Lymphaticovenular Anastomosis Research Articles

Validation of Novel Microsurgical Vessel Anastomosis Techniques: A Systematic Review.

Thorough validation of novel microsurgical techniques is deemed essential before their integration into clinical practice. To achieve proper validation, the design of randomized controlled trials (RCTs) should be undertaken, accompanied by the execution of comprehensive statistical analyses, including confounder adjustment and power analysis. This systematic review aims to provide an encompassing overview of the validation methodologies employed in microsurgical studies, with a specific focus on innovative vessel anastomosis techniques. A literature search was conducted in PubMed for articles describing the validation of novel microsurgical vessel anastomosis techniques in animal or human subjects. The literature search yielded 6,658 articles. A total of 6,564 articles were excluded based on title and abstract. Ninety-four articles were assessed for full-text eligibility. Forty-eight articles were included in this systematic review. Out of 30 comparative studies, 9 studies validated novel modified interrupted suture techniques, 6 studies modified continuous techniques, 6 studies modified sleeve anastomosis techniques, 1 study a modified vesselotomy technique, 7 studies sutureless techniques, and 1 study a modified lymphaticovenular anastomosis technique. Twenty-eight studies contained animals (n = 1,998). Fifteen animal studies were RCTs. Two studies contained human/cadaveric subjects (n = 29). Statistical power analysis and confounder adjustment were performed in one animal study. Out of 18 noncomparative studies, 5 studies validated novel modified interrupted suture techniques, 1 study a modified continuous technique, 2 studies modified sleeve anastomosis techniques, 4 studies modified vesselotomy techniques, 4 studies sutureless techniques, and 2 studies modified lymphaticovenular anastomosis techniques. Ten studies contained animal subjects (n = 320), with two RCTs. Eight studies contained human subjects (n = 173). Statistical power analysis and confounder adjustment were performed in none of the animal or human studies. The current methods of microsurgical technique validation should be reconsidered due to poor study design. Statistical analysis including confounder adjustment and power analysis should be performed as a standard method of novel technique validation.

Concordance between preoperative imaging methods in patients with limb lymphedema undergoing supermicrosurgical lymphaticovenular anastomosis

ObjectiveSupermicrosurgical lymphaticovenular anastomosis (LVA) is increasingly being recognized as a first-line treatment of limb lymphedema because it is minimally invasive and highly effective. Lymphoscintigraphy and indocyanine green (ICG) lymphography are the two most commonly performed diagnostic imaging examinations to establish the indication and plan the procedure for patients affected by limb lymphedema. In a small group of patients, the information between these two imaging tools can be discordant, showing different anatomical drainage pathways or the absence of drainage and dermal backflow in one examination and valid drainage pathways in the other. The purpose of this study is to examine the types of possible discrepancies between lymphoscintigraphy of the superficial system and ICG lymphography and to describe the surgical outcomes after LVA for patients presenting with such discrepancies. MethodsWe retrospectively reviewed the data of all patients who underwent LVA for upper or lower limb lymphedema between July 2015 and July 2023. From this series, we identified a group of patients with nonconcordant imaging results from lymphoscintigraphy and ICG lymphography before lymphatic surgery. Nonconcordant findings were described in terms of “pattern discordance” and “pathway discordance.” The surgical outcome was measured by the change in the mean circumference of the limb after surgery. The changes between the preoperative and postoperative limb measures were analyzed using the Student t test. P values < .05 were considered significant. ResultsA total of 28 patients with limb lymphedema exhibited inconsistencies between preoperative lymphoscintigraphy of the superficial system and ICG lymphography. Among these patients, 14 experienced pattern discordance, 13 had pathway discordance, and 1 patient had both. After LVA, we observed a significant reduction in the average circumference of the affected limb in the analyzed group. ConclusionsThe discrepancy in the information between lymphoscintigraphy and ICG lymphography in the preoperative study of patients affected by limb lymphedema is rare but possible. This phenomenon is still not fully explained; however, our results suggest that it does not correlate with the outcome of supermicrosurgical LVAs.

A multidisciplinary approach to managing lymphorroea in primary lymphoedema: a case study.

