Sensitivity of Each Index of Doppler, Cross, Uncollapsible, Parallel, and Superficial Fascia in Lymphatic Ultrasound.

Background: Recently, the usefulness of lymphatic ultrasound has been reported. It is beneficial not only to identify lymphatic vessels but also to evaluate lymphatic degeneration and diagnose lymphedema. We previously proposed D-CUPS (Doppler, Cross, Uncollapsible, Parallel, and Superficial fascia) to identify the lymphatic vessels on ultrasound. The purpose of this study was to clarify the sensitivity of each index of D-CUPS. Methods: We performed a retrospective study of 27 patients (44 limbs, 98 sites) with lower extremity lymphedema, who underwent lymphaticovenous anastomosis (LVA). We performed a lymphatic ultrasound the day before surgery. We used a linear probe commonly used for venous ultrasound (Noblus EUP-L65; Hitachi Medical Corp., Tokyo, Japan). We applied the D-CUPS index to identify the lymphatic vessels on ultrasound. We checked whether lymphatic vessels consistent with preoperative lymphatic ultrasound findings were observed during the LVA. We also calculated the sensitivity of each D-CUPS index. Results: All the 27 patients were women, with a mean age of 59.7 years. Totally, 98 incisions were made (59 incisions on the thigh and 39 incisions on the lower leg). During LVA, lymphatic vessels consistent with the preoperative lymphatic ultrasound findings were observed at all the sites. The sensitivities of each indicator of D-CUPS were 100.0%, 100.0%, 68.4%, 19.4%, and 100.0%, respectively. Conclusion: The sensitivity was 100.0% in D, C, and S. Although each index separately was not perfect, by combining them appropriately, we were able to identify lymphatic vessels with certainty.

Lymphatic Mapping for LVA with Noncontrast Lymphatic Ultrasound: How We Do It.

Recently, lymphatic ultrasonography has received increasing attention. Although there are several reports on contrast-enhanced lymphatic ultrasound as a preoperative examination for lymphaticovenous anastomosis (LVA), we have been reporting the usefulness of preoperative noncontrast lymphatic ultrasound. In this article, the detailed procedure for conducting lymphatic ultrasound during the preoperative examination of LVA is thoroughly described. The only items required for lymphatic ultrasound are an ultrasound device, an echo jelly, a straw for marking, and a marker. We use an ordinary ultrasound device with an 18-MHz linear probe. We apply the Doppler, Crossing, Uncollapsible, Parallel, and Superficial fascia index to identify the lymphatic vessels. While imagining the course of the lymph vessels, we position the probe perpendicular to the long axis of the lymphatic vessels. When a vessel is found under the superficial fascia, the probe is moved proximally to trace the vessel's path. If the vessel transverses a nearby vein without connecting to it, it is most likely a lymphatic vessel. To confirm, we ensure that the vessel does not exhibit coloration in the Doppler mode. As LVA is most effective when the dilated lymph vessels are anastomosed, we use lymphatic ultrasound to identify the most dilated lymphatic vessels in each lymphosome, and mark incision lines where suitable veins are in close proximity. No contrast agent is required; therefore, medical staff such as nurses and ultrasound technicians can autonomously conduct the test.

Lymphatic venous anastomosis and complex decongestive therapy for lymphoedema: randomized clinical trial.

