Recipient Venule Selection and Anastomosis Configuration for Lymphaticovenular Anastomosis in Extremity Lymphedema: Algorithm Based on 1,000 Lymphaticovenular Anastomosis

Alessandro Bianchi; Marzia Salgarello; Akitatsu Hayashi; Johnson C.-S. Yang; Giuseppe Visconti

doi:10.1055/s-0041-1735836

Journal of Reconstructive Microsurgery, Inhaltsverzeichnis

J Reconstr Microsurg 2022; 38(06): 472-480
DOI: 10.1055/s-0041-1735836

Original Article

Recipient Venule Selection and Anastomosis Configuration for Lymphaticovenular Anastomosis in Extremity Lymphedema: Algorithm Based on 1,000 Lymphaticovenular Anastomosis

Autor*innen

Alessandro Bianchi

¹Unità Operativa Complessa (UOC) Chirurgia Plastica, Dipartimento per la Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, Università Cattolica del “Sacro Cuore”, Rome, Italy
Marzia Salgarello

¹Unità Operativa Complessa (UOC) Chirurgia Plastica, Dipartimento per la Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, Università Cattolica del “Sacro Cuore”, Rome, Italy
Akitatsu Hayashi

²Department of Plastic Surgery, Lymphedema Clinic, Kameda Medical Centre, Kamogawa, Chiba, Japan
Johnson C.-S. Yang

³Division of Plastic and Reconstructive Surgery, Department of Surgery, Lymphedema Center, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Niaosong District, Taiwan
Giuseppe Visconti

¹Unità Operativa Complessa (UOC) Chirurgia Plastica, Dipartimento per la Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, Università Cattolica del “Sacro Cuore”, Rome, Italy

Abstract

Background The lymphaticovenular anastomosis (LVA) has three components, lymphatics, venules, and anastomosis, and all of them influence the anastomotic pressure gradient. Although it has been demonstrated that venule flow dynamics has an independent impact on the outcomes regardless the degeneration status of lymphatic vessels, recipient venules (RV) have been mainly neglected in literature.

Methods From January 2016 to February 2020, 232 nonconsecutive patients affected by extremity lymphedema underwent LVA, for a total of 1,000 LVAs. Only patients with normal-to-ectasic lymphatic collectors were included to focus the evaluation on the RV only. The preoperative collected data included the location, diameter, and continence of the selected venules, the expected number, the anastomoses configuration, and their flow dynamics according to BSO classification.

Results The 232 patients included 117 upper limb lymphedema (ULL) and 115 lower limb lymphedema (LLL). The average size of RV was 0.81 ± 0.32 mm in end-to-end (E-E), 114 ± 0.17 mm in end-to-side (E-S), 0.39 ± 0.22 mm in side-to-end (S-E), and 0.76 ± 0.38 mm in side-to-side (S-S) anastomoses. According to the BSO classification, on a total of 732 RV, 105(14%) were backflow venules, 136 (19%) were slack, and 491 (67%) were outlet venules. Also, 824 (82%) were E-E, 107 (11%) were E-S, 51 (5%) were S-E, and 18 (2%) were S-S anastomoses.

Conclusion Based on 1,000 LVAs with similar lymphatic characteristics, we propose our algorithm that may aid the lymphatic microsurgeon in the selection of RV and the consequent anastomosis configuration, in order of obtain the best flow dynamic through the LVA. This therapeutic study reflects level of evidence IV.