This case study describes the successful management of a patient with primary lymphoedema, who was experiencing lymphorrhoea and epidermolysis, using a multidisciplinary approach. The patient had Klippel-Trenaunay syndrome. The multidisciplinary team, in an outpatient clinic in Japan, included a certified lymphoedema therapist, plastic surgeons, and a wound, ostomy and continence nurse. The team performed complex physical therapy and lymphaticovenular anastomosis, which promoted the resolution of the lymphorrhoea. This resulted in improvements in skin condition, the prevention of recurrent cellulitis, and no increase in limb circumferences during the 1-year follow-up period. This report highlights the importance of a multidisciplinary approach to lymphoedema management, including lymphorrhoea control that fitted in with the patient's daily life. It is hoped that this article will contribute to the improvement of the quality of life of patients with lymphoedema.

Effectiveness of lymphaticovenular anastomosis for adult-onset primary lower limb lymphedema: A retrospective study

BackgroundSurgical treatments such as lymphaticovenular anastomosis (LVA) are widely used in addition to conservative treatment of secondary lymphedema. However, their indications and effectiveness for primary lymphedema are unclear. This study aims to objectively demonstrate the effectiveness of LVA for adult-onset primary lymphedema from various perspectives. MethodsWe retrospectively examined patients with primary lower limb lymphedema who underwent LVA between January 2018 and December 2021 and were 21 or older. Treatment effects were evaluated using lymphoscintigraphy, questionnaires, body mass index, extracellular fluid ratio, and lymphedema index preoperatively and 6 months postoperatively. The LVA was performed under general anesthesia. ResultsWe evaluated 11 patients (11 lower limbs). Out of seven patients with complete obstruction preoperatively, all presented partial obstruction according to the Taiwan Lymphoscintigraphy Staging classification with a significant decrease in the score. Significant improvements were observed in clinical symptoms (“hardness”) and in quality of life (“appearance” and “ease of wearing compression garments”) assessments. A significant change was observed in the extracellular water ratio but not in lower extremity lymphedema index (LELindex). ConclusionLVA was suggested as one of the potential treatment options for patients with adult-onset primary lymphedema in whom lymphatic flow was confirmed by lymphoscintigraphy. In addition to clinical symptoms and physical examination, the evaluation of adult-onset primary lymphedema should include the patient’s quality of life.

Nylon Suture Loop for Tagging Lymphatic Channels during Lymphaticovenular Anastomosis

Abstract Background Lymphaticovenular anastomosis (LVA) requires special supermicrosurgery techniques designed for vessels less than 0.8 mm in size. While preparing the field for LVA, it is often difficult to handle the lymphatic vessel directly without injuring it or fracturing it entirely. Method We propose a novel technique, which is used in LVA for tagging of lymphatic vessels, with the use of a nylon 6–0 suture and micro-ligaclip. Results We have successfully performed 78 LVAs in 26 cases with this method. The average lymphatic vessel size was 0.3 mm (0.15–0.8 mm). Conclusion This novel technique to implement the use of a nylon suture with a micro-ligaclip to use as a vessel loop for lymphatics has not been previously described in the literature. It is a useful technique that we find beneficial to lymphatic identification through tagging of the lymphatic channels, contributing to greater success in each anastomosis.

Fundamentals for Supermicrosurgical Lymphaticovenular Anastomosis: Part 1 Comprehensive Review of Anastomosis Techniques and Proposal for a Flowchart Algorithm

Fundamentals for Supermicrosurgical Lymphaticovenular Anastomosis: Part 1 Comprehensive Review of Anastomosis Techniques and Proposal for a Flowchart Algorithm

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 1.43mm 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 9.1min 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.

Comparative study of conservative treatment and lymphaticovenular anastomosis with compression therapy for early-stage breast cancer-related lymphoedema