BACKGROUND: Lymphatic venous anastomosis is associated with a low incidence of lower extremity lymphoedema-associated cellulitis; however, the exact relationship is unknown. This multicentre RCT evaluated the effect of lymphatic venous anastomosis on prevention of cellulitis. METHODS: Patients with secondary lower extremity lymphoedema who underwent at least 3 months of non-operative decongestive therapy were assigned randomly to lymphatic venous anastomosis or conservative therapy. The primary and secondary outcomes were cellulitis frequency, and assessments of circumference, hardness, and pain respectively. RESULTS: Overall, 336 patients were divided into two groups: 225 in the full-analysis set (primary outcome 225; secondary outcomes 170) and 156 in the per-protocol set (primary outcome 156; secondary outcomes 110). In both analyses, lymphatic venous anastomosis with non-operative decongestive therapy was more effective in preventing cellulitis than non-operative decongestive therapy alone; the difference between groups in reducing cellulitis frequency over 6 months was -0.35 (95 per cent c.i. -0.62 to -0.09; P = 0.010) in the full-analysis set (FAS) and -0.60 (-0.94 to -0.27; P = 0.001) in the per-protocol set (PPS) Limb circumference and pain were not significantly different, but lymphatic venous anastomosis reduced thigh area hardness (proximal medial and distal and lateral proximal). Four patients experienced contact dermatitis with non-operative decongestive therapy alone. CONCLUSION: Lymphatic venous anastomosis in combination with non-operative decongestive therapy prevents cellulitis. REGISTRATION NUMBER: UMIN00025137, UMIN00031462.

Psychological Changes During Inpatient Conservative Treatment for Lymphedema.

Background: Learning self-care for lymphedema is essential for patients to maintain their quality of life; however, it is sometimes difficult and stressful. There are only few studies about the psychological changes in patients hospitalized for conservative therapy. The purpose of this study was to evaluate the psychological changes in patients admitted for conservative therapy and training in self-care for lymphedema. Methods and Results: Nine patients who were hospitalized for conservative treatment of lymphedema of the lower limbs were administered the Profile of Moods States questionnaire twice: day of admission or the following day and after 5 days of hospital stay. Eight female patients and one male patient were included in this retrospective study. The mean age was 67.2 years. We provided standard compression therapy, manual lymph drainage, and exercise therapy to the patients. The Profile of Moods States 2nd edition, Japanese version of the Profile of Moods States, was used as an evaluation method of the psychological state. The results of the psychological tests were evaluated by a certified public psychologist. The scores for negative mood (anger or hostility, confusion or bewilderment, depression or rejection, fatigue or inertia, and tension and anxiety) were all lower on the fifth day of hospitalization compared with those at admission. In particular, the tension or anxiety scores decreased significantly (p = 0.019). However, the vigor or activity scores tended to increase. Conclusions: It was found that inpatient conservative therapy for lymphedema had a positive effect on the psychological state of the patients. Despite stressors such as a change in environment and introduction of new treatments (compression therapy and exercise therapy), the improvement in edema helped elevate the mood of the patients by the fifth day of hospitalization.

Effects of Ultrasound-guided Lower Abdominal Lymphaticovenous Anastomosis on Lower Abdominal Lymphedema.

Lymphedema of the lower extremities can be further complicated by lymphedema of the lower abdomen and genitalia. This study aimed to clarify the effect of lower abdominal lymphaticovenous anastomosis (LVA) on lower abdominal lymphedema. The patient was a 61-year-old woman. At the age of 49 years, she underwent treatment for ovarian cancer, including pelvic lymphadenectomy, and she developed lymphedema in the lower abdomen and bilateral thigh 2 years later. During lymphoscintigraphy, isotopes injected into the dorsum of the bilateral feet accumulated in the corresponding areas, indicating that lymph flowed into these areas from the legs. Compression therapy was performed with a girdle; however, its effect was limited. According to the lymphoscintigraphic findings, we performed LVA in the bilateral thighs (two anastomoses each), and the edema symptoms slightly improved postoperatively. However, as edema was still present and the patient sought further relief, we evaluated the lymphatic vessels in the lower abdomen using lymphatic ultrasound and found dilated lymphatic vessels. We performed another LVA in the lower abdomen 1 year after the first LVA (two anastomoses in the right abdomen, one anastomosis in the left abdomen, and an additional anastomosis in the bilateral thighs). The patient's subjective symptoms improved, and ultrasonography showed a reduction in abdominal lymphedema at 7 months follow-up. For lymphedema in the lower abdomen and genital area that does not improve with compression therapy, appropriate examination to evaluate lymphatic flow and lymphatic degeneration is necessary, and LVA in the lower abdomen may be effective.

