Supermicrosurgery lymphaticovenous and lymphaticolymphatic anastomosis: Technical detail and short-term follow-up for immediate lymphatic reconstruction in breast cancer treatment-related lymphedema prevention

Abstract

Objective: We describe the feasibility and short-term outcome of our surgical technique to repair the lymph vessel disruption directly after axillary lymph node dissection during breast cancer surgery. This procedure is called immediate lymphatic reconstruction to prevent breast cancer treatment-related lymphedema (BCRL), which frequently occurs after axillary lymph node dissection. The surgical technique consisted of lymphaticovenous anastomosis (LVA) or lymphaticolymphatic anastomosis. We named the procedure lymphatic bypass supermicrosurgery (LBS).

Methods: This study used a retrospective cohort design of patients with breast cancer between May 2020 and February 2023. LBS was performed by making an intima-to-intima coaptation between afferent lymph vessels and the recipient's veins (LVA) or efferent lymph vessels lymphaticolymphatic anastomosis.

Results: A total of 82 patients underwent lymphatic bypass. The mean age of patients was 50 ± 12 years, and most had stage III breast cancer (n = 59 [72%]). LVA was the most common type of lymphatic bypass (94.6%). The median number of LVA was 1 (range, 1-4) and 1 (range, 1-3) for lymphaticolymphatic anastomosis. The median follow-up time was 12.5 months (range, 1-33 months). The 50 patients who had postoperative indocyanine green lymphography described arm dermal backflow stage 0 in 20 (40%), stage 1 in 19 (38%), stage 2 in 2 (4%), and stage 3 in 9 (18%) cases. The proportion of BCRL was 11 (22%), and subclinical lymphedema was 19 (38%) in this period. Most cases were in stable subclinical lymphedema (10, 58.8%). The 1-year and 2-year BCRL rates were 14% (95% confidence interval, 4%-23.9%) and 22% (95% confidence interval, 10.1%-33.9%), respectively.

Conclusions: Along with the emerging immediate lymphatic reconstruction, LBS is a feasible supermicrosurgery technique that may have a potential role in BCRL prevention. A randomized controlled study would confirm the effectiveness of the technique.

Keywords: Axillary lymph node dissection; Breast cancer; Immediate lymphatic reconstruction; Lymphedema; Supermicrosurgery.

Fig 1

Indocyanine green (ICG) and axillary lymph node dissection (ALND) procedure. (I) The injection site for ICG: (A) Second and (B) fourth web spaces of the hand and (C) the ulnar border of the palmaris longus tendon at the level of the wrist joint. (II) Incision design for axillary approach, (A) in mastectomy and (B) breast-conserving surgery. (III) Direction and the lower limit of the recipient vein dissection. (A) The distal to proximal dissection of the lateral thoracic vein (red vessel), (B) proximal to distal dissection of the thoracoepigastric vein (green vessel) at the distal part of the axillary space, (C) inframammary line as the lower limit of dissection. (IV) The preserved veins at the end of ALND. CX, circumflex scapular vein; ICG, indocyanine green; LTV, Lateral thoracic vein; TE, thoracoepigastric vein; SV, superficial vein of axillary base; TD, thoracodorsal.

Fig 2

Identification of types of lymphatic vessels, anastomosis, and dermal backflow pattern. (I) Identification of afferent lymphatic vessels with (A) microscope-integrated ICG lymphography and (B) external near-infrared camera. (∗) Afferent lymphatic vessels. (II) Types of anastomosis. (A) End-to-end LVA with small-caliber side branches vein. (B) End-to-side LVA. (C) Funnelization. (D) Buffalo skull shape. (E) Y-Shaped venoplasty. (F) Lymphaticolymphatic anastomosis. (G) Vein graft for lymphaticolymphatic anastomosis (upper) or LVA (lower). (III) Clinical outcomes of the patients. (A) A patient without BCRL showed a linear pattern. (B) Subclinical lymphedema with splash pattern. (C) BCRL patient, which showed a stardust diffuse pattern. BCRL, breast cancer treatment-related lymphedema; ICG, indocyanine green; LVA, lymphaticovenous anastomosis.

Fig 3

Kaplan-Meier curve of the BCRL rate. BCRL, breast cancer treatment-related lymphedema.