This single-centre retrospective cohort study aimed to clarify the superiority of treatment by comparing the outcomes of lymphaticovenular anastomosis with compression therapy and conservative treatment centred on compression therapy in the early stage of breast cancer-related lymphoedema. Data were collected from all patients treated for breast cancer-related lymphoedema between January 2015 and December 2022. The patients were classified into conservative treatment and surgical treatment groups. The upper extremity lymphoedema index value was calculated, based on five circumference values of the upper extremity and body mass index, to compare the 6-, 12-, 18- and 24-month outcomes between the groups. Of 101 patients with breast cancer-related lymphoedema, 81 (conservative treatment: 52; surgical treatment: 29) were included in the analysis. The therapeutic effect was significantly higher in the surgical treatment group than in the conservative treatment group, when comparing the rate of change in oedema at 6 (-6.6%±7.3% vs. 0.9%±7.5%; p<0.001), 12 (-7.3%±6.2% vs. 2.9%±8.6%; p<0.001), 18 (-7.6%±8.0% vs. 3.9%± 9.2%; p<0.001) and 24 (-5.6%±6.0% vs. 4.4%±10.7%; p<0.001) months. The incidence of cellulitis increased in the conservative treatment group (from 9.6% to 15.4%), whereas it was suppressed in the surgical treatment group (from 13.8% to 0%). Conservative treatment centred on compression therapy increased oedema over time; however, lymphaticovenular anastomosis with compression therapy effectively reduced oedema.

Application of complete decongestive therapy after lymphaticovenular anastomosis of the lower limb combined with liposuction-A retrospective study research.

Complete decongestive therapy (CDT) is a conservative treatment for lymphedema that combines interventions and lifestyle changes. We evaluated the application of CDT after lymphaticovenular anastomosis (LVA) of the lower limb combined with liposuction. A total of 55 patients who underwent LVA of the lower limb combined with liposuction from January 2021 to July 2022 were enrolled in the study. The patients were divided into groups A (n = 24) and B (n = 31) according to whether they adhered to CDT treatment during the 12-month follow-up. Group A was the non-adherence CDT group and Group B was the adherence CDT group. Lower Extremity Lymphedema Index (LELI) and Lymphoedema Functioning, Disability, and Health Questionnaire for Lower Limb Lymphoedema (Lymph-ICF-LL) were used as prognostic indicators to observe the remission of postoperative lymphedema symptoms in the two groups. At 6-month and 12-month follow-up, LELI and the score of Lymph-ICF-LL in group B and group A were lower than before the operation (p < .05). The circumference of the affected limb was reduced, and the quality of life was improved in both groups after the operation. The reduction of LELI and Lymph-ICF-LL in group B was higher than in group A, and the difference was statistically significant (p < .05). This study preliminarily proves the effectiveness of CDT after LVA of the lower limb combined with liposuction, which can maintain and strengthen the surgical effect. Further, CDT treatment is still needed after the operation, which is necessary to reduce the circumference of the affected limb and improve patients' quality of life.

Effectiveness of Supramicrosurgical Lymphatico-venular Anastomosis in Treating Recurrent Lymphatic Fistulas: A Case Series

Objective: Lymphatic fistula is a complication that may occur in all cases where lymphostasis arise, due to a damage to the lymphatic drainage system. The current study evaluates the effectiveness of supramicrosurgical lymphatico-venular anastomosis (s-LVA) for treating lymphatic fistula.

Modified Preparatory Intravascular Stenting Technique in Super-microsurgical Lymphaticovenular Anastomosis for the Treatment of Lymphedema.

Clinical studies have reported that lymphaticovenular anastomosis (LVA) is more effective for early-stage lymphedema. However, the diameter of lymphatic vessels in early-stage lymphedema is thin (only about 0.3 mm). In this article, we report a modified preparatory intravascular stenting technique (PIST) for LVA with smaller lymphatic vessels and present the results of its application for the treatment of secondary lymphedema. In this technique, a 9-0 nylon thread is inserted into the target lymphatic vessel. Then, the thread is pulled until its tip has entered the lymphatic vessel. After that, the thread is allowed to proceed into the lumen by pushing it. Finally, with the nylon in place, the lymphatic vessel is transected and the lumen is secured. In this report, we investigated the surgical time for LVA between 10 patients who underwent LVA with modified PIST (group A) and another group of 10 patients who underwent LVA without the technique (group B). Lymphatic lumen was secured at all sites where indocyanine green lymphangiography confirmed lymphatic flow. The average outer diameter of lymphatic vessels in group A and B were 0.36 mm and 0.53 mm, respectively. The average surgical time for LVA in group A was 136 minutes, which was significantly shorter than the 187 minutes in group B. Our results indicated that modified PIST can help secure the lymphatic lumen even when the lymphatic vessels are thin. As a result, this technique can significantly reduce the surgical time for this procedure.

