RESEARCH
The Guide Wire Method A New Technique for Easier Side-to-End Lymphaticovenular Anastomosis Hidehiko Yoshimatsu, MD, Takumi Yamamoto, MD, Mitsunaga Narushima, MD, Takuya Iida, MD, and Isao Koshima, MD Abstract: Lymphaticovenular anastomosis has become one of the treatment options for lymphedema. Among several types of anastomosis, side-to-end anastomosis in which a window is made on the wall of a lymphatic vessel is considered to be the most effective, because it creates bidirectional bypasses through 1 anastomosis. However, making a side-to-end anastomosis with a small lymphatic vessel and a venule can be technically challenging. We developed a new technique using an intravascular stenting that significantly facilitates the procedure. Key Words: lymphedema, lymphaticovenular anastomosis, intravascular stenting, side-to-end anastomosis (Ann Plast Surg 2014;73: 231Y233)
M
anagement of lymphedema is difficult due to lack of understanding of its physiology and evaluation. Conservative treatments including compression therapy have been the mainstay of its management, but a surgical approach has been postulated to have the potential to become the treatment of choice, especially in cases refractory to conservative treatments.1Y9 In lymphaticovenular anastomosis (LVA), a lymphatic vessel is anastomosed to a venule to bypass an obstructed region of the lymphatic flow. Among several types of anastomosis, side-to-end (S-E) anastomosis, in which a window is made on the wall of a lymphatic vessel, is considered to be the most effective, because it creates bidirectional bypasses in one anastomosis.6,8 Although end-to-end anastomosis between vessels with small diameters can be greatly facilitated using intravascular stenting (IVaS) method, S-E anastomosis still remains a great challenge for many microsurgeons.10 To address this difficulty, we developed a new technique that can significantly facilitate the procedure. This study was aimed at reporting a new anastomotic technique in LVA, and assessment of its feasibility.
MATERIALS AND METHODS A new LVA method, the guide wire method, was adopted for S-E LVA. Under the University of Tokyo Hospital institutional review boardYapproved protocol, we performed S-E LVAs using the guide wire method on 6 patients with secondary lower extremity lymphedema (LEL). All patients included in this study received
Received July 9, 2012, and accepted for publication, after revision, September 28, 2012. From the Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan. Conflicts of interest and sources of funding: none declared. Reprints: Hidehiko Yoshimatsu, MD, Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan. E-mail: [email protected]. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.annalsplasticsurgery.com). Copyright * 2013 by Lippincott Williams & Wilkins ISSN: 0148-7043/14/7302-0231 DOI: 10.1097/SAP.0b013e318276d99a
Annals of Plastic Surgery
& Volume 73, Number 2, August 2014
compression therapy using elastic stockings, and experienced progressive lymphedema refractory to conservative therapy. Patients’ ages ranged from 57 to 79 years (average, 67.5 years), and body mass index ranged from 19 to 28 kg/m2 (average, 23.2 kg/m2). Indocyanine green (ICG) lymphography was performed preoperatively to determine the pathophysiological severity stage based on the leg dermal backflow (LDB) stage (Table 1).11Y16 Feasibility and intraoperative patency of the method, and postoperative volume reduction were evaluated 6 months and 1 year after the operation. Treatment efficacy in each case was analyzed using LEL index, which gives an absolute value reflecting the state of lymphedema, including correction considering different body types.17,18 The LEL index was calculated using the following equation (C1, circumference at 10 cm above the superior border of the patella; C2, at the superior border of the patella; C3, at 10 cm below the superior border of the patella; C4, at the lateral malleolus; and C5, at the dorsum of the foot)17: LEL index ¼ ð C 21 þ C 22 þ C 23 þ C 24 þ C 25 Þ = BMI:
A lymphatic vessel and a venule are identified and dissected for anastomosis. The venule is transected, leaving the proximal end long enough for anastomosis. In LVA, you should always choose a venule with a valve to prevent back flow of the venous blood into the lymphatic (Fig. 1A). Next, with microscissors, a small window is made on the sidewall of the lymphatic vessel (Fig. 1B). Lymphatic outflow from the window can be observed if the vessel is a functional lymphatic vessel. A piece of nylon suture, or an IVaS, is inserted from this window into the lumen of the lymphatic vessel (Fig. 1C). Unlike previous methods, once the tip of the nylon suture is inserted through the opening, further insertion along the vessel is very smooth, resembling insertion of a guide wire into the blood vessel. After the IVaS is completely inserted into the lymphatic vessel, the IVaS is slid back along the lumen. The edge of the window can clearly be seen due to the color contrast between the blue IVaS and the lymphatic wall. The anastomosis procedure, especially insertion of the needle, is significantly facilitated because the IVaS keeps the lumen open (Fig. 1D). The last suture is left untied for removal of the IVaS. The IVaS is smoothly pulled out along the lymphatic vessel (Fig. 1E), and the suture is tied to complete the anastomosis (Fig. 1F). Patency and efficacy of the anastomosis are confirmed by the flow of lymphatic fluid into the venule.
