7%), postoperative hematoma (4%), trachea necrosis (4%), cervical flap necrosis (1%), and thyroid necrosis (1%) occurred. These complications were managed by a cervical open wound and additional minor operation as needed. CONCLUSION: Thus, free jejunal transfer for TPLE is a good reconstruction technique with few complications and postoperative adverse events, regardless of the extent of resection and preoperative radiation therapy.

Microsurgery for Head and Neck Reconstruction.

The most serious complication of free flap transfer is total flap necrosis, which is usually due to a microvascular problem. The development of a microsurgical instrument has greatly lowered the prevalence of postoperative vascular trouble to a rate of 1% to 3%. However, necrosis of the transferred flap in head and neck reconstruction can cause serious complications and postoperative functional deficiency. Therefore, for blood circulation disorder of the flap following free flap transfer, it is necessary to perform re-operation, as soon as possible, in order to attempt salvaging the flap after the disorder has been diagnosed.The goal of this study was to analyze the microsurgery for head and neck reconstruction. The author, with an experience of more than 500 microsurgical anastomoses, discusses microsurgery in head and neck reconstruction through the choices of recipient vessels, aspects that require attention in order to prevent vascular complications, and correspondence when complications occur.