Changes in intracellular water volume after leg lymphedema onset and lymphaticovenular anastomosis as its surgical intervention

ObjectiveTo clarify the changes in the intracellular water (ICW) volume in lymphedema-affected legs after lymphedema onset and its surgical intervention (ie, lymphaticovenular anastomosis [LVA]), we investigated the changes in body water composition using bioelectrical impedance analysis. MethodsThis retrospective case series included 41 women with unilateral secondary leg lymphedema. The volume changes in the ICW and extracellular water (ECW) of the affected leg were measured using an InBody S10 (InBody Co, Ltd) multifrequency bioelectrical impedance analyzer, at both lymphedema onset and 1 year after LVA. ResultsThe volume increase with leg lymphedema onset was comparable between the ECW and ICW (0.59 L vs 0.56 L; 95% confidence interval [CI], −0.02 to 0.06; P = .27), and the increase rate was higher for ECW (35.3% vs 22.1%; 95% CI, 9.3%-17.2%; P < .001). The volume reduction at 1 year after LVA was comparable between ECW and ICW (0.23 L vs 0.27 L; 95% CI, −0.08 to 0.02; P = .20), and the reduction rate was higher for ECW (8.7% vs 7.0%, 95% CI, 0.04%-3.2%; P = .044). The volume difference between ICW and ECW remained constant throughout the six measurements before and after LVA (F[3.01, 120.20] = 1.85; P < .14). ConclusionsLeg LVA reduced ICW in the lymphedematous leg. The onset of leg lymphedema increased ECW and ICW in the affected limb, and LVA decreased both ECW and ICW. The volume change in the affected leg was comparable between ECW and ICW at both lymphedema onset and after LVA. However, the rate of change was higher for ECW. The volume difference between ICW and ECW remained constant. Using bioelectrical impedance analysis, alterations in ICW volume were detected in the legs affected by lymphedema, both after the onset of lymphedema and after LVA intervention.

The Dynamic Lymphaticovenular Anastomosis for Breast Cancer-related Lymphedema without Compression: Salvaging Lymphedema Patients Who Lost Conservative Treatment Opportunity.

The study involved 17 BCRL patients, 18 limbs. All patients had International Society of Lymphology stage-2 lymphedema, but they had no compression: six patients had difficulty by other diseases to undergo compression, and other 11 patients refused any compression usage because of the burden of the treatment itself. Three dynamic LVAs were performed in each patient. Patients' mean age was 60.4 ± 10.1, and mean body mass index was 24.0 ± 3.3. The mean follow-up period was 25.5 ± 9.2 months. The volume of the lymphedematous limb, according to the upper extremity lymphedema (UEL) index, was reduced in all 18 limbs postoperatively (postoperative UEL index 101.8 ± 9.4 versus preoperative UEL index 116.0 ± 20.1; P < 0.01). Twelve of the 18 limbs were cured without edema. Even without compression therapy, International Society of Lymphology stage-2 BCRL patients can be treated by the dynamic LVA method.

Conservative treatment versus lymphaticovenular anastomosis for early-stage lower extremity lymphedema

ObjectiveSeveral options for the treatment of lower extremity lymphedema (LEL) can be broadly classified into conservative treatment, such as compression garments and decongestive lymphatic therapy, and surgical treatment, such as lymphaticovenular anastomosis (LVA). The purpose of our study was to clarify the superiority of these treatments by comparing the outcomes of LVA with those of conservative treatment for early-stage LEL. MethodsWe performed a single-center, retrospective cohort study. The patients with LEL who presented to our department between January 2015 and December 2022 were identified and classified into two groups: conservative treatment and surgical treatment. The LEL indexes, calculated from the four lower extremity circumferences and the body mass index, were compared at the 6-, 12-, and 24-month follow-up between the two groups. ResultsOf the 101 patients with LEL, 53 with 72 affected limbs (conservative treatment, 39 patients and 53 affected limbs; surgical treatment, 15 patients and 19 affected limbs) were included in the present analysis. The therapeutic effect for reducing edema, as determined by comparing the corrected LEL index at 12 months (103.7 ± 12.7 vs 91.9 ± 10.7; P = .005) and 24 months (103.1 ± 12.9 vs 83.8 ± 7.2; P < .001), was significantly higher in the surgical treatment group than that in the conservative treatment group. The conservative treatment group showed little change in the corrected LEL index at ≤24 months of follow-up (+3.1%; P = .299). In contrast, the surgical treatment group showed a significant reduction in edema at 24 months according to the corrected LEL index (−16.2%; P = .019). ConclusionsIn early-stage LEL, conservative treatment centered on compression therapy alone only maintained edema (ie, edema did not worsen or improve). In contrast, LVA with compression therapy reduced edema.