RESULTS In the preoperative ICG lymphography, 1 limb was in LDB stage I, 3 were in LDB stage III, and 2 limbs were in LDB stage IV. Seven S-E anastomoses were made using the guide wire method on 6 lymphedematous limbs. No difficulties were experienced in any of the anastomoses, and good patency was confirmed in all anastomoses (see Video, Supplemental Digital Content 1, at http://links.lww.com/SAP/A68 which shows S-E LVA using the guide wire method). No lymph or blood leakage from the anastomosis site was observed in any of the procedures. One patient did not show up for the follow-up appointment 1 year after the operation. Postoperative LEL indices decreased www.annalsplasticsurgery.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
231
Annals of Plastic Surgery
Yoshimatsu et al
& Volume 73, Number 2, August 2014
TABLE 1. LDB Stage Based on DB Patterns of ICG Lymphography Stage 0 Stage I Stage II Stage III Stage IV Stage V
No dermal backflow pattern Splash pattern around the groin region Stardust pattern extended proximal to the superior border of the patella Stardust pattern extended distal to the superior border of the patella Stardust pattern extended to the whole limb Presence of diffuse pattern with stardust pattern in the background
DB indicates dermal backflow.
in all limbs after the operation, indicating edematous volume reduction after S-E LVA using the guide wire method (Table 2).
DISCUSSION Lymphaticovenular anastomosis is becoming the treatment of choice for lymphedema refractory to conservative treatments.1Y9 In LVA, Yamamoto et al8 have reported that making bypasses with not only the distal end of a lymphatic vessel but also the proximal end would lead to a better prognosis. This is because retrograde proximalto-distal lymph flow is often observed in lymphedema patients, probably the result of impaired valves in the lymphatic vessel. Yamamoto et al8 introduced lambda anastomosis to make bidirectional bypasses in which a window is created on the sidewall of the venule. However, lambda anastomosis entails 2 anastomoses, requiring more time. In an S-E anastomosis, in which a window is created on the sidewall of the lymphatic vessel, 2 bypasses of lymphatic fluid are made in one anastomosis. Thus, S-E anastomosis is considered to be the most efficient type of anastomosis in LVA, although the procedure’s technical difficulty has been a high hurdle for many microsurgeons.8,19Y22 In 2008, Narushima et al10 introduced the IVaS method, in which a part of the nylon suture is inserted into small vessels to facilitate end-to-end anastomosis. The original IVaS method was used only in end-to-end anastomosis. With the IVaS method, the most difficult step is insertion of the IVaS into the lumen of the vessel; the tip of the IVaS often gets caught in the intima of the vessel. Even after successful insertion of the IVaS, it is difficult to keep the IVaS in place during the first suture.
