Original Article
551
π-Shaped Lymphaticovenular Anastomosis: The Venous Flow Sparing Technique for the Treatment of Peripheral Lymphedema Benoit Ayestaray, MD, MS1
Farid Bekara, MD1
1 Department of Plastic and Reconstructive Surgery, Sud Francilien
Hospital, University Paris Sud XI, Evry, France
Address for correspondence Benoit Ayestaray, MD, MS, Department of Plastic and Reconstructive Surgery, Sud Francilien Hospital, University Paris Sud XI, Evry, France (e-mail: [email protected]).
Abstract
Keywords
► lymphedema ► venous flow sparing lymphaticovenular anastomosis ► end-to-side
Background Nowadays, lymphaticovenular anastomosis has been recognized as an efficient microsurgical treatment for peripheral lymphedema. The technique based on two end-to-side anastomosis is named π-shaped lymphaticovenular anastomosis. This is the venous flow-sparing technique, in which the distal endothelial cells are not sacrificed. The purpose of this study is to evaluate the clinical results of π-shaped lymphaticovenular anastomosis in chronic lymphedema of the upper and lower limbs. Patients and Methods From November 2010 to August 2011, 20 patients with a peripheral lymphedema were treated by π-shaped lymphaticovenular anastomosis. A total of 12 patients had a lymphedema of the upper limb and 8 patients had a lymphedema of the lower limb. The mean age of the patients was 57.2 years (range, 44–78 years). The mean duration of lymphedema was 6.2 years (range, 1–23 years). The Campisi clinical stage range 2 to 5 (average, 3.3). Every patient was operated under local anesthesia. Four π-shaped lymphaticovenular anastomoses were performed per limb. Results The mean caliber of lymphatic vessels used for lymphaticovenular anastomosis was 0.55 mm (range, 0.3–0.8 mm). The mean caliber of subdermal venules was 1.2 mm (range, 0.5–2.1 mm).The average operative time to perform one π-shaped lymphaticovenular anastomosis was 55 minutes (range, 45–65 minutes). A venous backflow was found in 98 lymphaticovenular anastomosis (55.7%). Total 16 patients (80%) had a clinically significant circumferential reduction after surgery. The average volume differential reduction rate was 22.9% (range, 4.9–46.3) (p < 0.001). Conclusions π-Shaped lymphaticovenular anastomosis is a supermicrosurgical method with a low morbidity to treat peripheral lymphedema. The procedure can easily be performed under local anesthesia, and the postoperative recovery is short. The results of this series demonstrate a clinical efficiency of the technique to reduce chronic lymphedema of the limbs. EBM level IV.
Lymphedema is an increasing issue for patients treated by lymphadenectomy and radiotherapy, associated with a cancer resection. Compression therapy and lymph drainage have
been the first conservative options, proposed for these patients. However, the recurrence of lymphedema, when these treatments are stopped, has led microsurgeons to use
received September 16, 2013 accepted after revision December 15, 2013 published online March 28, 2014
Copyright © 2014 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0034-1370356. ISSN 0743-684X.
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J Reconstr Microsurg 2014;30:551–560.
π-Shaped Lymphaticovenular Anastomosis
Ayestaray, Bekara
microsurgical bypasses, in view to create a new way of lymphatic drainage. Nowadays, lymphaticovenular anastomosis have been recognized as an efficient microsurgical treatment for chronic lymphedema.1 The procedure is based on supermicrosurgical techniques, to anastomose lymphatic vessels and adjacent subdermal venules with a caliber inferior to 0.8 mm.2 The venous system is mainly involved in the drainage of the interstitial fluid. Around 90% of the extravasated fluid is reabsorbed at the venous end of the capillaries and postcapillary venules.3 In fact, lymphatic vessels only drain the remaining 10% of the interstitial fluid. Moreover, the development of lymphatic vessels is based on the centrifugal sprouting of endothelial cells from the neighboring veins.4,5 Two lymphangiogenic growth factors, vascular endothelial growth factor (VEGF)-C and VEGF-D, are involved in the lymphatic endothelial cells proliferation.6,7 Endothelial cells have a specific receptor VEGFR-3 for these growth factors. Thus, the venous flow and lymphangiogenesis are two major elements to consider in the treatment of lymphedema. Most of microsurgeons use end-to-end lymphaticovenular anastomosis. In this procedure, the distal venous stump is ligated, and the distal venous flow is interrupted. We used a
configuration based on two end-to-side lymphaticovenular anastomosis: π-shaped lymphaticovenular anastomosis. This is the venous flow-sparing technique, in which the venous flow is not interrupted and the distal endothelial cells are not sacrificed. The purpose of this study is to evaluate the efficiency of π-shaped lymphaticovenular anastomosis for chronic lymphedema of the upper and lower limbs.
Patients and Methods From November 2010 to August 2011, 20 patients with a chronic lymphedema were treated by π-shaped lymphaticovenular anastomosis. All patients were enrolled at least 1 year after the beginning of their lymphedema. Lymphedema was defined as subjective complain of arm swelling and excess circumferential length superior to 1 cm between limbs. Primary lymphedema was considered as evolving without any previous surgery or radiochemotherapy. Cancer-related lymphedema was defined as newly appeared at least 1 month after lymph node dissection or radiochemotherapy. They were treated by conservative treatment, such as compression therapy with a level III elastic stocking associated with a daily elastic bandage and lymph drainage during at
Table 1 Summary of patients treated by π-lymphaticovenular anastomosis Patient
Age
Sex
(y)
Duration of lymphedema
Severity
Campisi stage
Limb
Side
(y)
Circumferential excess ratea (%)
1
48
F
8
þþþ
IV
Up
R
17
2
75
F
4
þþþ
III
Up
R
14
3
78
F
5
þþ
III
Lw
R
28
4
57
F
2
þ
II
Up
L
6
5
49
F
3
þþ
III
Up
L
12
6
51
M
6
þþþ
IV
Lw
L
15
7
47
F
9
þþ
II
Lw
RþL
–
8
69
F
5
þþþ
IV
Up
L
36
9
53
F
20
þþþ
V
Lw
R
35
10
47
F
9
þþþ
IV
Up
R
17
11
44
F
2
þþþ
IV
Lw
L
32
12
68
F
2
þ
II
Up
R
6
13
51
F
4
þþ
III
Lw
L
25
14
62
F
3
þ
II
Up
R
17
15
74
F
5
þþþ
IV
Up
R
22
16
34
F
23
þþþ
V
Lw
RþL
–
17
46
F
2
þ
II
Up
L
9
18
77
F
1
þþ
III
Lw
R
16
19
63
F
5
þþ
III
Up
L
12
20
52
F
7
þþþ
IV
Up
L
28
Average
57.2
6.2
3.3
Abbreviations: F, female; L, left; Lw, lower limb; M, male; R, right; Up, upper limb. Note: Severity: moderate (þ), severe (þþ), and fibrosis (þþþ). a Calculated for unilateral lymphedema. Journal of Reconstructive Microsurgery
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least 6 months. The mean age of the patients was 57.2 years (range, 44–78 years). The mean duration of their lymphedema was 6.2 years (range, 1–23 years). The Campisi clinical stage range 2 to 5 (average, 3.3). Overall 12 patients had a lymphedema of the upper limb. Height patients had a lymphedema of the lower limb (►Table 1). The assessment of the efficacy of surgery was made by analyzing two criteria, before and every 2 months after the surgery, during 1 year. 1. A qualitative analysis of the soft tissues characteristics: softness, thickness (pinch test), and sensibility. 2. A quantitative circumferential analysis: – By measuring the circumference of the limbs at three different levels (superior, middle, and inferior) of each anatomical segment (arm, forearm, thigh, and leg) and at the level of the wrist, the hand, the ankle, and the foot. – By calculating the cross-sectional area (CSA ¼ πr2 ¼ C2/4π) at the same levels, and the mean volume of lymphedema (V ¼ h/6 [C12 þ C32 þ 4C2]) (►Fig. 1).