Application of indocyanine green lymphography combined with methylene blue staining in lymphaticovenular anastomosis of lower limb vessels: A prospective study.

Methylene blue (MB) is a conventional lymphatic tracer. We evaluated the application of indocyanine green (ICG) lymphography combined with MB staining in lower limb lymphaticovenular anastomosis (LVA). A total of 49 patients with lower limb lymphedema were selected as the study subjects and divided into the research (n = 27) and control groups (n = 22). The patients were treated with LVA using ICG lymphography combined with MB staining and simple ICG lymphography as the positioning method, respectively. The number of lymphatic vessels anastomosed and the operating time were compared between the groups. Lower Extremity Lymphedema Index (LEL index) and Lymphoedema Functioning, Disability and Health Questionnaire for Lower Limb Lymphoedema (Lymph-ICF-LL) were used as prognostic indices; 6months after LVA, both groups were evaluated for the symptomatic relief of lymphedema. The number of anastomotic lymphatic vessels in the study group was higher than that in the control group (p < .05), and their procedural time was shorter than that in the control group. The two groups had no significant difference in lymphatic anastomosis time (p > .05). The LEL index and Lymph-ICF-LL of the research and control groups at 6-month follow-up after LVA were lower than those before the operation (p < .05). The circumference of the affected limb is reduced after LVA in patients with lower extremity lymphedema with a favorable prognosis. ICG lymphography combined with MB staining has the advantages of real-time visualization and accurate localization.

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.

First experience of lymphaticovenular anastomosis using BHC RobotiScope: A case report.

The RoboticScope (BHS Technologies GmbH, Innsbruck, Austria) is a robotic exoscope, which consists of a robotic arm that holds a 3-dimensional camera. It has an advantage that a surgeon can perform an operation comfortably with a favorable ergonomic position. Also, it allows the delivery of clear and high-quality visualization for surgeons. In this study, we would like to share our initial experience with this newly developed microscope technology in lymphaticovenular anastomosis (LVA). To the best of our knowledge, it is the first experience of LVA using this microscope in Asia. A 65-year-old woman presented with bilateral lower extremity lymphedema after a hysterectomy that was performed 25 years back. Despite complex decongestive physiotherapy, an edematous symptom in both legs worsened. In lymphoscintigraphy, a decreased visualization of main lymphatic flow in both the lower extremities was evident which was further suggestive of lymphatic obstruction. Although both sides showed edematous symptoms, we decided to proceed with the surgery on the left side first, because of the worsened condition. Four LVAs were performed at the dorsum of the foot (×2), ankle, and the superior edge of the knee using RoboticScope. At 6-months follow-up after operation, the postoperative circumference diameters were improved than preoperative in 10 cm above the knee (45 cm vs 49 cm), 10cm below the knee (37 cm vs 41 cm) and lateral malleolus (25 cm vs 28 cm). The lower extremity lymphedema index was also improved from 346.7 to 287.4 postoperatively. The RoboticScope provided a high-resolution image and a favorable ergonomic position during an operation. The results represent the possibility of the application of a robotic microscope in the field of microsurgery, and further studies are necessitated to confirm the efficacy of this system.

SP50. Can LVA Still Be Successfully Performed in Advanced Fluid-predominant Lymphedema?