In the guide wire method, the insertion of IVaS is smooth; the tip is guided through the lumen, as in insertion of a guide wire in to the blood vessel. After insertion, the IVaS stays inside the vessel without any special techniques. It keeps the lumen of the lymphatic vessel open, which often collapses after window creation. The anastomosis itself is facilitated to a great extent. The edge of the window made on the sidewall of the vessel can clearly be identified due to the color contrast between the IVaS and the vessel wall. This helps identification of the insertion site of the needle. The window is kept open with the IVaS in the lumen, decreasing the possibility of catching on the other side of the window when placing sutures. An insertion of the IVaS into the venule will not be necessary at anytime during the anastomosis. The wall of the venule used in E-S is thicker than that of the lymphatic vessel; identification of the lumen of the venule is not difficult. Another great advantage of the guide wire method is that it makes identification of the lymphatic vessels much easier. One of the most difficult tasks in LVA is identification of functional lymphatic vessels. In the guide wire method, you first make a small window on the sidewall of a vessel, whether it is a lymphatic vessel, a venule, or even a nerve. If a window is made on a functional lymphatic vessel, lymphatic fluid can be observed flowing out from the window (see Video, Supplemental Digital Content 1, at http://links.lww.com/SAP/A68). This can be a significant help in identifying lymphatic vessels suitable for LVA, especially for surgeons with less lymphatic surgery experience. One of the drawbacks of this method is the technical difficulty accompanying the creation of the window. Window creation is
FIGURE 1. Photographs from an actual end-to-side anastomosis using the guide wire method. A 0.65-mm lymphatic vessel and a 0.35-mm venule are identified and dissected for anastomosis (A). Creation of a window on the lymphatic vessel (B). IVaS inserted halfway through the window (C). Insertion of the needle is significantly facilitated because the IVaS keeps the lumen open (D). Removal of the IVaS from the lymphatic vessel (E). The last suture was left untied for the removal. Completion of the end-to-side anastomosis (F). Patency can be confirmed by the flow of the lymphatic fluid into the venule. 232
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* 2013 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Annals of Plastic Surgery
& Volume 73, Number 2, August 2014
The Guide Wire Method for Lymphedema Treatment
TABLE 2. Six S-E LVAs Using the Guide Wire Method on 6 Limbs of Secondary LEL Patients EL Index
1 2 3 4 5 6
Age, y
LDB Stage
No. S-E LVAs (Site)
Before LVA
PO 6 mo
PO 1 y
79 70 63 73 57 63
I III III IV IV III
1 (groin) 2 (ankle) 1 (ankle) 1 (groin) 1 (ankle) 1 (ankle)
182 291 341 387 304 365
172 275 275 266 289 271
176 V* 282 260 266 279
*The patient did not show up for the PO 1 year follow-up.
especially difficult in cases where severe fibrosis and sclerosis of lymphatic vessels are seen. In such cases, end-to-end anastomosis is recommended. Although this study revealed short-term volume-reducing effect of the guide wire method 1 year after the operation, long-term treatment effect is yet to be clarified. Patency of the anastomosis sites should be evaluated using indocyanine green lymphography, because lymphovenous operations entail a risk of thrombosis at the anastomosis sites.19,22,23 However, reduction of LEL indices 1 year after the operation infers intact patency of the bypassed lymphatics. Further studies are necessary to evaluate long-term patency and volume reduction after LVA using the guide wire method.
CONCLUSIONS The guide wire method facilitates S-E LVA via smooth insertion and removal of IVaS, resulting in efficient lymphedema treatment. REFERENCES 1. Yamada Y. Studies on lymphatico-venous anastomoses in lymphedema. Nagoya J Med. 1969;32:1Y21. 2. Koshima I, Inagawa K, Urushibara K, et al. Supermicrosurgical lymphaticovenular anastomosis for the treatment of lymphedema in the upper extremities. J Reconstr Microsurg. 2000;16:432Y437. 3. Koshima I, Nanba Y, Tsutsui T, et al. Long-term follow-up after lymphaticovenular anastomosis for lymphedema in the leg. J Reconstr Microsurg. 2003;19:209Y215. 4. Koshima I, Nanba Y, Tsutsui T, et al. Minimal invasive lymphaticovenular anastomosis under local anesthesia for leg lymphedema: is it effective for stage III and IV? Ann Plast Surg. 2004;53:261Y266. 5. Nagase T, Gonda K, Inoue K, et al. Treatment of lymphedema with lymphaticovenular anastomoses. Int J Clin Oncol. 2005;10:304Y310. 6. Narushima M, Mihara M, Yamamoto Y, et al. The intravascular stenting method for treatment of extremity lymphedema with multiconfiguration lymphaticovenous anastomoses. Plast Reconstr Surg. 2010;125:935Y943. 7. Chang DW. Lymphaticovenular bypass for lymphedema management in breast cancer patients: a prospective study. Plast Reconstr Surg. 2010;126:752Y758. 8. 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;127:1987Y1992. 9. Yamamoto T, Koshima I, Yoshimatsu H, et al. Simultaneous multi-site lymphaticovenular anastomoses for primary lower extremity and genital
* 2013 Lippincott Williams & Wilkins
10. 11.
