Optimal Sites for Supermicrosurgical Lymphaticovenular Anastomosis: An Analysis of Lymphatic Vessel Detection Rates on 840 Surgical Fields in Lower Extremity Lymphedema Patients
Plastic and Reconstructive Surgery December 2018 – Volume 142 – Issue – p924e-930e
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Optimal Sites for Supermicrosurgical Lymphaticovenular Anastomosis: An Analysis of Lymphatic Vessel Detection Rates on 840 Surgical Fields in Lower Extremity Lymphedema Patients
Plastic and Reconstructive Surgery December 2018 – Volume 142 – Issue – p924e-930e
Background: Supermicrosurgical lymphaticovenular anastomosis is becoming a useful treatment option for progressive lower extremity lymphedema because of its minimal invasiveness. Finding a lymphatic vessel is a minimum requirement for lymphaticovenular anastomosis surgery, but no study has reported comprehensive analysis on factors associated with lymphatic vessel detection.
Methods: One hundred thirty-four female secondary lower extremity lymphedema patients who underwent indocyanine green lymphography and lymphaticovenular anastomosis without a history of lymphedema surgery were included. Medical charts were reviewed to obtain clinical, indocyanine green lymphographic, and intraoperative findings. Lymphatic vessel detection was defined as positive when one or more lymphatic vessels were found in a surgical field of lymphaticovenular anastomosis. Logistic regression analysis was used to identify independent factors associated with lymphatic vessel detection.
Results: Patient age ranged from 36 to 81 years, duration of edema ranged from 3 to 324 months, and body mass index ranged from 16.2 to 33.3 kg/m2. Forty-eight patients (35.8 percent) had a history of radiation therapy, and 76 patients (56.7 percent) had a history of cellulitis. Lymphaticovenular anastomoses were performed in 840 surgical fields, among which lymphatic vessel detection was positive in 807 fields; the overall lymphatic vessel detection rate was 96.1 percent. Multivariate analysis revealed inverse associations in higher body mass index (OR, 0.323; p = 0.008) and the S-region/D-region on indocyanine green lymphography compared with the L-region (OR, 1.049 × 10–8/1.724 × 10–9; p < 0.001/p < 0.001).
Conclusions: Independent factors associated with lymphatic vessel detection were clarified. Lower body mass index and L-region on indocyanine green lymphography are favorable conditions for finding lymphatic vessels in lower extremity lymphedema patients.
Main findings
- Lymphatic vessels are more likely to be found in patients with lower body mass index and in regions where indocyanine green lymphography shows the linear pattern. In this study cohort, lymphatic vessel detection rate was 100 percent in the L-region, which revealed usefulness of indocyanine green lymphography guidance to detect lymphatic vessels in lymphaticovenular anastomosis surgery. This result seems quite natural, because the linear pattern on indocyanine green lymphography represents enhanced collecting lymphatic vessels, where collecting lymphatic vessels suitable for lymphaticovenular anastomosis can be easily found.
- Depth of lymphatic vessels is greater in patients with a higher body mass index than in those with a lower body mass index, which makes it more challenging for a surgeon to find lymphatic vessels. It is recommended for a surgeon with less experience with lymphaticovenular anastomosis to perform lymphaticovenular anastomosis on patients with a lower body mass index and a linear pattern on indocyanine green lymphography.
- L-region, where the linear pattern was shown; S-region, where the splash or stardust pattern was shown; and D-region, where the diffuse pattern was shown on indocyanine green lymphography. Lymphatic vessel conditions were good or acceptable in the L-region or S-region, but not in the D-region.
- Indocyanine green lymphographic findings have been clarified to be an independent lymphatic vessel detection–associated factor with the lowest odds ratios. The overall lymphatic vessel detection rate was 96.1 percent in this study cohort, which seemed high enough for lymphaticovenular anastomosis surgery. According to indocyanine green lymphographic findings, lymphatic vessel detection rates were significantly different: 100 percent in the L-region, 94.9 percent in the S-region, and 73.9 percent in the D-region. It is recommended for lymphatic surgeons to avoid the D-region for lymphaticovenular anastomosis.