The relationship between the degree of subcutaneous fluid accumulation and the lymphatic diameter.

BACKGROUND: The relationship between the fluid accumulation in the subcutaneous tissue and the lymphatic degeneration in the lymphedematous limbs has not been elucidated, and we have evaluated it in the current study. METHODS: Twenty-five patients (50 limbs) were included in this retrospective study. We performed lymphatic ultrasound by separating the limbs into four lymphosomes: the saphenous (medial) thigh, saphenous (medial) calf, lateral thigh, and lateral calf. In each lymphosome, the lymphatic diameter, the degree of lymphatic degeneration, and the fluid accumulation in the subcutaneous tissue were evaluated. The lymphatic vessels were detected based on the index of D-CUPS (Doppler, Crossing, Uncollapsibe, Parallel, and Superficial fascia). Lymphatic degeneration was diagnosed based on the NECST (Normal, Ectasis, Contraction, and Sclerosis Type) classification. RESULTS: All patients were women with a mean age of 62.7 years. Lymphatic vessels were detected using lymphatic ultrasonography in 50 saphenous (medial) thigh lymphosomes, 43 saphenous (medial) calf lymphosomes, 34 lateral thigh lymphosomes, and 22 lateral calf lymphosomes. The fluid accumulation tended to be more acute in the more severe stages of lymphedema. As for the NECST classification, the normal type was observed only in the areas without fluid accumulation. Among the other areas, the percentage of contraction type was the largest in the area with slight edema and decreased in the areas with severe edema. CONCLUSION: The lymphatic vessels were dilated to a greater extent in legs with more severe fluid accumulation. Therefore, there is no hesitation needed to perform lymphaticovenous anastomosis because of severe lymphedema.

Usefulness of 33 MHz Linear Probe in Lymphatic Ultrasound for Lymphedema Patients.

Background: Lymphatic ultrasound has recently been reported useful in the treatment of lymphedema. However, no conclusions have been reached regarding the best probe for lymphatic ultrasound. Methods: This was a retrospective study. Fifteen limbs of 13 patients with lymphedema in whom we could not find dilated lymphatic vessels on lymphatic ultrasound with an 18 MHz probe but later could find them with 33 MHz probe were included. All patients were women, and the mean age was 59.5 years. We performed lymphatic ultrasound in four areas per limb by applying an index of D-CUPS, as we previously reported. We measured the depth and diameter of the lumen of the lymphatic vessels. We also diagnosed the degree of lymphatic degeneration based on the normal, ectasis, contraction, and sclerosis type (NECST) classification. Results: We found lymphatic vessels in 22/24 (91.7%) areas in the upper limbs and 26/36 (72.2%) areas in the lower limbs. The mean depth and diameter of the lymphatic vessels were 5.2 ± 0.28 mm and 0.33 ± 0.029 mm, respectively. Based on the NECST classification, 68.2% of the upper limbs and 56.0% of the lower limbs were of the ectasis type. We found functional lymphatic vessels in 6/6 (100%) of the upper limbs and 5/7 (71.4%) of the lower limbs, which indicated lymphaticovenous anastomosis (LVA) in these 11 patients. Conclusion: Using 33 MHz probe, we could detect functional lymphatic vessels in most patients. Even if lymphatic vessels were not found with the 18 MHz probe, LVA could be performed using a higher frequency probe.

Lymphatic refill in ultrasound and lymphatic washout after lymphaticovenous anastomosis.