Ayestaray, Bekara
15 cm distal to the incision site, using a 0.5 mL syringe and 24G needle. The mean volume injected was 1.4 mL (range, 1–2 mL). A skin massage from distal to proximal was performed during 1 minute. This procedure enhanced the lymphatic vessels visualization intraoperatively. All patients were operated under local anesthesia with 1% lidocaine with 1/100,000 epinephrine. The mean volume of local anesthetic used was 6.3 mL (range, 3–10 mL). The lymphatic vessels were dissected subdermally, through a 2.5 cm (range, 2–4 cm) skin incision. Every lymphaticovenular anastomosis was performed at the medial and lateral parts of the limbs, where the lymphatic network is concentrated.8 The total number of π-shaped lymphaticovenular anastomosis performed per limb was four (i.e., eight end-to-side lymphaticovenular anastomosis). π-Shaped lymphaticovenular anastomosis were performed with EMI SuperMicrosurgery instruments (EMI Factory Co., Ltd, Nagano, Japan) or Ultrafine Microsurgical instruments (Medicon and Co., Tuttlingen, Germany), and 11–0 nylon monofilament on a 50 µm needle (Ethilon, Ethicon, Johnson
Surgical Procedure Before scrubbing, patent blue dye (2 mL; 2.5% Bleu Patenté V by Guerbet Laboratory, France) was injected subdermally
Fig. 1 Anatomical model for the assessment of the mean volume of the limb. Circumferences at the proximal (C1) and the distal (C2) parts of the limb are measured. The length (h) between these two values is measured. The mean volume is calculated by the formula V¼ h/ 6 (C 1 2 þ C 32 þ 4C 2 ). C, circumference; C 1 , circumference at the proximal part of the limb; C 2 , circumference at the central part of the limb; C 3, circumference at the distal part of the limb; h, length between C 1 and C 3 .
Fig. 2 Surgical model of π-shaped lymphaticovenular anastomosis. (A) Lymphedema is due to the excessive extravasation of the lymphatic fluid in the interstitium. π-Shaped lymphaticovenular anastomosis requires individualizing a lymphatic vessel and an adjacent subdermal venule. (B) Two windows, as large as the caliber of the lymphatic vessel, are performed through the wall of the venule. The lymphatic vessel is transected in two parts with microscissors. (C) Each lymphatic stump is connected to a lateral wall of the venule. Lymph is pumped through the venous flow. Journal of Reconstructive Microsurgery
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π-Shaped Lymphaticovenular Anastomosis
π-Shaped Lymphaticovenular Anastomosis
Ayestaray, Bekara
and Johnson Co., NJ). After dissection of subdermal lymphatic vessels and adjacent venules, their caliber was measured with a professional scaled ruler (Shinwa Sokutei Co., Ltd., Sapporo Eigyosho, Japan). In π-shaped procedure, a lymphatic vessel was transected in two parts with microscissors. Then, two windows, as large as the caliber of the lymphatic vessel, were performed through the wall of an adjacent venule. Each lymphatic stump was connected to a lateral window of the adjacent venule (►Figs. 2 and 3). These two end-to-side lymphaticovenular anastomosis describe the shape of a π. That is the reason why the procedure was named π-shaped lymphaticovenular anastomosis.
Statistical Analysis Quantitative data were analyzed by an independent biostatistician from the department of biostatistics of Montpellier University Hospital. The t-test was used to compare the mean of postoperative measures to the preoperative value, overall and for each patient, with a follow-up of 12 months. Values of p < 0.05 were considered statistically significant.
Results The skin incision length ranged 2 to 4 cm (average, 2.5 cm). The mean number of lymphatic vessels individualized per limb was 5.4 (range, 4–8). The caliber of lymphatic vessels used for anastomosis ranged 0.30 to 0.80 mm (average,
0.55 mm). The caliber of subdermal venules ranged 0.5 to 2.1 mm (average, 1.2 mm). The average operative time to perform a π-shaped lymphaticovenular anastomosis was 55 minutes (range, 45–65 minutes). The total number of end-toside lymphaticovenular anastomosis performed in this clinical series was 176. A venous backflow8 was found in 98 lymphaticovenular anastomosis (55.7%). No patient experienced a postoperative worsening of their lymphedema after surgery. No patient developed an allergy to the patent blue, or a postoperative infection, including lymphangitis. No patient experienced postoperative hematomas (►Table 2). One patient (5%)—with a Campisi stage III lymphedema of the upper limb (Case 5)—developed hypertrophic scars on the forearm. Total 20 patients (100%) had a qualitative improvement of soft tissues after surgery. The soft tissues were softer, the pinch test was thinner, and the subjective skin sensibility was improved. Papillomatosis and trophic ulcers were also reduced. The reduction of the pinch test ranges 2 to 9 mm (average, 5.8 mm). Total 16 patients (80%) had a clinically significant circumferential reduction after surgery. The weight of their limb was also felt as lighter. They had to change their elastic stocking for a smaller one 3 months after surgery. The average circumferential differential reduction rate was 13.1% (range, 3.5–28.1%) (p < 0.01). The average cross-sectional area differential reduction rate was 24.5% (range, 6.7–47.5) (p < 0.001). The average volume differential reduction rate was 22.9% (range, 4.9–46.3) (p < 0.001) (►Table 3). Nine patients (45%) stopped
Fig. 3 Intraoperative view of different π-shaped lymphaticovenular anastomosis (LVA). (a) Between a 0.30 mm lymphatic vessel and a 0.9 mm subdermal venule, with no venous backflow but a diffusion of patent blue through one LVA inside the recipient venule: π-shaped LVA 0.3–0.9 vb0 pb 1. (b) Between a 0.45 mm lymphatic vessel and a 1.1 mm subdermal venule, with two venous backflows but no diffusion of patent blue inside the recipient venule: π-shaped LVA 0.45–1.1 vb2 pb0 . (c) Between a 0.4 mm lymphatic vessel and a 1.5 mm subdermal venule, with one venous backflow but no diffusion of patent blue inside the recipient venule: π-shaped LVA 0.4–1.5 vb 1 pb0 . (d) Between a 0.60 mm lymphatic vessel and a 1.2 mm subdermal venule, with no venous backflow but a diffusion of patent blue through both LVAs inside the recipient venule: π-shaped LVA 0.6– 1.2 vb 0 pb 2 . Vb, venous backflow; pb, patent blue. Journal of Reconstructive Microsurgery
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π-Shaped Lymphaticovenular Anastomosis
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Table 2 Summary of operative findings and postoperative outcomes Patent blue volume
Number of skin incisions
Number of LV
(mL)
Caliber of LV
Caliber of SV
(mm)
(mm)
Complication
Allergy
Infection
Lymphangitis
Blue staining skin resorptiona Hypertrophic scar
(d)
1
1
3
6
0.5–0.7
0.9–1.5
None
None
None
None
35
2
1
4
6
0.5–0.7
1.2–2.0
None
None
None
None
20
3
2
4
4
0.4–0.8
0.7–1.6
None
None
None
None
30
4
1
4
6
0.3–0.7
0.8–2.1
None
None
None
None
45
5
1.5
3
4
0.4–0.6
0.5–1.2
None
None
None
þ
25
6
1
3
6
0.5–0.8
1.1–1.6
None
None
None
None
NC 30
7
1þ1
2þ4
4þ4
0.4–0.7
0.9–1.2
None
None
None
None
8
2
3
5
0.5–0.8
0.6–2.0
None
None
None
None
NC
9
1
4
6
0.4–0.6
1.2–1.5
None
None
None
None
20
10
1
4
8
0.6–0.8
0.7–1.1
None
None
None
None
20
11
1.5
2
4
0.4–0.7
0.9–1.4
None
None
None
None
25
12
1.5
3
6
0.5–0.8
1.0–1.6
None
None
None
None
30
13
2
3
5
0.3–0.5
0.6–0.8
None
None
None
None
45
14
1
4
7
0.5–0.8
0.8–1.3
None
None
None
None
20
15
1.5
2
4
0.4–0.7
1.1–1.6
None
None
None
None
35 30
16
2þ2
3þ 4
4 þ5
0.3–0.7
0.6–1.5
None
None
None
None
17
1
4
6
0.5–0.6
0.9–1.4
None
None
None
None
NC
18
1.5
2
5
0.3–0.5
0.8–2.1
None
None
None
None
25
19
2
4
8
0.3–0.8
0.5–1.8
None
None
None
None
25
20
1
4
7
0.3–0.6
1.1–1.5
None
None
None
None
20
Average
1.4
3.3
5.4
0.55
1.2
28.2
Abbreviations: LV, lymphatic vessel; NC, Not Completed; SV, subdermal venule. a Calculated for the 17 patients having a complete blue staining resorption.