Keywords

LVB - LVA - supermicrosurgery

Volltext

Referenzen

References
1 Basta MN, Gao LL, Wu LC. Operative treatment of peripheral lymphedema: a systematic meta-analysis of the efficacy and safety of lymphovenous microsurgery and tissue transplantation. Plast Reconstr Surg 2014; 133 (04) 905-913
2 Koshima I, Inagawa K, Urushibara K, Moriguchi T. Supermicrosurgical lymphaticovenular anastomosis for the treatment of lymphedema in the upper extremities. J Reconstr Microsurg 2000; 16 (06) 437-442
3 Chang DW, Suami H, Skoracki R. A prospective analysis of 100 consecutive lymphovenous bypass cases for treatment of extremity lymphedema. Plast Reconstr Surg 2013; 132 (05) 1305-1314
4 Mihara M, Hara H, Tange S. et al. Multisite lymphaticovenular bypass using supermicrosurgery technique for lymphedema management in lower lymphedema cases. Plast Reconstr Surg 2016; 138 (01) 262-272
5 Scaglioni MF, Fontein DBY, Arvanitakis M, Giovanoli P. Systematic review of lymphovenous anastomosis (LVA) for the treatment of lymphedema. Microsurgery 2017; 37 (08) 947-953
6 AlJindan FK, Lin CY, Cheng MH. Comparison of outcomes between side-to-end and end-to-end lymphovenous anastomoses for early-grade extremity lymphedema. Plast Reconstr Surg 2019; 144 (02) 486-496
7 Tsai PL, Wu SC, Lin WC. et al. Determining factors in relation to lymphovascular characteristics and anastomotic configuration in supermicrosurgical lymphaticovenous anastomosis - A retrospective cohort study. Int J Surg 2020; 81: 39-46
8 Hayashi A, Visconti G. Supermicrosurgical Lymphaticovenular Anastomosis: A Practical Textbook. HV projects, Lulu Press; 2020
9 Visconti G, Salgarello M, Hayashi A. The recipient venule in supermicrosurgical lymphaticovenular anastomosis: flow dynamic classification and correlation with surgical outcomes. J Reconstr Microsurg 2018; 34 (08) 581-589
10 Hayashi A, Visconti G, Yamamoto T. et al. Intraoperative imaging of lymphatic vessel using ultra high-frequency ultrasound. J Plast Reconstr Aesthet Surg 2018; 71 (05) 778-780
11 Brahma B, Putri RI, Reuwpassa JO. et al. Lymphaticovenular anastomosis in breast cancer treatment-related lymphedema: a short-term clinicopathological analysis from Indonesia. J Reconstr Microsurg 2021; 37 (08) 643-654
12 Hayashi A, Yoshimatsu H, Visconti G. et al. Intraoperative real-time visualization of the lymphatic vessels using microscope-integrated laser tomography. J Reconstr Microsurg 2021; 37 (05) 427-435
13 Narushima M, Yamamoto T, Ogata F, Yoshimatsu H, Mihara M, Koshima I. Indocyanine green lymphography findings in limb lymphedema. J Reconstr Microsurg 2016; 32 (01) 72-79
14 Visconti G, Hayashi A, Bianchi A. et al. Technological advances in lymphatic surgery: bringing to light the invisible. Plast Reconstr Surg 2019; 144 (05) 940e-942e
15 Visconti G, Yamamoto T, Hayashi N, Hayashi A. Ultrasound-assisted lymphaticovenular anastomosis for the treatment of peripheral lymphedema. Plast Reconstr Surg 2017; 139 (06) 1380e-1381e
16 Hayashi A, Giacalone G, Yamamoto T. et al. Ultra high-frequency ultrasonographic imaging with 70 MHZ scanner for visualization of the lymphatic vessels. Plast Reconstr Surg Glob Open 2019; 7 (01) e2086
17 Visconti G, Hayashi A, Bianchi A, Salgarello M. Technological advances in lymphatic surgery: bringing to light the invisible. Plast Reconstr Surg 2019; 144 (05) 940e-942e
18 Bianchi A, Visconti G, Hayashi A, Santoro A, Longo V, Salgarello M. Ultra-High frequency ultrasound imaging of lymphatic channels correlates with their histological features: a step forward in lymphatic surgery. J Plast Reconstr Aesthet Surg 2020; 73 (09) 1622-1629
19 Mihara M, Hara H, Hayashi Y. et al. Pathological steps of cancer-related lymphedema: histological changes in the collecting lymphatic vessels after lymphadenectomy. PLoS One 2012; 7 (07) e41126
20 Yamamoto T, Yamamoto N, Yoshimatsu H, Narushima M, Koshima I. Factors associated with lymphosclerosis: an analysis on 962 lymphatic vessels. Plast Reconstr Surg 2017; 140 (04) 734-741
21 Pereira N, Lee YH, Suh Y. et al. Cumulative experience in lymphovenous anastomosis for lymphedema treatment: the learning curve effect on the overall outcome. J Reconstr Microsurg 2018; 34 (09) 735-741
22 Conti F. Medical. Physiology of organs and systems. Edi-Ermes (ed) Milan, Italy, 2010
23 Standring ed. S. Gray's Anatomy.. The Anatomical Basis of Clinical Practice. 40th ed.. London, United Kingdom: Churchill Livingstone; 2008
24 Yamamoto T. New advances in lymphatic supermicrosurgery: supermicrosurgical lymphaticovenular anastomosis for extremity lymphedema. In: Chen HC, Ciudad P, Tang YB, Chen SH. eds. Lymphedema Surgical Approach and Specific Topics. 2nd ed.. Taiwan: Elsevier; 2018: 78-85
25 Yamamoto T, Mukarramah DA. Anastomosis configurations. In: Hayashi A, Visconti G. eds. Supermicrosurgical Lymphaticovenular Anastomosis: A Practical Textbook. HV Projects; 2020: 89-101
26 Yang JC, Wu SC, Lin WC, Chiang MH, Hsieh CH. Reversing venous-lymphatic reflux following side-to-end lymphaticovenous anastomosis with ligation of the proximal lymphatic vessel. J Plast Reconstr Aesthet Surg 2021; 74 (02) 407-447
27 Visconti G, Hayashi A, Salgarello M, Narushima M, Koshima I, Yamamoto T. Supermicrosurgical T-shaped lymphaticovenular anastomosis for the treatment of peripheral lymphedema: bypassing lymph fluid maximizing lymphatic collector continuity. Microsurgery 2016; 36 (08) 714-715
28 Visconti G, Bianchi A, Hayashi A, Salgarello M. Ultra-high frequency ultrasound preoperative planning of the rerouting method for lymphaticovenular anastomosis in incisions devoid of vein. Microsurgery 2020; 40 (06) 717-718
29 Visconti G, Salgarello M. Venule valve graft in lymphatic supermicrosurgery: a novel strategy for managing blood backflow. Microsurgery 2017; 37 (08) 958-959
30 Akita S, Yamaji Y, Tokumoto H. et al. Prevention of venous reflux with full utilization of venoplasty in lymphaticovenular anastomosis. J Plast Reconstr Aesthet Surg 2020; 73 (03) 537-543
31 Visconti G, Salgarello M. Supermicrosurgical lymphatico comitantes perforator venule anastomosis for the treatment of peripheral lymphedema: A new configuration for patients with superficial vein insufficiency?. Microsurgery 2017; 37 (06) 719-720