BACKGROUND: Lymphaticovenous anastomosis (LVA) drains lymph accumulated in the lymphatic vessels into the veins (lymphatic washout). A method to identify the ideal lymphatic vessels to achieve washout has not been established. This study examined the relationship between lymphatic washout, lymphatic ultrasonographic findings, and surgical outcomes. METHODS: We reviewed consecutive patients who underwent LVA for lower limb lymphedema between September 2020 and March 2021. Patients who lacked data were excluded. Preoperative ultrasonography was performed to measure the lymphatic diameter. After the probe was pressed against the skin and released, the reaction of the lymphatic vessels was classified as either refilled, crushed, undecidable, or solid. Intraoperatively, whether lymphatic washout was observed or not, was recorded and compared to preoperative findings using the chi-square test. In 54 limbs from 32 patients, the total number of LVA, number of anastomoses with washout, number of refills detected by ultrasound, and severity of lymphedema were compared with the surgical result (postoperative limb volume change) by multiple regression analysis (49 limbs whose pre-or postoperative circumference data were lacking or who underwent intensive compression therapy postoperatively were excluded). RESULTS: Sixty-five patients were reviewed. After excluding six patients with missing data, 59 patients (103 limbs) were included. The median patient age was 63 years (interquartile range, 51-76 years). We performed LVA at 217 sites (mean, 2.1 anastomoses per limb). "Refilled" lymphatics were observed at 156 sites (71.6%) and significantly thicker than those classified as "undecidable" (p = .020 in the lower leg and p < .001 in the thigh). In the thigh, "refilled" lymphatics had a higher rate of a washout than those classified as "undecidable." In Pearson's correlation coefficient for the surgical result, as the number of washout positive LVA increased, the limb volume tended to decrease postoperatively (correlation coefficient: -0.25). However, multiple regression analysis did not identify any factors that significantly affected the surgical outcomes. CONCLUSION: "Refilled" lymphatic vessels had a higher rate of intraoperative lymphatic washout after anastomosis.

Ultrasound-guided lymphaticovenous anastomosis without indocyanine green lymphography mapping: A preliminary report.

BACKGROUND: Although indocyanine green (ICG) lymphography is the standard preoperative examination for lymphaticovenous anastomosis (LVA), it cannot be performed in patients allergic to ICG. This report aimed to clarify the effects of LVA with lymphatic ultrasound and without ICG lymphography. METHOD: Lymphatic ultrasound was performed preoperatively on six limbs of four patients with lower limb lymphedema who were allergic to ICG to detect the lymphatic vessels. All patients were women and had secondary lymphedema after uterine cancer treatment, with a mean age of 57.0 years (range; 47-68 years). The severity of lymphedema was stage 2a in two limbs, stage 2b in three limbs, and stage 3 in one limb. During the preoperative lymphatic ultrasound, we searched for the dilated lymphatic vessels in the saphenous, lateral calf, and lateral thigh lymphosomes. The incision sites were determined based on the ultrasonographic findings, and LVA was performed under local anesthesia. The surgical results were evaluated based on the limb volume calculated from the circumferences. RESULT: Totally, 13 skin incisions were made, and the lymphatic vessels consistent with the ultrasonographic findings were found in all locations. The mean number of the lymphatic vessels anastomosed per limb was 2.2 (range; 1-4). The mean diameter of the lymphatic vessel was 0.69 mm (range; 0.3-1.0 mm). No complications were observed in the perioperative period. The mean follow-up period was 386.8 days. The mean preoperative and postoperative limb volumes were 5468 ml (range; 4552-6378 ml) and 5027.4 ml (range; 4353-5561 ml). Limb volume decreased in all six limbs. CONCLUSION: The effectiveness of performing LVA by identifying the lymphatic vessels using lymphatic ultrasound was demonstrated. More medical institutions will be able to perform LVA in the future, even without ICG devices.

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.

The accuracy of lymphatic ultrasound in measuring the lymphatic vessel size in lower limb lymphedema patients.

