Abstract: Venous Anastomosis to Control Lymph Flow for Lymphatic Malformations

Abstract

INTRODUCTION: There are several lymphatic diseases that could be treated surgically. Lymphatic venous anastomosis (LVA) was developed to improve lymphedema. On the other hand, in children settings, the majority of lymph diseases are not lymphedema, but lymphangioma or also called lymphatic malformations (LM). This LM especially micro-cystic type LM (mLM) had been challenging to treat because the conventional therapy had been limited efficacy and highly cause complications. To change the strategy, focusing on the lymph flow was the key for this disease. Thus we modified and analysed LVA to improve mLM of children. METHODS: We indicated 14 sequential cases of mLM patients who appeared to our clinic from July 2015 to June 2016, 10 males and 4 females, between 0 to 12 (mean 4) year-old. All cases underwent indocyanine green (ICG) lymphangiography and modified LVA under general anesthesia. Single surgeon (presenting author) performed all surgeries. Depend on the ICG findings of flow pattern we classified anastomosis manners into 2 groups; 1, LVA to decrease the in-flow and 2, increase the out-flow directly from the cysts. RESULTS: In all cases successful assessment with ICG were possible. 11 out of 14 (79%) cases were improved their situations such as size decrease, vesicle disappearance, or prevent following functional loss. Only one case increased vesicles on the surgical site. No complications such as allergy reactions, lymphorrhea, functional loss, surgical site infections or post-operative bleeding were observed. CONCLUSION: We applied ICG and modified LVA for mLM patients and found they are effective. This flow oriented surgical strategy with ICG and LVA for LM was very unique. To our best knowledge, this is the first report that shows the effectiveness of ICG and of LVA on LM. mLM were considered that related to the obstruction of lymph flow proximally. Conventional surgeries were limited, so this surgical strategy could be a break-through for this challenging disease. And also ICG and LVA could spread their indications to a new field. The limitation of this study was the short time follow-up period after the surgery, so more cases should be indicated.