The Recipient Venule in Supermicrosurgical Lymphaticovenular Anastomosis: Flow Dynamic Classification and Correlation with Surgical Outcomes

Giuseppe Visconti; Marzia Salgarello; Akitatsu Hayashi

doi:10.1055/s-0038-1649518

Journal of Reconstructive Microsurgery, Table of Contents

J Reconstr Microsurg 2018; 34(08): 581-589
DOI: 10.1055/s-0038-1649518

Original Article: WSRM 2017 Scientific Paper

Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

The Recipient Venule in Supermicrosurgical Lymphaticovenular Anastomosis: Flow Dynamic Classification and Correlation with Surgical Outcomes

Giuseppe Visconti

¹Centre for Surgical Treatment of Lymphedema, Department of Plastic and Reconstructive Surgery, University Hospital “A. Gemelli,” Università Cattolica del “Sacro Cuore,” Rome, Italy

,

Marzia Salgarello

¹Centre for Surgical Treatment of Lymphedema, Department of Plastic and Reconstructive Surgery, University Hospital “A. Gemelli,” Università Cattolica del “Sacro Cuore,” Rome, Italy

,

Akitatsu Hayashi

²Department of Plastic Surgery, Asahi General Hospital, Chiba, Japan

› Author Affiliations

Abstract

Background Venules have been usually neglected in the literature on lymphaticovenular anastomosis (LVA). The aim of this study was to analyze the flow dynamic of recipient venules in LVA and their impact on the surgical outcomes.

Patients and Methods Data from 128 patients affected by extremity lymphedema, who underwent LVA, were collected in two institutions from August 2014 to May 2016. Recipient venules were classified according to their flow dynamic into backflow, slack, and outlet (BSO classification). Quantitative (lower extremity lymphedema/upper extremity lymphedema index) and qualitative outcomes (needing of compression garment and compression garment class) were evaluated. Chi-square test or Fisher's exact test was used for categorical variables and independent-samples t-test for continuous variables. The association between lymphatic collector degeneration status (normal, ectasis, contractile, sclerotic type [NECST]) and BSO classification with the outcomes was analyzed by the Mantel–Haenszel test.

Results On a total of 128 patients, 37 suffered from upper and 91 from lower limb lymphedema. An average number of four LVA were performed for each patient (range: 2–8). A significant association was observed between NECST and BSO categories and the outcomes were evaluated. Patients with contractile and sclerotic collectors had 2.24 times the odd of having poor composite outcome compared with those with normal-to-ectasis collectors (p < 0.05). Patients with backflow venules had 3.32 times the odd of having poor composite outcome compared with those without outlet or slack pattern (p < 0.05).

Conclusion The subtype of recipient venule flow dynamic has a significant impact on the surgical outcome of patients undergoing LVA for the treatment of lymphedema, regardless of the lymphatic collector degeneration status. Locating favorable venules in the preoperative mapping might enhance the surgical outcomes.