PURPOSE: Historically, supermicrosurgical lymphaticovenular anastomosis (LVA) is regarded technically difficult/unachievable and therefore contraindicated in advanced lymphedema demonstrating “diffuse” pattern and/or absence of “linear” pattern on indocyanine green (ICG) lymphography. More invasive vascularized lymph node transplants are preferred in these cases. In this study, we describe our experience of attempting LVA in these challenging cases. METHODS: All patients with fluid-predominant lymphedema who underwent LVA between February 2020 and March 2022 were included. Patients with pre-operative ICG lymphography demonstrating “diffuse” pattern and/or absence of “linear” pattern were included in the study group, while the remainder of LVA patients were assigned to the control group. Surgical time, number of LVAs, patient report, physical examination, and post-operative ICG lymphography at 3, 6, and 12 months were compared between study and control groups. RESULTS: Thirteen limbs showed “diffuse” pattern and/or absent “linear” pattern while 70 limbs showed “linear” pattern on pre-operative immediate ICG scan. Mean follow-up time was 14.18 ± 6.46 months and 14.83 ± 9.12 months for study and control groups, respectively. Surgical times (p=0.31) and number of LVAs (0.25) did not vary significantly between groups. Patient-reported symptom relief and reduction in swelling were seen in 11 limbs in the study group and 65 limbs in the control group (p=0.19). Post-operative ICG scans improved in 11 limbs in the study group and 68 limbs in the control group (p=0.22). No differences were identified in each comparison. CONCLUSION: LVA can be performed in advanced fluid-predominant lymphedema. The technical difficulty and efficacy of LVA in this group is not significantly different from patients with “linear” patterns on ICG lymphography.

D40. Effects of Lymphaticovenular Anastomosis in Contralateral Leg in Patients with Acquired Bilateral Leg Lymphedema

PURPOSE: Lymphaticovenular anastomosis (LVA) is an established treatment for fluid-predominant lymphedema. Its mechanism of action is believed to be mechanical decompression and therefore its benefits limited to where it is established. When LVA is performed in one leg in bilateral leg lymphedema, improvement is conventionally expected only in the treated leg and not in the contralateral leg. We aimed to investigate this widely accepted hypothesis. METHODS: All patients with acquired bilateral leg lymphedema who underwent LVA in one leg between February 2020 and March 2022 were included. Baseline and postoperative outcomes (at 3, 6, 12 months, and annually) were assessed by relief of symptoms, clinical examination, and indocyanine green (ICG) lymphography. RESULTS: Ten patients (7 females,3 males) met the inclusion criteria. All sustained lymphatic injury secondary to lymphadenectomy and/or radiation for cancer treatment. Five patients (50%) were symptomatic in bilateral legs while all ten had ICG lymphography confirmed lymphatic dysfunction in both legs. LVA was successfully performed in all cases. Mean follow-up was 11.3 months. Following LVA, relief of symptoms and improved functions were reported by all patients and confirmed on examination in all symptomatic limbs, with correlating improvements on ICG lymphography. Favorable ICG lymphography changes were also seen in the contralateral leg in all (5/5) who had asymptomatic contralateral leg lymphedema. CONCLUSION: The benefit of LVA extends beyond the anatomic region in which it is established.

Cystic Lymphatic Malformation with Lymphedema Treated by Lymphaticovenular Anastomosis Combined with Ethanol Sclerotherapy

The incidence of cystic lymphatic malformation (CL) in an extremity is very rare. CL can be a cause of lymphedema in a lower limb. The most effective treatment for CL is sclerotherapy or excision; however, these treatments have the potential to cause fibrosis and obliteration of ruptured lymphatic vessels, which impairs lymphatic drainage and increases the risk of lymphedema. Lymphaticovenular anastomosis (LVA) combined with sclerotherapy may be a minimally invasive treatment option for CL in a lower limb. In this report, we describe a patient with CL complicated by lymphedema in a lower extremity, who we treated using LVA and ethanol sclerotherapy with satisfactory results. The patient was a 60-year-old man with a CL measuring 16 cm in diameter in the thigh region above the knee with lower limb lymphedema. The percentage of excess volume of the affected lower leg was 24.7%, preoperatively. Combined treatment using LVA with sclerotherapy was performed under general anesthesia. At 2 years after surgery, the reduction of excess volume of affected lower leg between preoperative and postoperative was 85.4%. In our previous report, the same combination therapy was used to treat CL and prevent lymphedema; however, in the present case, it was used to treat CL and lymphedema at one stage. LVA combined with sclerotherapy is a complementary minimally invasive treatment for CL accompanied by lymphedema.