BACKGROUND: Lymphatic ultrasound is a newly developed method to observe the lymphatic vessels. In this study, we compared the diameter of lymphatic vessels observed on preoperative ultrasound with the actual lymphatic diameter (LD) of lymphatic vessels observed intraoperatively. METHODS: The study included 32 lower limbs in 17 patients with lower limb lymphedema. Lymphatic ultrasound was performed using a commonly used ultrasound device, Noblus ultrasound system, with an 18 MHz linear probe on preoperative day 1. We tracked the lymphatic vessels along the great saphenous vein, at the lateral calf, and at the lateral thigh, based on the lymphosome principle. We measured the cross-sectional height (CSH) and the cross-sectional width (CSW) of lymphatic vessels using ultrasound at the incision sites. Intraoperatively, we measured the diameter of the lymphatic vessel. Based on lymphatic degeneration, lymphatic vessels were categorized into four types using the normal-, ectasis-, contraction-, and sclerosis-type (NECST) classification. RESULTS: We evaluated 68 lymphatic vessels. The mean CSH, CSW, and LD were 0.65 ± 0.35 mm, 1.3 ± 0.41 mm, and 0.79 ± 0.35 mm, respectively. The correlation coefficient between the CSH and the LD was 0.36 and that between the CSW and LD was 0.24. A significant difference was observed in CSH between the ectasis and contraction types (p = 0.0025). CONCLUSIONS: We can somehow predict the size of the lymphatic vessels with CSH in the lymphatic ultrasound, whereas CSW is not reliable.

Evaluation of lymphatic vessel diameters in healthy people using lymphatic ultrasound examination.

OBJECTIVE: The aim of this study was to examine lymphatic diameters in lower limbs of healthy volunteers in different body positions using lymphatic ultrasound examinations. METHODS: Thirty-five healthy volunteers participated in this study. Those who had a history of varicose veins in the leg, deep venous thrombosis, or surgery on their legs or abdomen were excluded. We measured the vertical width of the lymphatics with a 33 MHz linear ultrasound probe, at 20 cm above the knee (thigh) and 10 cm below the knee (lower leg). First, the participants were placed supine, then sitting, and then standing. We performed lymphatic ultrasound examinations in each body position. The Student t test was used to compare lymphatic vessel diameters in the supine, sitting, and standing positions. The significance level was set at .05. RESULTS: Among 35 healthy volunteers, 17 were men and 18 were women. Mean age was 30.9 (range, 23-55) years. The mean body mass index was 21.3 kg/m2 (range, 29.0-16.1 kg/m2). We could not detect lymphatic vessels in 1 thigh and 3 lower legs, leaving 69 thighs and 67 lower legs for evaluation. In the thigh, the mean lymphatic diameters in the supine and standing positions were 0.154 mm and 0.150 mm, respectively, which were not significantly different. In the lower leg, the mean lymphatic diameters in the supine, sitting, and standing positions were 0.160 mm, 0.163 mm, and 0.164 mm, respectively, which were not significantly different. In the thigh, the mean lymphatic diameter in the supine position was larger in the men (0.17 mm) than in the women (0.14 mm) (P = .022). Similarly, in the lower leg, the mean lymphatic diameter in the supine position was greater in the men (0.19 mm) than in the women (0.14 mm) (P = .0044). There was no correlation between the supine lymphatic diameters and the age or body mass index of the participants. CONCLUSIONS: In healthy legs, lymphatic diameters do not change with body positioning. Supine lymphatic vessel diameters are greater in men than in women.

[Successful treatment of refractory chylothorax associated with diffuse large B-cell lymphoma by multidisciplinary care].