wearing their elastic stocking and bandage definitively 1 year after surgery. A total of 19 patients (95%) concluded to a better quality of life 1 year after surgery.
Case Reports Case 8 A 69-year-old female presented in our clinic for a postoperative lymphedema of the left upper limb, secondary to an axillary lymphadenectomy 6 years ago. Her lymphedema started 1 year after the lymphadenectomy. Eight end-toside lymphaticovenular anastomoses (four π-shaped) were performed through three skin incisions at the medial and lateral parts of her forearm. The circumferential reduction rate was 28.1%, the cross-sectional area reduction rate was 47.5%, and the average volume reduction rate was 47.3% after a follow-up of 12 months (►Figs. 4 and 5). She stopped lymph drainage by physiotherapists 4 months after surgery. She definitively stopped wearing her compressive elastic stocking and open glove garment 6 months after surgery.
Case 16 A 34-year-old female presented in our clinic for a bilateral congenital lymphedema of the lower limbs since the early
childhood, secondary to a Turner syndrome. Her lymphedema increased at the puberty. She presented a severe deformity of the left foot, associated with a large area of hyperkeratosis and skin fibrosis. She also developed chronic skin ulcers at the inferior part of the legs (►Fig. 6). Eight lymphaticovenular anastomoses were performed (four πshaped) through four skin incisions at each lower limb. The circumferential reduction rate was 17%, the cross-sectional area reduction rate was 32.2%, and the average volume reduction rate was 36.5% after a follow-up of 12 months (►Fig. 7). She definitively stopped wearing her compressive elastic stocking and lymph drainage 8 months after surgery.
Discussion Chronic lymphedema is a public health issue, leading to severe functional troubles in everyday life. Nowadays, medical treatments are not efficient enough to have a stable reduction of a chronic lymphedema in time. Recurrence is usual when compressive therapy and lymph drainage are stopped. That is the reason why lymphaticovenular anastomoses were introduced in view to improve the efficacy and stability of the edema relief. Lymphaticovenular anastomosis derives from lymphaticovenous bypasses described by Journal of Reconstructive Microsurgery
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Patient
π-Shaped Lymphaticovenular Anastomosis
Ayestaray, Bekara
Table 3 Summary of clinical results in patients treated by π-lymphaticovenular anastomosis Patient
mC
mC Reduction
Average mC reduction rate
mCSA
mCSA Reduction
Average mCSA reduction rate
mV
mV Reduction
Average mV reduction rate
(cm)
(cm)
(%)
(cm2)
(cm2)
(%)
(cm3)
(cm3)
(%)
1
31.5
5.3
16.8
82.1
22.3
27.1
1549.1
438.4
28.3
2
27.8
3
10.8
65.3
14.2
21.7
1518.5
343.2
22.6
3
43
10.8
24.6
155.1
67.5
43.5
3087.5
849.1
27.5
4
27.2
1.2
4.4
60.7
5.3
8.7
1272.6
62.3
4.9
5
38.1
1.3
3.5
125.9
8.5
6.7
3092.3
315.4
10.2
6
28
1.8
6.6
65.4
7.8
11.9
1850
179.4
9.7
7
45
3.3
7.8
169.8
22.2
13
3262.5
515.4
15.8
8
35.5
10
28.1
100.3
50
47.5
1640.8
740
45.1
9
49.2
3.5
6.1
207.9
30.6
14.7
3562.5
384.7
10.8
10
29.8
5
16.5
73.1
22.4
30.6
1631.6
396.5
24.3
11
49.5
7.5
14.8
208
59
28.3
3587.5
925.6
25.8
12
35
9.4
27.2
101.9
46.7
45.8
1723.3
797.9
46.3
13
35.5
2.3
6.3
115.9
14.3
12.3
2125.1
265.6
12.5
14
30.5
3.8
12.4
77.4
17.4
22.5
1595
306.2
19.2
15
33.8
5
16.5
98
33.1
33.7
1833.3
632.5
34.5
16
47.5
8.3
17
187.8
60.5
32.2
3425
1230.5
35.9
17
32.6
2.2
6.8
90.9
11.8
12.9
1787.5
262.8
14.7
18
36
3
7.2
114.6
20
17.4
2887.5
470.6
16.3
19
28.6
2.2
7.7
69.3
10.4
15
1521.6
265.8
17.5
20
37.4
9.8
20.5
116.5
51.7
44.4
1888.3
696.7
36.9
Average
36.1
4.9
13.1
114.3
28.8
24.5
2242.1
503.9
22.9
Abbreviations: mC, mean circumference; mCSA, mean cross-sectional area; mV, mean volume.
Fig. 4 Case 8: A 69-year-old female having a postoperative lymphedema of the left upper limb (Campisi clinical stage IV), secondary to an axillary lymphadenectomy 6 years ago. (a) Preoperative view: The hand, the forearm, and the arm were infiltrated by the lymphedema. Skin fibrosis was present at the forearm. The patient had to wear continuously an open glove garment. The mobility of the upper limb was limited by the weight of the edema. (b) Postoperative view: The edema relief was visible at the hand, the forearm, and the arm. The patient stopped wearing her open glove garment. Journal of Reconstructive Microsurgery
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Fig. 5 Case 8: Clinical aspect of the left hand and forearm. (a) Preoperative view: The dorsum of the hand and the fingers were affected by the lymphedema. The forearm and the wrist were also infiltrated. The mobility of the hand was limited, and the sensibility was reduced. (b) Postoperative view: The intermetacarpal spaces were visible and the fingers were thinner. The edema relief was also visible at the wrist and the forearm. A small area of blue staining (< 2 cm) remained at the dorsum of the wrist.
