Intraoperative Detection of Efferent Lymphatic Vessels Emerging from Lymph Node during Lymphatic Microsurgery

Abstract

Background Although the usefulness of efferent lymphaticovenular anastomosis (ELVA) in lymphatic microsurgery has been reported, the optimal method to distinguish efferent from afferent lymphatics is not yet established. We propose a novel technique to detect efferent lymphatics appropriate for anastomosis.

Methods In total, 62 groin lymph nodes (LNs) of 46 limbs were divided into four groups based on the findings of indocyanine green lymphography: n = 15 in normal, 15 in dermal backflow stage 0, 18 in stage I, and 14 in stage II groups. The target LN and afferent lymphatic connecting it were preoperatively detected using ultrasonography. Intraoperatively, 0.05 mL patent blue dye was slowly manually injected from the afferent lymphatic; the lymphatic(s) subsequently stained was diagnosed as the efferent lymphatic(s) emerging from the node. The success rates of efferent lymphatic detection, sizes of LN, and diameter of efferent lymphatics were compared among the groups.

Results Both LN size and diameter of efferent lymphatic were significantly larger in the stage 0 and I groups than the other groups (p < 0.01). Efferent lymphatic could be stained in 13, 13, 18, and 9 LNs in the normal and stage 0, I, and II groups, respectively. A significant difference was observed between the stage I and II groups regarding the success rate of efferent lymphatic detection (p = 0.04).

Conclusion Efferent lymphatics could be detected using patent blue dye in 85.5% of the cases. The patients in early-stage lymphostasis might be the most appropriate candidates for ELVA.

Keywords

lymphedema - efferent lymphatic - lymphaticovenular anastomosis

Disclosure

None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript.

• References

• 1 Ohtani O, Ohtani Y. Recent developments in morphology of lymphatic vessels and lymph nodes. Ann Vasc Dis 2012; 5 (02) 145-150
• 2 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
• 3 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
• 4 Yamamoto T, Yamamoto N, Yamashita M, Furuya M, Hayashi A, Koshima I. Efferent lymphatic vessel anastomosis: supermicrosurgical efferent lymphatic vessel-to-venous anastomosis for the prophylactic treatment of subclinical lymphedema. Ann Plast Surg 2016; 76 (04) 424-427
• 5 Todokoro T, Furniss D, Oda K. , et al. Effective treatment of pelvic lymphocele by lymphaticovenular anastomosis. Gynecol Oncol 2013; 128 (02) 209-214
• 6 Scaglioni MF, Arvanitakis M, Chen YC, Giovanoli P, Chia-Shen Yang J, Chang EI. Comprehensive review of vascularized lymph node transfers for lymphedema: outcomes and complications. Microsurgery 2018; 38 (02) 222-229
• 7 Chang DW, Masia J, Garza III R, Skoracki R, Neligan PC. Lymphedema: surgical and medical therapy. Plast Reconstr Surg 2016; 138 (3, Suppl): 209S-218S
• 8 Tourani SS, Taylor GI, Ashton MW. Vascularized lymph node transfer: a review of the current evidence. Plast Reconstr Surg 2016; 137 (03) 985-993
• 9 Granzow JW, Soderberg JM, Kaji AH, Dauphine C. Review of current surgical treatments for lymphedema. Ann Surg Oncol 2014; 21 (04) 1195-1201
• 10 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
• 11 Akita S, Mitsukawa N, Kuriyama M. , et al. Comparison of vascularized supraclavicular lymph node transfer and lymphaticovenular anastomosis for advanced stage lower extremity lymphedema. Ann Plast Surg 2015; 74 (05) 573-579
• 12 Yamamoto T, Yoshimatsu H, Yamamoto N. Complete lymph flow reconstruction: A free vascularized lymph node true perforator flap transfer with efferent lymphaticolymphatic anastomosis. J Plast Reconstr Aesthet Surg 2016; 69 (09) 1227-1233
• 13 Akita S, Yamaji Y, Tokumoto H. , et al. Improvement of the efficacy of vascularized lymph node transfer for lower-extremity lymphedema via a prefabricated lympho-venous shunt through lymphaticovenular anastomosis between the efferent lymphatic vessel and small vein in the elevated vascularized lymph node. Microsurgery 2018; 38 (03) 270-277
• 14 Yamamoto T, Matsuda N, Doi K. , et al. The earliest finding of indocyanine green lymphography in asymptomatic limbs of lower extremity lymphedema patients secondary to cancer treatment: the modified dermal backflow stage and concept of subclinical lymphedema. Plast Reconstr Surg 2011; 128 (04) 314e-321e
• 15 Akita S, Tokumoto H, Yamaji Y. , et al. Contribution of simultaneous breast reconstruction by deep inferior epigastric artery perforator flap to the efficacy of vascularized lymph node transfer in patients with breast cancer-related lymphedema. J Reconstr Microsurg 2017; 33 (08) 571-578
• 16 Dayan JH, Dayan E, Smith ML. Reverse lymphatic mapping: a new technique for maximizing safety in vascularized lymph node transfer. Plast Reconstr Surg 2015; 135 (01) 277-285
• 17 Yamamoto T, Yamamoto N, Hara H, Mihara M, Narushima M, Koshima I. Upper extremity lymphedema index: a simple method for severity evaluation of upper extremity lymphedema. Ann Plast Surg 2013; 70 (01) 47-49
• 18 Yamamoto T, Matsuda N, Todokoro T. , et al. Lower extremity lymphedema index: a simple method for severity evaluation of lower extremity lymphedema. Ann Plast Surg 2011; 67 (06) 637-640
• 19 Akita S, Mitsukawa N, Kuriyama M. , et al. External valvuloplasty for subcutaneous small veins to prevent venous reflux in lymphaticovenular anastomosis for lower extremity lymphedema. Plast Reconstr Surg 2013; 132 (04) 1008-1014
• 20 Akita S, Mitsukawa N, Kuriyama M. , et al. Suitable therapy options for sub-clinical and early-stage lymphoedema patients. J Plast Reconstr Aesthet Surg 2014; 67 (04) 520-525