Efficacy and patient satisfaction regarding lymphovenous bypass with sleeve-in anastomosis for extremity lymphedema

Abstract

Background: When performing lymphovenous anastomosis, it is sometimes difficult to find venules in the proximity of an ideal lymphatic vessel that have a similar diameter to that of the lymphatic vessel. In this situation, larger venules can be used.

Methods: The authors evaluated the efficacy of and patient satisfaction with lymphovenous bypass with sleeve-in anastomosis. Between January 2014 and December 2016, we performed this procedure in 18 patients (eight upper extremities and 10 lower extremities) with secondary lymphedema. Lymphovenous bypass with sleeve-in anastomosis was performed under microscopy after injecting indocyanine green dye. The circumferential diameter was measured before lymphovenous bypass and at 1, 2, and 6 months after the procedure. An outcomes survey that included patients' qualitative satisfaction with lymphovenous bypass was conducted at 6 months postoperatively.

Results: Almost all patients showed quantitative improvements after surgery. The circumferential reduction rate in patients with stage II lymphedema of both the upper and lower extremities was significantly greater than in their counterparts with stage III/IV lymphedema. The circumferential reduction rate was lower in lower-extremity patients than in upper-extremity patients.

Conclusions: Lymphovenous bypass surgery with sleeve-in anastomosis in lymphedema patients is beneficial, and appears to be effective, when adequately-sized venules cannot be found in the proximity of an ideal lymphatic vessel.

Keywords: Lower extremity; Lymphedema; Microsurgery; Upper extremity.

Fig. 1.. Schematic image of the anastomosis technique

A lymphatic vessel with the surrounding adventitia was tucked into the venule by about 0.2 to 0.3 mm and anchored to the wall of the venule using the pull-out suture technique.

Fig. 2.. Intraoperative photo of lymphovenous anastomosis

Sleeve-in anastomosis between a lymphatic vessel and venule. The larger-caliber vessel is the venule. The black arrow indicates the anastomosis site.

Fig. 3.. Circumferential reduction rates

Circumferential reduction rates of upper- and lower-extremity lymphedema patients at 1, 2, and 6 months after lymphovenous bypass.

Fig. 4.. Patient survey responses

Note that the question labels (Q1–Q8) correlate with the questions in Table 2.

Fig. 5.. Case 1

A 55-year-old woman with stage II lymphedema of the left leg for 3 years. The patient underwent lymphovenous bypass on the anterior aspect of the ankle and popliteal area. (A) Preoperative photography. (B) Six months after surgery. A postoperative decrease in circumference was noted in the left leg.

Fig. 6.. Case 2

A 61-year-old woman with stage III lymphedema of the left leg. The edema had continued for 1.5 years, during which time she had worn elastic stockings continuously. Three lymphovenous anastomoses were performed. (A) Preoperative photography taken using an indocyanine green dye detection camera. (B) Preoperative photography. (C) Six months after surgery.

Fig. 7.. Case 3

A 59-year-old woman with stage III left arm lymphedema for a duration of 7 years following left mastectomy and lymph node dissection. She rarely used elastic stockings during this period. Two lymphovenous anastomoses were performed at the anterior aspect of the elbow. (A) Preoperative photography. (B) Two months after surgery. (C) Six months after surgery.