Yamada in 1969.9 The surgical technique was refined by O’Brien et al,10–12 then by Koshima et al who introduced the concept of supermicrosurgery.13,14 The difference of pressure gradient between lymphatic vessels and subdermal venules is sufficient to pump up the lymphatic fluid, when a lymphatic channel is anastomosed to a venule. The drainage is mainly due to the Venturi effect (Pvenule > Plymphatic). The differential pressure gradient between lymphatic vessels and subdermal venules is low, comparing to larger veins.15 Then the rate of thrombosis at the anastomosis site is decreased with supermicrosurgical techniques, comparing to classical lymphaticovenous bypasses.16 π-Shaped lymphaticovenular anastomosis is a double endto-side lymphaticovenular anastomosis, corresponding to a venous flow-sparing technique. This technique was introduced by Japanese supermicrosurgeons.17,18 The distal venous flow is not interrupted with this configuration. As the venous system is mainly involved in lymphatic drainage,3 this method is the configuration to favor when the vascular
Ayestaray, Bekara
Fig. 6 Case 16: A 34-year-old female having a bilateral congenital lymphedema of the lower limbs since the early childhood, secondary to Turner syndrome. Preoperative views (a) left leg: Campisi clinical stage V lymphedema. The foot was masked by the deformity of the soft tissues. An important hyperkeratosis was present at the dorsum of the foot. Chronic dermitis was visible along the leg. (b) Left leg: The soft tissues were affected by an important fibrosis. Trophic ulcers were developed around areas of hyperkeratosis. (c) Right leg: Campisi clinical stage V lymphedema. The deformity was less important than the other side, but fibrosis and hyperkeratosis were severe. A large skin ulcer was visible at the inferior part of the leg.
anatomy makes two end-to-side anastomosis possible. This is also a minimal invasive technique which respects endothelial cells in the venous wall. These endothelial cells are involved in lymphangiogenesis by centrifugal sprouting.4,5 For these reasons, π-shaped lymphaticovenular anastomosis should be favored if the vascular anatomy is suitable as often as possible. The only disadvantage of end-to-side anastomosis is to be a little bit more difficult and longer than end-to-end anastomosis.19 In our clinical series, the average operative time was 45 minutes to perform one end-to-end lymphaticovenular anastomosis, and 55 minutes to perform one endto-side lymphaticovenular anastomosis. In comparison with other clinical series reported in the literature, the outcomes of this series are very encouraging (►Fig. 8). Lambda-shaped lymphaticovenular anastomosis leads to an average cross-sectional area reduction rate of 5.9% (range, 1.9–11.3%).18 One series20 has reported a higher rate of edema reduction without specifying the configuration of anastomosis (35% of volume reduction at 1 year). Other Journal of Reconstructive Microsurgery
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π-Shaped Lymphaticovenular Anastomosis
π-Shaped Lymphaticovenular Anastomosis
Ayestaray, Bekara compare this technique with the other configurations of lymphaticovenular anastomosis.
Conclusions π-Shaped lymphaticovenular anastomosis is an effective method, based on two end-to-side lymphaticovenular anastomosis, to reduce the volume and the severity of peripheral lymphedema. This is the venous flow-sparing technique which does not interrupt the distal venous flow and respects the related endothelial cells. The results of this clinical series demonstrate a clinical efficiency to reduce chronic lymphedema of upper and lower limbs with this supermicrosurgical technique.
Acknowledgement The authors thank Dr. Claire Duflos, MD, from the department of biostatistics of Montpellier University Hospital for the statistical analysis of the data. Fig. 7 Case 16: Postoperative clinical aspect of the lower limbs, 8 months after surgery. (a, b) The edema relief was visible for both legs. The deformity of the lower limbs was improved. The dermitis disappeared. The hyperkeratosis was completely resorbed, but the fibrosis was still present at the dorsum of the left foot. Skin ulcers were completely healed at the lower part of the legs.
Disclosure None. Conflict of Interest None.
References 1 Penha TR, Ijsbrandy C, Hendrix NA, et al. Microsurgical techniques
2
3 4
Fig. 8 Variations of the average volume of lymphedema in patients treated by π-shaped lymphaticovenular anastomosis.
series have reported higher rates of circumferential reduction (47.3% at 2.2 years,13 55.6% at 3.3 years14) but the reduction was calculated on the basis on the circumferential excess length, and not on the preoperative mean circumference. So far, lymphaticovenular anastomoses represent an effective supermicrosurgical method with a low morbidity to treat peripheral lymphedema. They can be easily performed under local anesthesia, but require a high magnification microscope and a supermicrosurgical training. The postoperative recovery is short. Different configurations of lymphaticovenular anastomosis have been described. Nowadays, end-to-end anastomosis remains the most popular.1,20 However, the efficiency of end-to-side lymphaticovenular anastomosis has been demonstrated in this clinical series. Further studies with a longer follow-up of patients should be made to Journal of Reconstructive Microsurgery
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6
7 8 9 10
11
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for the treatment of breast cancer-related lymphedema: a systematic review. J Reconstr Microsurg 2013;29(2):99–106 Koshima I, Kawada S, Moriguchi T, Kajiwara Y. Ultrastructural observations of lymphatic vessels in lymphedema in human extremities. Plast Reconstr Surg 1996;97(2):397–405, discussion 406–407 Starling EH. On the absorption of fluids from the connective tissue spaces. J Physiol 1896;19(4):312–326 Sabin FR. On the origin of the lymphatic system from the veins and the development of the lymph hearts and thoracic duct in the pig. Am J Anat 1902;1:367–391 Wigle JT, Harvey N, Detmar M, et al. An essential role for Prox1 in the induction of the lymphatic endothelial cell phenotype. EMBO J 2002;21(7):1505–1513 Joukov V, Pajusola K, Kaipainen A, et al. A novel vascular endothelial growth factor, VEGF-C, is a ligand for the Flt4 (VEGFR-3) and KDR (VEGFR-2) receptor tyrosine kinases. EMBO J 1996;15(2):290–298 Jussila L, Alitalo K. Vascular growth factors and lymphangiogenesis. Physiol Rev 2002;82(3):673–700 Zuther JE. Anatomy. In Zuther JE, ed. Lymphedema Management. 2nd ed. Stuttgart: Thieme Verlag; 2009:1–28 Yamada Y. Studies on lymphatic venous anastomosis in lymphedema. Nagoya J Med Sci 1969;32:1–21 O’Brien BM, Sykes P, Threlfall GN, Browning FS. Microlymphaticovenous anastomoses for obstructive lymphedema. Plast Reconstr Surg 1977;60(2):197–211 O’Brien BM, Shafiroff BB. Microlymphaticovenous and resectional surgery in obstructive lymphedema. World J Surg 1979;3(1):3–15, 121–123 O’Brien BM, Mellow CG, Khazanchi RK, Dvir E, Kumar V, Pederson WC. Long-term results after microlymphaticovenous anastomoses
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π-Shaped Lymphaticovenular Anastomosis
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17 Narushima M, Mihara M, Yamamoto Y, Iida T, Koshima I,
Mundinger GS. The intravascular stenting method for treatment of extremity lymphedema with multiconfiguration lymphaticovenous anastomoses. Plast Reconstr Surg 2010;125(3): 935–943 18 Yamamoto T, Narushima M, Kikuchi K, et al. Lambda-shaped anastomosis with intravascular stenting method for safe and effective lymphaticovenular anastomosis. Plast Reconstr Surg 2011;127(5):1987–1992 19 Lasso JM, Perez Cano R. Practical solutions for lymphaticovenous anastomosis. J Reconstr Microsurg 2013;29(1):1–4 20 Chang DW. Lymphaticovenular bypass for lymphedema management in breast cancer patients: a prospective study. Plast Reconstr Surg 2010;126(3):752–758
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13
for the treatment of obstructive lymphedema. Plast Reconstr Surg 1990;85(4):562–572 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(6):437–442 Koshima I, Nanba Y, Tsutsui T, Takahashi Y, Itoh S. Long-term follow-up after lymphaticovenular anastomosis for lymphedema in the leg. J Reconstr Microsurg 2003;19(4):209–215 Baumeister RG, Siuda S. Treatment of lymphedemas by microsurgical lymphatic grafting: what is proved? Plast Reconstr Surg 1990;85(1):64–74, discussion 75–76 Nagase T, Gonda K, Inoue K, et al. Treatment of lymphedema with lymphaticovenular anastomoses. Int J Clin Oncol 2005;10(5): 304–310
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No. 8/2014
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551
π-Shaped Lymphaticovenular Anastomosis: The Venous Flow Sparing Technique for the Treatment of Peripheral Lymphedema Benoit Ayestaray, MD, MS1
Farid Bekara, MD1
1 Department of Plastic and Reconstructive Surgery, Sud Francilien
Hospital, University Paris Sud XI, Evry, France
Address for correspondence Benoit Ayestaray, MD, MS, Department of Plastic and Reconstructive Surgery, Sud Francilien Hospital, University Paris Sud XI, Evry, France (e-mail: [email protected]).