Keywords

lymphovenous bypass - lymphedema - lymphatic surgery - supermicrosurgery - LVA

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References

References
1 Basta MN, Gao LL, Wu LC. Operative treatment of peripheral lymphedema: a systematic meta-analysis of the efficacy and safety of lymphovenous microsurgery and tissue transplantation. Plast Reconstr Surg 2014; 133 (04) 905-913
2 Koshima I, Narushima M, Mihara M. , et al. Lymphadiposal flaps and lymphaticovenular anastomoses for severe leg edema: functional reconstruction for lymph drainage system. J Reconstr Microsurg 2016; 32 (01) 50-55
3 Carl HM, Walia G, Bello R. , et al. Systematic review of the surgical treatment of extremity lymphedema. J Reconstr Microsurg 2017; 33 (06) 412-425
4 Sosin M, Yin C, Poysophon P, Patel KM. Understanding the concepts and physiologic principles of lymphatic microsurgery. J Reconstr Microsurg 2016; 32 (08) 571-579
5 Koshima I, Inagawa K, Urushibara K, Moriguchi T. Supermicrosurgical lymphaticovenular anastomosis for the treatment of lymphedema in the upper extremities. J Reconstr Microsurg 2000; 16 (06) 437-442
6 Chang DW, Suami H, Skoracki R. A prospective analysis of 100 consecutive lymphovenous bypass cases for treatment of extremity lymphedema. Plast Reconstr Surg 2013; 132 (05) 1305-1314
7 Mihara M, Hara H, Tange S. , et al. Multisite lymphaticovenular bypass using supermicrosurgery technique for lymphedema management in lower lymphedema cases. Plast Reconstr Surg 2016; 138 (01) 262-272
8 Winters H, Tielemans HJ, Sprangers PN, Ulrich DJ. Peri-operative care for patients undergoing lymphaticovenular anastomosis: a systematic review. J Plast Reconstr Aesthet Surg 2017; 70 (02) 178-188
9 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 (05) 1979-1986
10 Yamamoto T, Yamamoto N, Hayashi N, Hayashi A, Koshima I. Practicality of the lower extremity lymphedema index: lymphedema index versus volumetry-based evaluations for body-type-corrected lower extremity volume evaluation. Ann Plast Surg 2016; 77 (01) 115-118
11 Yamamoto N, Yamamoto T, Hayashi N, Hayashi A, Iida T, Koshima I. Arm volumetry versus upper extremity lymphedema index: validity of upper extremity lymphedema index for body-type corrected arm volume evaluation. Ann Plast Surg 2016; 76 (06) 697-699
12 RAL-GZ 387 for compression stockings. Deutsches Institut für Gütesicherung und Kennzeichnung Medizinische Kompressionsstrümpfe. Available at: http://www.gzg-kompressionsstruempfe.de/ . Accessed November 20, 2017
13 Yamamoto T, Yamamoto N, Yoshimatsu H, Narushima M, Koshima I. Factors associated with lymphosclerosis: an analysis on 962 lymphatic vessels. Plast Reconstr Surg 2017; 140 (04) 734-741
14 Yamamoto T, Narushima M, Koshima I. Lymphatic vessel diameter in female pelvic cancer-related lower extremity lymphedematous limbs. J Surg Oncol 2018; 117 (06) 1157-1163
15 Mihara M, Hara H, Hayashi Y. , et al. Pathological steps of cancer-related lymphedema: histological changes in the collecting lymphatic vessels after lymphadenectomy. PLoS One 2012; 7 (07) e41126
16 Tugrul M, Camci E, Pembeci K, Al-Darsani A, Telci L. Relationship between peripheral and central venous pressures in different patient positions, catheter sizes, and insertion sites. J Cardiothorac Vasc Anesth 2004; 18 (04) 446-450
17 Yamamoto T, Ishiura R, Kato M. Hands-free vein visualizer for selection of recipient vein with an intact valve in lymphatic supermicrosurgery. J Plast Reconstr Aesthet Surg 2015; 68 (06) 871-873
18 Yang JC, Wu SC, Chiang MH, Lin WC. Targeting reflux-free veins with a vein visualizer to identify the ideal recipient vein preoperatively for optimal lymphaticovenous anastomosis in treating lymphedema. Plast Reconstr Surg 2018; 141 (03) 793-797
19 Visconti G, Yamamoto T, Hayashi N, Hayashi A. Ultrasound-assisted lymphaticovenular anastomosis for the treatment of peripheral lymphedema. Plast Reconstr Surg 2017; 139 (06) 1380e-1381e
20 Hayashi A, Hayashi N, Yoshimatsu H, Yamamoto T. Effective and efficient lymphaticovenular anastomosis using preoperative ultrasound detection technique of lymphatic vessels in lower extremity lymphedema. J Surg Oncol 2018; 117 (02) 290-298