Indocyanine Green (ICG) Lymphography Is Superior to Lymphoscintigraphy for Diagnostic Imaging of Early Lymphedema of the Upper Limbs

BACKGROUND: Secondary lymphedema causes swelling in limbs due to lymph retention following lymph node dissection in cancer therapy. Initiation of treatment soon after appearance of edema is very important, but there is no method for early diagnosis of lymphedema. In this study, we compared the utility of four diagnostic imaging methods: magnetic resonance imaging (MRI), computed tomography (CT), lymphoscintigraphy, and Indocyanine Green (ICG) lymphography. PATIENTS AND METHODS: Between April 2010 and November 2011, we examined 21 female patients (42 arms) with unilateral mild upper limb lymphedema using the four methods. The mean age of the patients was 60.4 years old (35-81 years old). Biopsies of skin and collecting lymphatic vessels were performed in 7 patients who underwent lymphaticovenous anastomosis. RESULTS: The specificity was 1 for all four methods. The sensitivity was 1 in ICG lymphography and MRI, 0.62 in lymphoscintigraphy, and 0.33 in CT. These results show that MRI and ICG lymphography are superior to lymphoscintigraphy or CT for diagnosis of lymphedema. In some cases, biopsy findings suggested abnormalities in skin and lymphatic vessels for which lymphoscintigraphy showed no abnormal findings. ICG lymphography showed a dermal backflow pattern in these cases. CONCLUSIONS: Our findings suggest the importance of dual diagnosis by examination of the lymphatic system using ICG lymphography and evaluation of edema in subcutaneous fat tissue using MRI

Feasibility and reliability of supermicrosurgical vasa recta anastomosis for double-pedicled free jejunum transfer

Background: Although free jejunal transfer is an established and reliable procedure for reconstruction after total pharyngolaryngectomy (TPL), vascular thrombosis remains a surgical challenge. To reduce the risk, a double-pedicled free jejunal flap transfer has been attempted using a root jejunal artery and an arcade artery, although several drawbacks exist. The vasa recta are terminal straight vessels that arborize from an arcade artery without branching. We present a novel double-pedicled free jejunum transfer using vasa recta anastomosis. Methods: Between 2011 and 2015, we performed 14 double-pedicled free jejunal flap transfers for reconstruction after TPL. Vasa recta were used for second arterial anastomosis in 5 out of 14 patients. Others include a root artery in three patients and an arcade artery in six patients. Indocyanine green (ICG) angiography was performed to confirm the patency and perfusion of the entire flap by the second artery alone. Results: The flaps survived completely in all cases. The vasa recta (average diameter; 0.8 mm) were anastomosed to the superior thyroid artery and transverse cervical artery in four and one cases, respectively. Supramicrosurgical end-to-side anastomosis was performed in two cases. ICG angiography showed sufficient perfusion of the entire flap with the second artery alone in all cases. Conclusion: As vasa recta were confirmed as being capable of perfusing the entire flap up to 25 cm, the double-pedicle method using vasa recta might be an option to reduce the risk of flap necrosis, particularly in high-risk patients. Keywords: Vasa recta, Free jejunum, Double pedicle, Supermicrosurger

Side-to-End Lymphaticovenular Anastomosis through Temporary Lymphatic Expansion

<div><p>Objective</p><p>The number of bypasses is the most important factor in lymphaticovenular anastomosis (LVA) for lymphedema treatment. Side-to-end (S-E) LVA, which can bypass bidirectional lymph flows via one anastomosis, is considered to be the most efficient bypass, but creation of lateral window to a small lymphatic vessel is technically demanding. To overcome the difficulty, we introduced S-E anastomosis through temporary lymphatic expansion (SEATTLE) procedure in S-E LVA.</p><p>Methods</p><p>This was a retrospective observational study set in a teaching hospital. Forty eight lower extremity lymphedema (LEL) patients underwent LVA. S-E LVAs were performed with (SEATTLE group) or without (non-SEATTLE group) temporary lymphatic expansion. S-E LVAs were evaluated to compare anastomosis result in SEATTLE and non-SEATTLE groups.</p><p>Results</p><p>S-E LVAs resulted in 44 anastomoses in SEATTLE group (n = 25) and 37 anastomoses in non-SEATTLE group (n = 23). LEL index reduction in SEATTLE group was significantly greater than that in non-SEATTLE group (16.5±14.5 vs. 10.9±11.8, <i>P</i> = 0.041). Success rate of S-E LVA in SEATTLE group was significantly higher than that in non-SEATTLE group (95.5% vs 81.1%, <i>P</i> = 0.040). Thirty seven of 44 (84.1%) lymph vessels in SEATTLE group were successfully dilated by temporary lymphatic expansion maneuver. All of 9 failed S-E LVAs used a lymphatic vessel with diameter of 0.35 mm or smaller.</p><p>Conclusions</p><p>The SEATTLE procedure facilitates S-E LVA by a simple and easy maneuver. When the diameter of the lymphatic vessel is 0.35 mm or smaller even after the temporary lymphatic expansion maneuver, S-E LVA is not recommended due to relatively high failure rate.</p></div

Failure in 9 of 81 S-E anastomoses.

<p>Failure in 9 of 81 S-E anastomoses.</p

Patient demographics in SEATTLE and non-SEATTLE group.

<p>Patient demographics in SEATTLE and non-SEATTLE group.</p