Abstract
Keywords
► lymphedema ► venous flow sparing lymphaticovenular anastomosis ► end-to-side
Background Nowadays, lymphaticovenular anastomosis has been recognized as an efficient microsurgical treatment for peripheral lymphedema. The technique based on two end-to-side anastomosis is named π-shaped lymphaticovenular anastomosis. This is the venous flow-sparing technique, in which the distal endothelial cells are not sacrificed. The purpose of this study is to evaluate the clinical results of π-shaped lymphaticovenular anastomosis in chronic lymphedema of the upper and lower limbs. Patients and Methods From November 2010 to August 2011, 20 patients with a peripheral lymphedema were treated by π-shaped lymphaticovenular anastomosis. A total of 12 patients had a lymphedema of the upper limb and 8 patients had a lymphedema of the lower limb. The mean age of the patients was 57.2 years (range, 44–78 years). The mean duration of lymphedema was 6.2 years (range, 1–23 years). The Campisi clinical stage range 2 to 5 (average, 3.3). Every patient was operated under local anesthesia. Four π-shaped lymphaticovenular anastomoses were performed per limb. Results The mean caliber of lymphatic vessels used for lymphaticovenular anastomosis was 0.55 mm (range, 0.3–0.8 mm). The mean caliber of subdermal venules was 1.2 mm (range, 0.5–2.1 mm).The average operative time to perform one π-shaped lymphaticovenular anastomosis was 55 minutes (range, 45–65 minutes). A venous backflow was found in 98 lymphaticovenular anastomosis (55.7%). Total 16 patients (80%) had a clinically significant circumferential reduction after surgery. The average volume differential reduction rate was 22.9% (range, 4.9–46.3) (p < 0.001). Conclusions π-Shaped lymphaticovenular anastomosis is a supermicrosurgical method with a low morbidity to treat peripheral lymphedema. The procedure can easily be performed under local anesthesia, and the postoperative recovery is short. The results of this series demonstrate a clinical efficiency of the technique to reduce chronic lymphedema of the limbs. EBM level IV.
Lymphedema is an increasing issue for patients treated by lymphadenectomy and radiotherapy, associated with a cancer resection. Compression therapy and lymph drainage have
been the first conservative options, proposed for these patients. However, the recurrence of lymphedema, when these treatments are stopped, has led microsurgeons to use
received September 16, 2013 accepted after revision December 15, 2013 published online March 28, 2014
Copyright © 2014 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0034-1370356. ISSN 0743-684X.
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J Reconstr Microsurg 2014;30:551–560.
π-Shaped Lymphaticovenular Anastomosis
Ayestaray, Bekara
microsurgical bypasses, in view to create a new way of lymphatic drainage. Nowadays, lymphaticovenular anastomosis have been recognized as an efficient microsurgical treatment for chronic lymphedema.1 The procedure is based on supermicrosurgical techniques, to anastomose lymphatic vessels and adjacent subdermal venules with a caliber inferior to 0.8 mm.2 The venous system is mainly involved in the drainage of the interstitial fluid. Around 90% of the extravasated fluid is reabsorbed at the venous end of the capillaries and postcapillary venules.3 In fact, lymphatic vessels only drain the remaining 10% of the interstitial fluid. Moreover, the development of lymphatic vessels is based on the centrifugal sprouting of endothelial cells from the neighboring veins.4,5 Two lymphangiogenic growth factors, vascular endothelial growth factor (VEGF)-C and VEGF-D, are involved in the lymphatic endothelial cells proliferation.6,7 Endothelial cells have a specific receptor VEGFR-3 for these growth factors. Thus, the venous flow and lymphangiogenesis are two major elements to consider in the treatment of lymphedema. Most of microsurgeons use end-to-end lymphaticovenular anastomosis. In this procedure, the distal venous stump is ligated, and the distal venous flow is interrupted. We used a
configuration based on two end-to-side lymphaticovenular anastomosis: π-shaped lymphaticovenular anastomosis. This is the venous flow-sparing technique, in which the venous flow is not interrupted and the distal endothelial cells are not sacrificed. The purpose of this study is to evaluate the efficiency of π-shaped lymphaticovenular anastomosis for chronic lymphedema of the upper and lower limbs.
