The Superior-Edge-of-the-Knee Incision Method in Lymphaticovenular Anastomosis for Lower Extremity Lymphedema :

Over the last eight years, the authors analyzed obstructive lymphedema of a unilateral upper extremity in a total of 27 females, comparing the use of supramicrosurgical lymphaticovenule anastomoses and/or conservative treatment. The most common cause of edema was mastectomy, with or without subsequent radiation therapy for breast cancer. As an objective assessment of the extent of edema, the circumferences of the affected and opposite normal forearms were measured at 10 cm below the olecranon of the arm. Twelve of these patients received continual bandaging. In these patients, the average excess circumference of the affected arm was 6.4 cm over that of the normal forearm; the average duration of edema before treatment was 3.5 years; the average period for conservative treatment was 10.6 months; and the average decrease in circumference was 0.8 cm (11.7 percent of the preoperative excess). Twelve patients underwent surgery and postoperative continual bandaging. In these patients, the average excess circumference was 8.9 cm; the average duration of edema before surgery was 8.2 years; the average follow-up after surgery was 2.2 years; and the average decrease in circumference was 4.1 cm (47.3 percent of the preoperative excess). These results indicated that supermicrolymphaticovenular anastomoses with postoperative bandaging have a valuable place in the treatment of obstructive lymphedema.

Management of arm lymphedema following breast cancer treatment is challenging, and emphasis should be put on early diagnosis and prevention of secondary lymphedema. Indocyanine green lymphography is becoming a method of choice for evaluation of lymphedema. Twenty patients with secondary arm lymphedema after breast cancer treatment underwent indocyanine green lymphography. Characteristic findings of indocyanine green lymphography were analyzed according to corresponding clinical stages and duration of edema. Based on changes in indocyanine green lymphography findings with progression of lymphedema, a new severity stage, arm dermal backflow stage, was developed and compared with clinical stages. The indocyanine green lymphographic findings were classified into two large groups: linear pattern and dermal backflow patterns. The dermal backflow pattern could be subdivided into splash, stardust, and diffuse patterns. The dermal backflow patterns were found more frequently than the linear pattern in the proximal upper extremity (p=0.001). The dermal backflow patterns also increased significantly in prevalence overall as the duration of lymphedema increased (p=0.032). The arm dermal backflow stage was linearly correlated with clinical stage as described by the line y=1.092x+0.083 (R=0.997; analysis of variance, p<0.001). Indocyanine green lymphography is a safe and convenient evaluation method for lymphedema that allows qualitative pathophysiologic assessment of lymphedema. The arm dermal backflow stage, based on indocyanine green lymphographic findings, is a simple severity staging system that demonstrates a significant correlation with clinical stage. Indocyanine green lymphography may come to play an important role in early diagnosis of secondary arm lymphedema. Diagnostic, V.

Lymphedema is a common and debilitating condition. Management options for lymphedema are limited and controversial. The purpose of this prospective study was to provide a preliminary analysis of lymphaticovenular bypass for the treatment of upper limb lymphedema in breast cancer patients. Twenty patients with upper extremity lymphedema secondary to treatment of breast cancer underwent lymphaticovenular bypass using a "supermicrosurgical" approach. The mean age of the patients was 54 years, 16 patients had received preoperative radiation therapy, and all patients had received axillary lymph node dissection. The mean duration of lymphedema was 4.8 years, and the mean volume differential of the lymphedematous arm compared with the unaffected arm was 34 percent. Evaluation included qualitative assessment and quantitative volumetric analysis before surgery and at 1 month, 3 months, 6 months, and 1 year after the procedure. The mean number of bypasses performed per patient was 3.5 (range, two to five), and the size of bypasses ranged from 0.3 to 0.8 mm. The mean operative time was 3.3 hours (range, 2 to 5 hours). Hospital stay was less than 24 hours for all patients. The mean follow-up time was 18 months. Nineteen patients (95 percent) reported symptom improvement following surgery, and 13 patients had quantitative improvement. The mean volume differential reduction was 29 percent at 1 month, 36 percent at 3 months, 39 percent at 6 months, and 35 percent at 1 year. No patients experienced postoperative complications or lymphedema exacerbation. Lymphaticovenular bypass may effectively reduce the severity of lymphedema in breast cancer patients. Long-term analysis is needed.