12.
13.
14. 15. 16. 17. 18. 19. 20.
21. 22. 23.
lymphoedema complicated with severe lymphorrhea. J Plast Reconstr Aesthet Surg. 2011;64:812Y815. Narushima M, Koshima I, Mihara M, et al. Intravascular stenting (IVaS) for safe and precise supermicrosurgery. Ann Plast Surg. 2008;60:41Y44. Yamamoto T, Narushima M, Doi K, et al. Characteristic indocyanine green lymphography findings in lower extremity lymphedema: the generation of a novel lymphedema severity staging system using dermal backflow patterns. Plast Reconstr Surg. 2011;127:1979Y1986. Yamamoto T, Matsuda N, Doi K, et al. The earliest finding of indocyanine green (ICG) lymphography in asymptomatic limbs of lower extremity lymphedema patients secondary to cancer treatment: the modified dermal backflow (DB) stage and concept of subclinical lymphedema. Plast Reconstr Surg. 2011;128:314eY321e. Yamamoto T, Yamamoto N, Doi K, et al. Indocyanine green (ICG)-enhanced lymphography for upper extremity lymphedema: a novel severity staging system using dermal backflow (DB) patterns. Plast Reconstr Surg. 2011;128: 941Y947. Yamamoto T, Iida T, Matsuda N, et al. Indocyanine green (ICG)-enhanced lymphography for evaluation of facial lymphoedema. J Plast Reconstr Aesthet Surg. 2011;64:1541Y1544. Yamamoto T, Yamamoto N, Yoshimatsu H, et al. LEC score: a judgment tool for indication of indocyanine green lymphography. Ann Plast Surg. 2013;70: 227Y230. Yamamoto T, Narushima M, Yoshimatsu H, et al. Indocyanine green velocity: lymph transportation capacity deterioration with progression of lymphedema. Ann Plast Surg. 2013;71:591Y594. Yamamoto T, Matsuda N, Todokoro T, et al. Lower extremity lymphedema (LEL) index: a simple method for severity evaluation of lower extremity lymphedema. Ann Plast Surg. 2011;67:637Y640. Yamamoto T, Yamamoto N, Hara H, et al. Upper extremity lymphedema (UEL) index: a simple method for severity evaluation of upper extremity lymphedema. Ann Plast Surg. 2013;70:47Y49. Yamamoto T, Yoshimatsu H, Narushima M, et al. Split intravascular stents for side-to-end lymphaticovenular anastomosis. Ann Plast Surg. 2013;71: 538Y540. Yamamoto T, Narushima M, Yoshimatsu H, et al. Minimally invasive lymphatic supermicrosurgery (MILS): indocyanine green-guided simultaneous multi-site lymphaticovenular anastomoses via millimeter skin incisions. Ann Plast Surg. 2011;64:812Y815. Yamamoto T, Yoshimatsu H, Narushima M, et al. A modified side-to-end lymphaticovenular anastomosis. Microsurgery. 2013;33:130Y133. Yamamoto T, Yoshimatsu H, Narushima M, et al. Sequential anastomosis for lymphatic supermicrosurgery: multiple lymphaticovenular anastomoses on one venule. Ann Plast Surg. 2014;73:46Y49. Maegawa J, Mikami T, Yamamoto Y, et al. Outcomes of lymphaticovenous side-to-end anastomoses in peripheral lymphedema. J Vasc Surg. 2012; 55:753Y760.