Patients and Methods From November 2010 to August 2011, 20 patients with a chronic lymphedema were treated by π-shaped lymphaticovenular anastomosis. All patients were enrolled at least 1 year after the beginning of their lymphedema. Lymphedema was defined as subjective complain of arm swelling and excess circumferential length superior to 1 cm between limbs. Primary lymphedema was considered as evolving without any previous surgery or radiochemotherapy. Cancer-related lymphedema was defined as newly appeared at least 1 month after lymph node dissection or radiochemotherapy. They were treated by conservative treatment, such as compression therapy with a level III elastic stocking associated with a daily elastic bandage and lymph drainage during at
Table 1 Summary of patients treated by π-lymphaticovenular anastomosis Patient
Age
Sex
(y)
Duration of lymphedema
Severity
Campisi stage
Limb
Side
(y)
Circumferential excess ratea (%)
1
48
F
8
þþþ
IV
Up
R
17
2
75
F
4
þþþ
III
Up
R
14
3
78
F
5
þþ
III
Lw
R
28
4
57
F
2
þ
II
Up
L
6
5
49
F
3
þþ
III
Up
L
12
6
51
M
6
þþþ
IV
Lw
L
15
7
47
F
9
þþ
II
Lw
RþL
–
8
69
F
5
þþþ
IV
Up
L
36
9
53
F
20
þþþ
V
Lw
R
35
10
47
F
9
þþþ
IV
Up
R
17
11
44
F
2
þþþ
IV
Lw
L
32
12
68
F
2
þ
II
Up
R
6
13
51
F
4
þþ
III
Lw
L
25
14
62
F
3
þ
II
Up
R
17
15
74
F
5
þþþ
IV
Up
R
22
16
34
F
23
þþþ
V
Lw
RþL
–
17
46
F
2
þ
II
Up
L
9
18
77
F
1
þþ
III
Lw
R
16
19
63
F
5
þþ
III
Up
L
12
20
52
F
7
þþþ
IV
Up
L
28
Average
57.2
6.2
3.3
Abbreviations: F, female; L, left; Lw, lower limb; M, male; R, right; Up, upper limb. Note: Severity: moderate (þ), severe (þþ), and fibrosis (þþþ). a Calculated for unilateral lymphedema. Journal of Reconstructive Microsurgery
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552
least 6 months. The mean age of the patients was 57.2 years (range, 44–78 years). The mean duration of their lymphedema was 6.2 years (range, 1–23 years). The Campisi clinical stage range 2 to 5 (average, 3.3). Overall 12 patients had a lymphedema of the upper limb. Height patients had a lymphedema of the lower limb (►Table 1). The assessment of the efficacy of surgery was made by analyzing two criteria, before and every 2 months after the surgery, during 1 year. 1. A qualitative analysis of the soft tissues characteristics: softness, thickness (pinch test), and sensibility. 2. A quantitative circumferential analysis: – By measuring the circumference of the limbs at three different levels (superior, middle, and inferior) of each anatomical segment (arm, forearm, thigh, and leg) and at the level of the wrist, the hand, the ankle, and the foot. – By calculating the cross-sectional area (CSA ¼ πr2 ¼ C2/4π) at the same levels, and the mean volume of lymphedema (V ¼ h/6 [C12 þ C32 þ 4C2]) (►Fig. 1).
Ayestaray, Bekara
15 cm distal to the incision site, using a 0.5 mL syringe and 24G needle. The mean volume injected was 1.4 mL (range, 1–2 mL). A skin massage from distal to proximal was performed during 1 minute. This procedure enhanced the lymphatic vessels visualization intraoperatively. All patients were operated under local anesthesia with 1% lidocaine with 1/100,000 epinephrine. The mean volume of local anesthetic used was 6.3 mL (range, 3–10 mL). The lymphatic vessels were dissected subdermally, through a 2.5 cm (range, 2–4 cm) skin incision. Every lymphaticovenular anastomosis was performed at the medial and lateral parts of the limbs, where the lymphatic network is concentrated.8 The total number of π-shaped lymphaticovenular anastomosis performed per limb was four (i.e., eight end-to-side lymphaticovenular anastomosis). π-Shaped lymphaticovenular anastomosis were performed with EMI SuperMicrosurgery instruments (EMI Factory Co., Ltd, Nagano, Japan) or Ultrafine Microsurgical instruments (Medicon and Co., Tuttlingen, Germany), and 11–0 nylon monofilament on a 50 µm needle (Ethilon, Ethicon, Johnson
Surgical Procedure Before scrubbing, patent blue dye (2 mL; 2.5% Bleu Patenté V by Guerbet Laboratory, France) was injected subdermally
Fig. 1 Anatomical model for the assessment of the mean volume of the limb. Circumferences at the proximal (C1) and the distal (C2) parts of the limb are measured. The length (h) between these two values is measured. The mean volume is calculated by the formula V¼ h/ 6 (C 1 2 þ C 32 þ 4C 2 ). C, circumference; C 1 , circumference at the proximal part of the limb; C 2 , circumference at the central part of the limb; C 3, circumference at the distal part of the limb; h, length between C 1 and C 3 .
Fig. 2 Surgical model of π-shaped lymphaticovenular anastomosis. (A) Lymphedema is due to the excessive extravasation of the lymphatic fluid in the interstitium. π-Shaped lymphaticovenular anastomosis requires individualizing a lymphatic vessel and an adjacent subdermal venule. (B) Two windows, as large as the caliber of the lymphatic vessel, are performed through the wall of the venule. The lymphatic vessel is transected in two parts with microscissors. (C) Each lymphatic stump is connected to a lateral wall of the venule. Lymph is pumped through the venous flow. Journal of Reconstructive Microsurgery
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π-Shaped Lymphaticovenular Anastomosis
π-Shaped Lymphaticovenular Anastomosis
Ayestaray, Bekara
and Johnson Co., NJ). After dissection of subdermal lymphatic vessels and adjacent venules, their caliber was measured with a professional scaled ruler (Shinwa Sokutei Co., Ltd., Sapporo Eigyosho, Japan). In π-shaped procedure, a lymphatic vessel was transected in two parts with microscissors. Then, two windows, as large as the caliber of the lymphatic vessel, were performed through the wall of an adjacent venule. Each lymphatic stump was connected to a lateral window of the adjacent venule (►Figs. 2 and 3). These two end-to-side lymphaticovenular anastomosis describe the shape of a π. That is the reason why the procedure was named π-shaped lymphaticovenular anastomosis.
Statistical Analysis Quantitative data were analyzed by an independent biostatistician from the department of biostatistics of Montpellier University Hospital. The t-test was used to compare the mean of postoperative measures to the preoperative value, overall and for each patient, with a follow-up of 12 months. Values of p < 0.05 were considered statistically significant.
