From the Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan.
Ann Plast Surg. 2022 May 1;88(5):524-532. doi: 10.1097/SAP.0000000000003023. Epub 2021 Oct 8.
Lymphovenous anastomosis (LVA) has become an increasingly common treatment for patients with extremity lymphedema. In this article, we present our current strategy for patient selection, preoperative planning, and a series of intraoperative clues that may help to perform a supermicrosurgical LVA. Technical considerations are presented using a systematic step-by-step method to make this procedure more reproducible and straightforward.
We conducted a review of patients operated between January 2015 and June 2018 using the aforementioned approach. Data were collected prospectively, and all procedures were performed by the senior author. Preoperative assessment included lymphoscintigraphy, indocyanine green lymphography, noncontrast magnetic resonance lymphography and high-frequency ultrasonography. Lymphovenous anastomosis was decomposed into a sequential 6-step approach considering the main aspects that determine a successful anastomosis.
Lymphovenous anastomosis was performed in 229 patients, including 677 anastomoses. Median follow-up was 33 months (range, 13-51 months). A median of 3.1 (range, 1-7) LVA were performed on 2.7 (range, 1-6) incision sites per patient. Median time for dissection of lymphatic(s) and vein(s) was 8.7 minutes (1-18 minutes) with a median time of 27.2 minutes (range, 13-51 minutes) for a complete LVA. Lymphatic detection rate was 100% (677 of 677) and vein detection rate was 99.7% (675 of 677), with 31.0% (210 of 677) of reflux-free veins. For upper-extremity lymphedema (47 of 229; 20.6%), volume reduction was achieved in 100% (47 of 47) of the cases, with a median volume reduction rate of 67% (range, 7-93%). In lower-extremity lymphedema (182 of 229; 79.4%), volume reduction was achieved in 86.8% (158 of 182) of the cases, with a median volume reduction rate of 41% (range, 7-81%). Cellulitis episodes decreased from 2.1 to 0.2 episodes/year after LVA (P < 0.05).
Acceptable success rates were obtained using a sequential strategy for planning and execution of supermicrosurgical LVA for secondary extremity lymphedema. We believe including a stepwise approach may help to simplify this procedure, especially for surgeons in their early practice.
淋巴静脉吻合术（LVA）已成为治疗四肢淋巴水肿患者的一种越来越常见的治疗方法。本文介绍了我们目前在患者选择、术前规划以及一系列术中线索方面的策略，这些线索可能有助于进行超显微淋巴静脉吻合术。使用系统的逐步方法介绍技术注意事项，使该手术更具可重复性和简单性。
我们回顾了 2015 年 1 月至 2018 年 6 月期间采用上述方法治疗的患者。前瞻性收集数据，所有手术均由资深作者完成。术前评估包括淋巴闪烁显像、吲哚菁绿淋巴造影、非对比磁共振淋巴造影和高频超声。将淋巴静脉吻合术分解为一个连续的 6 步方法，考虑了决定吻合术成功的主要方面。
对 229 例患者进行了淋巴静脉吻合术，共进行了 677 次吻合术。中位随访时间为 33 个月（范围，13-51 个月）。每位患者平均进行 3.1 次（范围，1-7 次）LVA，在 2.7 个（范围，1-6 个）切口部位进行。淋巴管和静脉解剖的中位时间为 8.7 分钟（1-18 分钟），完全 LVA 的中位时间为 27.2 分钟（范围，13-51 分钟）。淋巴管检出率为 100%（677 例中的 677 例），静脉检出率为 99.7%（677 例中的 675 例），无反流静脉率为 31.0%（677 例中的 210 例）。对于上肢淋巴水肿（229 例中的 47 例；20.6%），100%（47 例中的 47 例）达到了体积减少，中位数体积减少率为 67%（范围，7-93%）。在下肢淋巴水肿（229 例中的 182 例；79.4%）中，182 例中的 158 例（86.8%）达到了体积减少，中位数体积减少率为 41%（范围，7-81%）。LVA 后，蜂窝织炎发作次数从 2.1 次/年减少至 0.2 次/年（P < 0.05）。
采用逐步策略规划和执行继发性四肢淋巴水肿的超显微淋巴静脉吻合术，可获得可接受的成功率。我们认为，包括逐步方法可能有助于简化该手术，特别是对于处于早期实践阶段的外科医生。