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Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
233
The Guide Wire Method A New Technique for Easier Side-to-End Lymphaticovenular Anastomosis Hidehiko Yoshimatsu, MD, Takumi Yamamoto, MD, Mitsunaga Narushima, MD, Takuya Iida, MD, and Isao Koshima, MD Abstract: Lymphaticovenular anastomosis has become one of the treatment options for lymphedema. Among several types of anastomosis, side-to-end anastomosis in which a window is made on the wall of a lymphatic vessel is considered to be the most effective, because it creates bidirectional bypasses through 1 anastomosis. However, making a side-to-end anastomosis with a small lymphatic vessel and a venule can be technically challenging. We developed a new technique using an intravascular stenting that significantly facilitates the procedure. Key Words: lymphedema, lymphaticovenular anastomosis, intravascular stenting, side-to-end anastomosis (Ann Plast Surg 2014;73: 231Y233)
M
anagement of lymphedema is difficult due to lack of understanding of its physiology and evaluation. Conservative treatments including compression therapy have been the mainstay of its management, but a surgical approach has been postulated to have the potential to become the treatment of choice, especially in cases refractory to conservative treatments.1Y9 In lymphaticovenular anastomosis (LVA), a lymphatic vessel is anastomosed to a venule to bypass an obstructed region of the lymphatic flow. Among several types of anastomosis, side-to-end (S-E) anastomosis, in which a window is made on the wall of a lymphatic vessel, is considered to be the most effective, because it creates bidirectional bypasses in one anastomosis.6,8 Although end-to-end anastomosis between vessels with small diameters can be greatly facilitated using intravascular stenting (IVaS) method, S-E anastomosis still remains a great challenge for many microsurgeons.10 To address this difficulty, we developed a new technique that can significantly facilitate the procedure. This study was aimed at reporting a new anastomotic technique in LVA, and assessment of its feasibility.
MATERIALS AND METHODS A new LVA method, the guide wire method, was adopted for S-E LVA. Under the University of Tokyo Hospital institutional review boardYapproved protocol, we performed S-E LVAs using the guide wire method on 6 patients with secondary lower extremity lymphedema (LEL). All patients included in this study received
Received July 9, 2012, and accepted for publication, after revision, September 28, 2012. From the Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan. Conflicts of interest and sources of funding: none declared. Reprints: Hidehiko Yoshimatsu, MD, Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan. E-mail: [email protected]. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.annalsplasticsurgery.com). Copyright * 2013 by Lippincott Williams & Wilkins ISSN: 0148-7043/14/7302-0231 DOI: 10.1097/SAP.0b013e318276d99a
Annals of Plastic Surgery
& Volume 73, Number 2, August 2014
compression therapy using elastic stockings, and experienced progressive lymphedema refractory to conservative therapy. Patients’ ages ranged from 57 to 79 years (average, 67.5 years), and body mass index ranged from 19 to 28 kg/m2 (average, 23.2 kg/m2). Indocyanine green (ICG) lymphography was performed preoperatively to determine the pathophysiological severity stage based on the leg dermal backflow (LDB) stage (Table 1).11Y16 Feasibility and intraoperative patency of the method, and postoperative volume reduction were evaluated 6 months and 1 year after the operation. Treatment efficacy in each case was analyzed using LEL index, which gives an absolute value reflecting the state of lymphedema, including correction considering different body types.17,18 The LEL index was calculated using the following equation (C1, circumference at 10 cm above the superior border of the patella; C2, at the superior border of the patella; C3, at 10 cm below the superior border of the patella; C4, at the lateral malleolus; and C5, at the dorsum of the foot)17: LEL index ¼ ð C 21 þ C 22 þ C 23 þ C 24 þ C 25 Þ = BMI:
A lymphatic vessel and a venule are identified and dissected for anastomosis. The venule is transected, leaving the proximal end long enough for anastomosis. In LVA, you should always choose a venule with a valve to prevent back flow of the venous blood into the lymphatic (Fig. 1A). Next, with microscissors, a small window is made on the sidewall of the lymphatic vessel (Fig. 1B). Lymphatic outflow from the window can be observed if the vessel is a functional lymphatic vessel. A piece of nylon suture, or an IVaS, is inserted from this window into the lumen of the lymphatic vessel (Fig. 1C). Unlike previous methods, once the tip of the nylon suture is inserted through the opening, further insertion along the vessel is very smooth, resembling insertion of a guide wire into the blood vessel. After the IVaS is completely inserted into the lymphatic vessel, the IVaS is slid back along the lumen. The edge of the window can clearly be seen due to the color contrast between the blue IVaS and the lymphatic wall. The anastomosis procedure, especially insertion of the needle, is significantly facilitated because the IVaS keeps the lumen open (Fig. 1D). The last suture is left untied for removal of the IVaS. The IVaS is smoothly pulled out along the lymphatic vessel (Fig. 1E), and the suture is tied to complete the anastomosis (Fig. 1F). Patency and efficacy of the anastomosis are confirmed by the flow of lymphatic fluid into the venule.