Results The skin incision length ranged 2 to 4 cm (average, 2.5 cm). The mean number of lymphatic vessels individualized per limb was 5.4 (range, 4–8). The caliber of lymphatic vessels used for anastomosis ranged 0.30 to 0.80 mm (average,
0.55 mm). The caliber of subdermal venules ranged 0.5 to 2.1 mm (average, 1.2 mm). The average operative time to perform a π-shaped lymphaticovenular anastomosis was 55 minutes (range, 45–65 minutes). The total number of end-toside lymphaticovenular anastomosis performed in this clinical series was 176. A venous backflow8 was found in 98 lymphaticovenular anastomosis (55.7%). No patient experienced a postoperative worsening of their lymphedema after surgery. No patient developed an allergy to the patent blue, or a postoperative infection, including lymphangitis. No patient experienced postoperative hematomas (►Table 2). One patient (5%)—with a Campisi stage III lymphedema of the upper limb (Case 5)—developed hypertrophic scars on the forearm. Total 20 patients (100%) had a qualitative improvement of soft tissues after surgery. The soft tissues were softer, the pinch test was thinner, and the subjective skin sensibility was improved. Papillomatosis and trophic ulcers were also reduced. The reduction of the pinch test ranges 2 to 9 mm (average, 5.8 mm). Total 16 patients (80%) had a clinically significant circumferential reduction after surgery. The weight of their limb was also felt as lighter. They had to change their elastic stocking for a smaller one 3 months after surgery. The average circumferential differential reduction rate was 13.1% (range, 3.5–28.1%) (p < 0.01). The average cross-sectional area differential reduction rate was 24.5% (range, 6.7–47.5) (p < 0.001). The average volume differential reduction rate was 22.9% (range, 4.9–46.3) (p < 0.001) (►Table 3). Nine patients (45%) stopped
Fig. 3 Intraoperative view of different π-shaped lymphaticovenular anastomosis (LVA). (a) Between a 0.30 mm lymphatic vessel and a 0.9 mm subdermal venule, with no venous backflow but a diffusion of patent blue through one LVA inside the recipient venule: π-shaped LVA 0.3–0.9 vb0 pb 1. (b) Between a 0.45 mm lymphatic vessel and a 1.1 mm subdermal venule, with two venous backflows but no diffusion of patent blue inside the recipient venule: π-shaped LVA 0.45–1.1 vb2 pb0 . (c) Between a 0.4 mm lymphatic vessel and a 1.5 mm subdermal venule, with one venous backflow but no diffusion of patent blue inside the recipient venule: π-shaped LVA 0.4–1.5 vb 1 pb0 . (d) Between a 0.60 mm lymphatic vessel and a 1.2 mm subdermal venule, with no venous backflow but a diffusion of patent blue through both LVAs inside the recipient venule: π-shaped LVA 0.6– 1.2 vb 0 pb 2 . Vb, venous backflow; pb, patent blue. Journal of Reconstructive Microsurgery
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π-Shaped Lymphaticovenular Anastomosis
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555
Table 2 Summary of operative findings and postoperative outcomes Patent blue volume
Number of skin incisions
Number of LV
(mL)
Caliber of LV
Caliber of SV
(mm)
(mm)
Complication
Allergy
Infection
Lymphangitis
Blue staining skin resorptiona Hypertrophic scar
(d)
1
1
3
6
0.5–0.7
0.9–1.5
None
None
None
None
35
2
1
4
6
0.5–0.7
1.2–2.0
None
None
None
None
20
3
2
4
4
0.4–0.8
0.7–1.6
None
None
None
None
30
4
1
4
6
0.3–0.7
0.8–2.1
None
None
None
None
45
5
1.5
3
4
0.4–0.6
0.5–1.2
None
None
None
þ
25
6
1
3
6
0.5–0.8
1.1–1.6
None
None
None
None
NC 30
7
1þ1
2þ4
4þ4
0.4–0.7
0.9–1.2
None
None
None
None
8
2
3
5
0.5–0.8
0.6–2.0
None
None
None
None
NC
9
1
4
6
0.4–0.6
1.2–1.5
None
None
None
None
20
10
1
4
8
0.6–0.8
0.7–1.1
None
None
None
None
20
11
1.5
2
4
0.4–0.7
0.9–1.4
None
None
None
None
25
12
1.5
3
6
0.5–0.8
1.0–1.6
None
None
None
None
30
13
2
3
5
0.3–0.5
0.6–0.8
None
None
None
None
45
14
1
4
7
0.5–0.8
0.8–1.3
None
None
None
None
20
15
1.5
2
4
0.4–0.7
1.1–1.6
None
None
None
None
35 30
16
2þ2
3þ 4
4 þ5
0.3–0.7
0.6–1.5
None
None
None
None
17
1
4
6
0.5–0.6
0.9–1.4
None
None
None
None
NC
18
1.5
2
5
0.3–0.5
0.8–2.1
None
None
None
None
25
19
2
4
8
0.3–0.8
0.5–1.8
None
None
None
None
25
20
1
4
7
0.3–0.6
1.1–1.5
None
None
None
None
20
Average
1.4
3.3
5.4
0.55
1.2
28.2
Abbreviations: LV, lymphatic vessel; NC, Not Completed; SV, subdermal venule. a Calculated for the 17 patients having a complete blue staining resorption.
wearing their elastic stocking and bandage definitively 1 year after surgery. A total of 19 patients (95%) concluded to a better quality of life 1 year after surgery.
Case Reports Case 8 A 69-year-old female presented in our clinic for a postoperative lymphedema of the left upper limb, secondary to an axillary lymphadenectomy 6 years ago. Her lymphedema started 1 year after the lymphadenectomy. Eight end-toside lymphaticovenular anastomoses (four π-shaped) were performed through three skin incisions at the medial and lateral parts of her forearm. The circumferential reduction rate was 28.1%, the cross-sectional area reduction rate was 47.5%, and the average volume reduction rate was 47.3% after a follow-up of 12 months (►Figs. 4 and 5). She stopped lymph drainage by physiotherapists 4 months after surgery. She definitively stopped wearing her compressive elastic stocking and open glove garment 6 months after surgery.
Case 16 A 34-year-old female presented in our clinic for a bilateral congenital lymphedema of the lower limbs since the early
childhood, secondary to a Turner syndrome. Her lymphedema increased at the puberty. She presented a severe deformity of the left foot, associated with a large area of hyperkeratosis and skin fibrosis. She also developed chronic skin ulcers at the inferior part of the legs (►Fig. 6). Eight lymphaticovenular anastomoses were performed (four πshaped) through four skin incisions at each lower limb. The circumferential reduction rate was 17%, the cross-sectional area reduction rate was 32.2%, and the average volume reduction rate was 36.5% after a follow-up of 12 months (►Fig. 7). She definitively stopped wearing her compressive elastic stocking and lymph drainage 8 months after surgery.
Discussion Chronic lymphedema is a public health issue, leading to severe functional troubles in everyday life. Nowadays, medical treatments are not efficient enough to have a stable reduction of a chronic lymphedema in time. Recurrence is usual when compressive therapy and lymph drainage are stopped. That is the reason why lymphaticovenular anastomoses were introduced in view to improve the efficacy and stability of the edema relief. Lymphaticovenular anastomosis derives from lymphaticovenous bypasses described by Journal of Reconstructive Microsurgery
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Patient
π-Shaped Lymphaticovenular Anastomosis
Ayestaray, Bekara
Table 3 Summary of clinical results in patients treated by π-lymphaticovenular anastomosis Patient
mC
mC Reduction
Average mC reduction rate
mCSA
mCSA Reduction
Average mCSA reduction rate
mV
mV Reduction
Average mV reduction rate
(cm)
(cm)
(%)
(cm2)
(cm2)
(%)
(cm3)
(cm3)
(%)
1
31.5
5.3
16.8
82.1
22.3
27.1
1549.1
438.4
28.3
2
27.8
3
10.8
65.3
14.2
21.7
1518.5
343.2
22.6
3
43
10.8
24.6
155.1
67.5
43.5
3087.5
849.1
27.5
4
27.2
1.2
4.4
60.7
5.3
8.7
1272.6
62.3
4.9
5
38.1
1.3
3.5
125.9
8.5
6.7
3092.3
315.4
10.2
6
28
1.8
6.6
65.4
7.8
11.9
1850
179.4
9.7
7
45
3.3
7.8
169.8
22.2
13
3262.5
515.4
15.8
8
35.5
10
28.1
100.3
50
47.5
1640.8
740
45.1
9
49.2
3.5
6.1
207.9
30.6
14.7
3562.5
384.7
10.8
10
29.8
5
16.5
73.1
22.4
30.6
1631.6
396.5
24.3
11
49.5
7.5
14.8
208
59
28.3
3587.5
925.6
25.8
12
35
9.4
27.2
101.9
46.7
45.8
1723.3
797.9
46.3
13
35.5
2.3
6.3
115.9
14.3
12.3
2125.1
265.6
12.5
14
30.5
3.8
12.4
77.4
17.4
22.5
1595
306.2
19.2
15
33.8
5
16.5
98
33.1
33.7
1833.3
632.5
34.5
16
47.5
8.3
17
187.8
60.5
32.2
3425
1230.5
35.9
17
32.6
2.2
6.8
90.9
11.8
12.9
1787.5
262.8
14.7
18
36
3
7.2
114.6
20
17.4
2887.5
470.6
16.3
19
28.6
2.2
7.7
69.3
10.4
15
1521.6
265.8
17.5
20
37.4
9.8
20.5
116.5
51.7
44.4
1888.3
696.7
36.9
Average
36.1
4.9
13.1
114.3
28.8
24.5
2242.1
503.9
22.9
Abbreviations: mC, mean circumference; mCSA, mean cross-sectional area; mV, mean volume.