Chylothorax is an intrathoracic leakage of chyle due to thoracic duct damage. Malignant lymphoma is the most common nontraumatic cause of chylothorax. In March 2019, a 74-year-old woman presented to our department with bilateral pleural effusion and mesenteric/retroperitoneal masses. She was diagnosed with diffuse large B-cell lymphoma upon performing a biopsy. In May 2019, she was hospitalized for dyspnea due to pleural effusion, and thoracentesis revealed abundant chyle. Although the tumor shrunk after chemotherapy, chylothorax improvement was poor; thus, she could not be discharged. For the management of refractory chylothorax, lymphangiography, thoracic duct embolization, and pleurodesis were performed, and the chylothorax improved immediately. However, in May 2020, right chylothorax recurred without a relapse of malignant lymphoma, which did not improve with conservative treatment. Lymphangiography was performed again; however, treatment via the lymphatic vessels was difficult. Thus, pleurodesis was performed four times, after which the chylothorax regressed. Chylothorax is often refractory. When chemotherapy for malignant lymphoma does not improve chylothorax, multidisciplinary treatment is effective.

Lymphatic Dysfunction Detected by Multi-lymphosome Indocyanine Green Lymphography and Lymphatic Ultrasound.

Investigation into the cause of lower extremity edema is essential for successful treatment; however, it is sometimes difficult to diagnose. In this case report, we present a patient with bilateral lower extremity edema in whom abnormalities were detected with multi-lymphosome indocyanine green (ICG) lymphography and lymphatic ultrasound. An 87-year-old woman underwent total hysterectomy and pelvic lymphadenectomy for uterine cancer when she was 55 years old. Ten years ago, she was prescribed with a diuretic agent for bilateral edema of the lower extremities; however, the edema did not subside. Conventional general examination, including blood tests, electrocardiography, echocardiography, duplex ultrasound for the legs, and lymphoscintigraphy, did not show any significant abnormalities that may occur with lower limb edema. We performed multi-lymphosome ICG lymphography by injecting ICG in the first web space of the foot, the lateral ankle, and the lateral thigh. This helped us detect lymphatic dysfunction in both lower extremities. Additionally, we performed lymphatic ultrasound and found dilated lymphatic vessels in both lower limbs, indicating lymphatic accumulation within these vessels. Injecting ICG into multiple lymphosomes appears to be useful in diagnosing the causes of lower extremity edema as well as evaluating the lymphatic function of those lymphosomes. Furthermore, lymphatic ultrasound can be used to scan the whole lower extremity because it does not rely on the flow of a contrast agent to produce an image. We believe that combining these diagnostic examinations will make it possible to diagnose patients who have previously been misdiagnosed due to insufficient screening measures.

Genital lymphaticovenous anastomosis (LVA) and leg LVA to prevent the recurrence of genital acquired lymphangiectasia.

BACKGROUND: Genital acquired lymphangiectasia (GAL) commonly recurs after simple resection. This study aimed to elucidate the efficacy of lymphaticovenous anastomosis (LVA) in the genital region or legs for preventing GAL recurrence after resection. METHODS: We retrospectively investigated 25 female patients who underwent GAL resection and LVA, lymphoscintigraphy, and indocyanine green (ICG) lymphography. Isotope or ICG was injected into the leg. Medicine accumulating in the genitals indicates lymphatic flow from the legs to the genitals (type 1). In some cases, we injected ICG into the anus to detect lymphatic flow from the anus to the genitals (type 2). Based on the findings, we selected LVA site (genital or leg). RESULTS: The mean patient age was 61.4 (range, 42-81) years. Seventeen patients underwent leg LVA only, while eight patients underwent genital LVA. The mean follow-up period was 285 (range, 87-365) days. GAL recurrence was observed in 10 patients (40.0%): three of eight (37.5%) who underwent genital LVA versus seven of 17 (41.2%) who underwent leg LVA. Among patients with type 2 lymphatic vessels, GAL recurrence was observed in two of six (33.3%) who underwent genital LVA versus five of nine (55.6%) who underwent leg LVA. CONCLUSION: Genital LVA prevented GAL recurrence in patients with type 2 lymphatic flow. Detecting the direction of lymphatic flow around GAL is essential to its successful treatment.