RESULTS In the preoperative ICG lymphography, 1 limb was in LDB stage I, 3 were in LDB stage III, and 2 limbs were in LDB stage IV. Seven S-E anastomoses were made using the guide wire method on 6 lymphedematous limbs. No difficulties were experienced in any of the anastomoses, and good patency was confirmed in all anastomoses (see Video, Supplemental Digital Content 1, at http://links.lww.com/SAP/A68 which shows S-E LVA using the guide wire method). No lymph or blood leakage from the anastomosis site was observed in any of the procedures. One patient did not show up for the follow-up appointment 1 year after the operation. Postoperative LEL indices decreased www.annalsplasticsurgery.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
231
Annals of Plastic Surgery
Yoshimatsu et al
& Volume 73, Number 2, August 2014
TABLE 1. LDB Stage Based on DB Patterns of ICG Lymphography Stage 0 Stage I Stage II Stage III Stage IV Stage V
No dermal backflow pattern Splash pattern around the groin region Stardust pattern extended proximal to the superior border of the patella Stardust pattern extended distal to the superior border of the patella Stardust pattern extended to the whole limb Presence of diffuse pattern with stardust pattern in the background
DB indicates dermal backflow.
in all limbs after the operation, indicating edematous volume reduction after S-E LVA using the guide wire method (Table 2).
DISCUSSION Lymphaticovenular anastomosis is becoming the treatment of choice for lymphedema refractory to conservative treatments.1Y9 In LVA, Yamamoto et al8 have reported that making bypasses with not only the distal end of a lymphatic vessel but also the proximal end would lead to a better prognosis. This is because retrograde proximalto-distal lymph flow is often observed in lymphedema patients, probably the result of impaired valves in the lymphatic vessel. Yamamoto et al8 introduced lambda anastomosis to make bidirectional bypasses in which a window is created on the sidewall of the venule. However, lambda anastomosis entails 2 anastomoses, requiring more time. In an S-E anastomosis, in which a window is created on the sidewall of the lymphatic vessel, 2 bypasses of lymphatic fluid are made in one anastomosis. Thus, S-E anastomosis is considered to be the most efficient type of anastomosis in LVA, although the procedure’s technical difficulty has been a high hurdle for many microsurgeons.8,19Y22 In 2008, Narushima et al10 introduced the IVaS method, in which a part of the nylon suture is inserted into small vessels to facilitate end-to-end anastomosis. The original IVaS method was used only in end-to-end anastomosis. With the IVaS method, the most difficult step is insertion of the IVaS into the lumen of the vessel; the tip of the IVaS often gets caught in the intima of the vessel. Even after successful insertion of the IVaS, it is difficult to keep the IVaS in place during the first suture.