Fig. 4 Case 8: A 69-year-old female having a postoperative lymphedema of the left upper limb (Campisi clinical stage IV), secondary to an axillary lymphadenectomy 6 years ago. (a) Preoperative view: The hand, the forearm, and the arm were infiltrated by the lymphedema. Skin fibrosis was present at the forearm. The patient had to wear continuously an open glove garment. The mobility of the upper limb was limited by the weight of the edema. (b) Postoperative view: The edema relief was visible at the hand, the forearm, and the arm. The patient stopped wearing her open glove garment. Journal of Reconstructive Microsurgery
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Fig. 5 Case 8: Clinical aspect of the left hand and forearm. (a) Preoperative view: The dorsum of the hand and the fingers were affected by the lymphedema. The forearm and the wrist were also infiltrated. The mobility of the hand was limited, and the sensibility was reduced. (b) Postoperative view: The intermetacarpal spaces were visible and the fingers were thinner. The edema relief was also visible at the wrist and the forearm. A small area of blue staining (< 2 cm) remained at the dorsum of the wrist.
Yamada in 1969.9 The surgical technique was refined by O’Brien et al,10–12 then by Koshima et al who introduced the concept of supermicrosurgery.13,14 The difference of pressure gradient between lymphatic vessels and subdermal venules is sufficient to pump up the lymphatic fluid, when a lymphatic channel is anastomosed to a venule. The drainage is mainly due to the Venturi effect (Pvenule > Plymphatic). The differential pressure gradient between lymphatic vessels and subdermal venules is low, comparing to larger veins.15 Then the rate of thrombosis at the anastomosis site is decreased with supermicrosurgical techniques, comparing to classical lymphaticovenous bypasses.16 π-Shaped lymphaticovenular anastomosis is a double endto-side lymphaticovenular anastomosis, corresponding to a venous flow-sparing technique. This technique was introduced by Japanese supermicrosurgeons.17,18 The distal venous flow is not interrupted with this configuration. As the venous system is mainly involved in lymphatic drainage,3 this method is the configuration to favor when the vascular
Ayestaray, Bekara
Fig. 6 Case 16: A 34-year-old female having a bilateral congenital lymphedema of the lower limbs since the early childhood, secondary to Turner syndrome. Preoperative views (a) left leg: Campisi clinical stage V lymphedema. The foot was masked by the deformity of the soft tissues. An important hyperkeratosis was present at the dorsum of the foot. Chronic dermitis was visible along the leg. (b) Left leg: The soft tissues were affected by an important fibrosis. Trophic ulcers were developed around areas of hyperkeratosis. (c) Right leg: Campisi clinical stage V lymphedema. The deformity was less important than the other side, but fibrosis and hyperkeratosis were severe. A large skin ulcer was visible at the inferior part of the leg.
anatomy makes two end-to-side anastomosis possible. This is also a minimal invasive technique which respects endothelial cells in the venous wall. These endothelial cells are involved in lymphangiogenesis by centrifugal sprouting.4,5 For these reasons, π-shaped lymphaticovenular anastomosis should be favored if the vascular anatomy is suitable as often as possible. The only disadvantage of end-to-side anastomosis is to be a little bit more difficult and longer than end-to-end anastomosis.19 In our clinical series, the average operative time was 45 minutes to perform one end-to-end lymphaticovenular anastomosis, and 55 minutes to perform one endto-side lymphaticovenular anastomosis. In comparison with other clinical series reported in the literature, the outcomes of this series are very encouraging (►Fig. 8). Lambda-shaped lymphaticovenular anastomosis leads to an average cross-sectional area reduction rate of 5.9% (range, 1.9–11.3%).18 One series20 has reported a higher rate of edema reduction without specifying the configuration of anastomosis (35% of volume reduction at 1 year). Other Journal of Reconstructive Microsurgery
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π-Shaped Lymphaticovenular Anastomosis
π-Shaped Lymphaticovenular Anastomosis
Ayestaray, Bekara compare this technique with the other configurations of lymphaticovenular anastomosis.
Conclusions π-Shaped lymphaticovenular anastomosis is an effective method, based on two end-to-side lymphaticovenular anastomosis, to reduce the volume and the severity of peripheral lymphedema. This is the venous flow-sparing technique which does not interrupt the distal venous flow and respects the related endothelial cells. The results of this clinical series demonstrate a clinical efficiency to reduce chronic lymphedema of upper and lower limbs with this supermicrosurgical technique.
Acknowledgement The authors thank Dr. Claire Duflos, MD, from the department of biostatistics of Montpellier University Hospital for the statistical analysis of the data. Fig. 7 Case 16: Postoperative clinical aspect of the lower limbs, 8 months after surgery. (a, b) The edema relief was visible for both legs. The deformity of the lower limbs was improved. The dermitis disappeared. The hyperkeratosis was completely resorbed, but the fibrosis was still present at the dorsum of the left foot. Skin ulcers were completely healed at the lower part of the legs.
Disclosure None. Conflict of Interest None.
References 1 Penha TR, Ijsbrandy C, Hendrix NA, et al. Microsurgical techniques
2
3 4
Fig. 8 Variations of the average volume of lymphedema in patients treated by π-shaped lymphaticovenular anastomosis.
series have reported higher rates of circumferential reduction (47.3% at 2.2 years,13 55.6% at 3.3 years14) but the reduction was calculated on the basis on the circumferential excess length, and not on the preoperative mean circumference. So far, lymphaticovenular anastomoses represent an effective supermicrosurgical method with a low morbidity to treat peripheral lymphedema. They can be easily performed under local anesthesia, but require a high magnification microscope and a supermicrosurgical training. The postoperative recovery is short. Different configurations of lymphaticovenular anastomosis have been described. Nowadays, end-to-end anastomosis remains the most popular.1,20 However, the efficiency of end-to-side lymphaticovenular anastomosis has been demonstrated in this clinical series. Further studies with a longer follow-up of patients should be made to Journal of Reconstructive Microsurgery
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for the treatment of obstructive lymphedema. Plast Reconstr Surg 1990;85(4):562–572 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(6):437–442 Koshima I, Nanba Y, Tsutsui T, Takahashi Y, Itoh S. Long-term follow-up after lymphaticovenular anastomosis for lymphedema in the leg. J Reconstr Microsurg 2003;19(4):209–215 Baumeister RG, Siuda S. Treatment of lymphedemas by microsurgical lymphatic grafting: what is proved? Plast Reconstr Surg 1990;85(1):64–74, discussion 75–76 Nagase T, Gonda K, Inoue K, et al. Treatment of lymphedema with lymphaticovenular anastomoses. Int J Clin Oncol 2005;10(5): 304–310
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