Classification of the lymphatic pathways in each lymphosome based on multi-lymphosome indocyanine green lymphography: Saphenous, calf, and thigh (SCaT) classification.

BACKGROUND: The anatomy of the lymphatic vessels in the extremities is not completely understood. The aim of this study was to elucidate the patterns of the lymphatic pathways of each lymphosome in lymphedematous legs. METHODS: We performed a retrospective study on 630 lymphosomes from 105 patients with leg lymphedema. The mean age of the subjects was 58.9 (range: 20-91) years, and the mean duration of lymphedema was 8.8 (range: 1-91) years. In indocyanine green (ICG) lymphography, we injected ICG into the multi-lymphosome: the first web space of the foot (saphenous lymphosome), lateral ankle (lateral calf lymphosome), and lateral knee (lateral thigh lymphosome). We established the saphenous, calf, and thigh (SCaT) classification based on the lymphatic location: lymphatic vessels on the medial side (type 1) and lymphatic vessels in other locations (type 2). RESULTS: In the saphenous lymphosome, 157 lymphatics (95.5%) were type 1. In the lateral calf lymphosome, 164 lymphatics (29.9%) were type 1. In the lateral thigh lymphosome, 148 lymphatics (16.9%) were type 1. The percentage of type 2 lymphatic vessels increased as the lymphoscintigraphic staging progressed. CONCLUSIONS: The lymphatic vessels in the lymphedematous legs shifted from the medial to the lateral side and finally disappeared in all lymphosomes as lymphedema worsened. We propose the SCaT classification to describe the condition of the lymphatic vessels in each lymphosome with the hope that it becomes a common staging system for sharing information on lymphedema severity among interdisciplinary medical professionals.

Comparison of Various Kinds of Probes for Lymphedematous Limbs.

Recently, there has been a growing interest in the use of lymphatic ultrasound in the preoperative investigation of lymphaticovenous anastomosis. The device used for the performance of lymphatic ultrasound varies among surgeons. In this case report, we compared several probes (18 MHz, 24 MHz, and 33 MHz linear probes) in 2 cases, to detect the lymphatic vessels in the lymphedematous limbs. In the upper limb lymphedema case, the lymphatic vessels were located at a depth of <5 mm. They could be better observed with the 33 MHz probe than with the 18 MHz probe. The probe with a high frequency (33 MHz) and high resolution seemed to be suitable for superficial layers <5 mm in depth. On the other hand, the probe of 33 MHz was not appropriate for the lymphedematous lower limb because the lymphatic vessels are usually located at around a depth of 1 cm. When comparing the 18 MHz and 24 MHz probes in observing the lymphatic vessels in the lower limb, the 24 MHz probe seemed more suitable because of its higher resolution. Among these options, the 33 MHz probe was suitable for lymphedematous upper limbs, and the 24 MHz probe was suitable for lymphedematous lower limbs.

Lymphaticovenous anastomosis for advanced-stage lower limb lymphedema.

BACKGROUND: Early-stage lymphedema patients are said to be candidates for lymphaticovenous anastomosis (LVA). The progressions in the preoperative examinations have made it possible to find the suitable lymphatic vessels even in advanced-stage lymphedema. The aim of this study was to elucidate the surgical effect of LVA in cases of advanced-stage lymphedema. METHODS: We evaluated 42 limbs of 34 patients with lymphoscintigraphic type 4 or 5. A mean disease duration was 7.5 ± 6.5 years. We performed multi-lymphosome indocyanine green (ICG) lymphography preoperatively to detect the saphenous lymphatics, the lateral calf lymphatics, and the lateral thigh lymphatics. We also performed ultrasound to detect the subcutaneous veins and the dilated lymphatic vessels. The pre- and postoperative evaluation was made by the sum of circumference measurements at 6 points per limb. RESULTS: The mean number of anastomosis per limb was 2.8 (range, 1-5). Of the 41 limbs for which we performed ICG lymphography, we found the saphenous lymphatics in 29 limbs (70.7%), lateral calf lymphatics in 28 limbs (68.3%), and lateral thigh lymphatics in 21 limbs (51.2%). We found at least 1 linear pattern in ICG lymphography for 39 limbs (95.1%). The mean pre- and postoperative circumference (sum of 6 points) were 221.7 ± 4.9 cm and 215.9 ± 4.9 cm, which was significantly reduced (p < .01). CONCLUSIONS: LVA was effective for advanced-stage lymphedema patients. An adequate preoperative examination with plural imaging methods seems helpful for achieving a successful surgical result.