In the guide wire method, the insertion of IVaS is smooth; the tip is guided through the lumen, as in insertion of a guide wire in to the blood vessel. After insertion, the IVaS stays inside the vessel without any special techniques. It keeps the lumen of the lymphatic vessel open, which often collapses after window creation. The anastomosis itself is facilitated to a great extent. The edge of the window made on the sidewall of the vessel can clearly be identified due to the color contrast between the IVaS and the vessel wall. This helps identification of the insertion site of the needle. The window is kept open with the IVaS in the lumen, decreasing the possibility of catching on the other side of the window when placing sutures. An insertion of the IVaS into the venule will not be necessary at anytime during the anastomosis. The wall of the venule used in E-S is thicker than that of the lymphatic vessel; identification of the lumen of the venule is not difficult. Another great advantage of the guide wire method is that it makes identification of the lymphatic vessels much easier. One of the most difficult tasks in LVA is identification of functional lymphatic vessels. In the guide wire method, you first make a small window on the sidewall of a vessel, whether it is a lymphatic vessel, a venule, or even a nerve. If a window is made on a functional lymphatic vessel, lymphatic fluid can be observed flowing out from the window (see Video, Supplemental Digital Content 1, at http://links.lww.com/SAP/A68). This can be a significant help in identifying lymphatic vessels suitable for LVA, especially for surgeons with less lymphatic surgery experience. One of the drawbacks of this method is the technical difficulty accompanying the creation of the window. Window creation is
FIGURE 1. Photographs from an actual end-to-side anastomosis using the guide wire method. A 0.65-mm lymphatic vessel and a 0.35-mm venule are identified and dissected for anastomosis (A). Creation of a window on the lymphatic vessel (B). IVaS inserted halfway through the window (C). Insertion of the needle is significantly facilitated because the IVaS keeps the lumen open (D). Removal of the IVaS from the lymphatic vessel (E). The last suture was left untied for the removal. Completion of the end-to-side anastomosis (F). Patency can be confirmed by the flow of the lymphatic fluid into the venule. 232
www.annalsplasticsurgery.com
* 2013 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Annals of Plastic Surgery
& Volume 73, Number 2, August 2014
The Guide Wire Method for Lymphedema Treatment
TABLE 2. Six S-E LVAs Using the Guide Wire Method on 6 Limbs of Secondary LEL Patients EL Index
1 2 3 4 5 6
Age, y
LDB Stage
No. S-E LVAs (Site)
Before LVA
PO 6 mo
PO 1 y
79 70 63 73 57 63
I III III IV IV III
1 (groin) 2 (ankle) 1 (ankle) 1 (groin) 1 (ankle) 1 (ankle)
182 291 341 387 304 365
172 275 275 266 289 271
176 V* 282 260 266 279
*The patient did not show up for the PO 1 year follow-up.
especially difficult in cases where severe fibrosis and sclerosis of lymphatic vessels are seen. In such cases, end-to-end anastomosis is recommended. Although this study revealed short-term volume-reducing effect of the guide wire method 1 year after the operation, long-term treatment effect is yet to be clarified. Patency of the anastomosis sites should be evaluated using indocyanine green lymphography, because lymphovenous operations entail a risk of thrombosis at the anastomosis sites.19,22,23 However, reduction of LEL indices 1 year after the operation infers intact patency of the bypassed lymphatics. Further studies are necessary to evaluate long-term patency and volume reduction after LVA using the guide wire method.
CONCLUSIONS The guide wire method facilitates S-E LVA via smooth insertion and removal of IVaS, resulting in efficient lymphedema treatment. REFERENCES 1. Yamada Y. Studies on lymphatico-venous anastomoses in lymphedema. Nagoya J Med. 1969;32:1Y21. 2. Koshima I, Inagawa K, Urushibara K, et al. Supermicrosurgical lymphaticovenular anastomosis for the treatment of lymphedema in the upper extremities. J Reconstr Microsurg. 2000;16:432Y437. 3. Koshima I, Nanba Y, Tsutsui T, et al. Long-term follow-up after lymphaticovenular anastomosis for lymphedema in the leg. J Reconstr Microsurg. 2003;19:209Y215. 4. Koshima I, Nanba Y, Tsutsui T, et al. Minimal invasive lymphaticovenular anastomosis under local anesthesia for leg lymphedema: is it effective for stage III and IV? Ann Plast Surg. 2004;53:261Y266. 5. Nagase T, Gonda K, Inoue K, et al. Treatment of lymphedema with lymphaticovenular anastomoses. Int J Clin Oncol. 2005;10:304Y310. 6. Narushima M, Mihara M, Yamamoto Y, et al. The intravascular stenting method for treatment of extremity lymphedema with multiconfiguration lymphaticovenous anastomoses. Plast Reconstr Surg. 2010;125:935Y943. 7. Chang DW. Lymphaticovenular bypass for lymphedema management in breast cancer patients: a prospective study. Plast Reconstr Surg. 2010;126:752Y758. 8. 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;127:1987Y1992. 9. Yamamoto T, Koshima I, Yoshimatsu H, et al. Simultaneous multi-site lymphaticovenular anastomoses for primary lower extremity and genital
* 2013 Lippincott Williams & Wilkins
10. 11.
12.
13.
14. 15. 16. 17. 18. 19. 20.
21. 22. 23.
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