Compression Pressure Variability in Upper Limb Multilayer Bandaging Applied by Lymphedema Therapists.

Background: Multilayer bandaging (MLB) is often used for lymphedema treatment. Even experienced lymphedema therapists have difficulty applying bandages correctly. The aim of this study was to demonstrate upper limb MLB pressure variability applied by lymphedema therapists. Methods and Results: Twenty-four lymphedema therapists were asked to apply MLB to the healthy volunteer's upper limb. The participants consisted of 20 females and 4 males with a mean age of 43.4 (range: 24-62) years. They included licensed massage therapists, nurses, a judo therapist, an occupational therapist, and a medical doctor. Twenty therapists (83.3%) had clinical experience applying MLB. Compression pressure was measured with PicoPress at 5 cm proximal to the wrist, immediately after the application (phase 1) and after exercise (phase 2). The mean MLB pressure was 67.7 ± 5.0 mmHg in phase 1 and 55.3 ± 4.1 mmHg in phase 2, which were significantly different (p = 1.2 × 10-10). There was a weak negative correlation between how long the therapist had been practicing MLB and MLB pressure (R = 0.29). Seventeen participants (70.8%) expressed that they had a target pressure in mind when performing MLB. Among the 17 participants, there was no correlation between the target and actual pressures (R = -0.055). Only three participants (17.6%) had an actual MLB pressure within 5 mmHg of their target. Conclusions: The mean MLB pressure was 55.3 ± 4.1 mmHg, which was thought to be too high for the upper limb. Education about applying appropriate MLB pressures to the limbs is necessary.

Diagnosis of Lymphatic Dysfunction by Evaluation of Lymphatic Degeneration with Lymphatic Ultrasound.

Background: The standard examination for diagnosing lymphedema is lymphoscintigraphy, which has a disadvantage in versatility and radiation exposure. We have reported the usefulness of echography in observing the lymphatic degeneration. The purpose of this study was to investigate the usefulness of lymphatic ultrasound in diagnosing lymphedema. Methods and Results: The study included 14 patients (28 lower limbs) who underwent lymphaticovenous anastomosis for lower limb lymphedema. Preoperative echography with a common 18-MHz linear probe was used to detect lymphatic vessels. We evaluated abnormal expansion or sclerosis of lymphatic vessels in the medial legs, which indicated the presence of lymphedema. We proposed the method "D-CUPS" on how to detect and observe the lymphatic vessels. We then performed indocyanine green (ICG) lymphography to diagnose lymphedema. The results of examination were compared. Stage 1 lymphedema was diagnosed in 9 limbs, Stage 2a in 7, Stage 2b in 8, and Stage 3 in 4. Lymphatic vessel detection was possible in all 28 medial thighs and in 27 medial lower legs. The sensitivity and specificity for diagnosis of lymphedema based on echography of the medial leg were 95.0% and 100.0%, respectively. The accuracy rate was 94.6%. We could detect lymphatic vessels with echography in 39 of 54 areas that failed detection using lymphoscintigraphy or ICG lymphography (72.2%). Conclusion: The location and degeneration of lymphatic vessels in lymphedematous limbs can be evaluated with a commonly used ultrasound device. Although exclusion of comorbidities is still necessary, lymphatic ultrasound has potential for use in diagnosis of lymphedema or lymphatic dysfunction.