Introduction: Pelvic lymphadenectomy (PL) causes changes to the inguinal lymph nodes with progressive loss of immune and lymphatic pump function. Efferent lymphatic vessel-to-venous anastomosis (ELVA) has been reported to address this problem. The aim of this report was to describe the feasibility of the SPECT/CT combined with ultrasound fusion imaging (UFI) to target the groin efferent lymph node (GELN) for ELVA.Patients and Methods: Twelve patients with lower limb lymphedema after PL were scheduled for peripheric lymphaticovenular anastomosis (LVA) combined with ELVA.All-patients were clinically ISL-stage1, with good visualization of the inguinal lymph nodes at preoperative lymphoscintigraphy. The mean patient age was 55.4 years and the mean BMI was 25.5.The mean limb circumference (MLC) was calculated before surgery and 1 year after surgery. The LymQoL-Leg questionnaire was administered before surgery and 6 months after surgery. Before surgery, the GELN was identified by SPECT/CT and its location was marked on the skin by UFI virtual navigation. Peripheric LVA sites were planned by ultrasound and indocyanine green (ICG) lymphography. Pre and postoperative MLC and LymQoL-Leg scores were compared.Results: In all-patients, the SPECT/CT succeeded at detecting and targeting the GELN. In all-patients, real-time anatomical coregistration with US was feasible, and it was possible to mark on the groin skin the depth and position of the GELN on the skin at the groin. During surgery, in every patient, we found the GELN marked before surgery and performed ELVA. We also performed two or three peripheric LVAs in every patient. The mean value of MLC decreased (38.2 ± 2.13 cm vs. 36.33 ± 2.14 cm; p = .04) and the mean score of the LymQoL-Leg questionnaire improved (9.3 ± 1.7 vs. 7.7 ± 1.1; p = .02).Conclusion: SPECT/CT combined with UFI is feasible for the preoperative identification of GELN for ELVA.

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Nonalcoholic fatty-liver disease (NAFLD) is the most common cause of liver-related mortality. NAFLD is associated with obesity, hepatic fat accumulation and insulin-resistance, all of which contribute to its pathophysiology. Weight-loss is the main therapy for NAFLD and metabolic surgery is the most effective treatment for morbid obesity and its metabolic comorbidities. Although has been reported that Roux-en-Y gastric bypass can reverse NAFLD, it is unclear if such effects result from reduced weight, from a less calorie-intake or from the direct influence of surgery on mechanisms contributing to NAFLD. We aim to investigate whether gastrointestinal (GI) bypass surgery can induce direct effects on hepatic fat accumulation and insulin-resistance, independently of weight reduction. Twenty Wistar rats under a high-fat diet underwent duodenal-jejunal-bypass (DJB) or sham-operation and were pair-fed (PF) for 15 weeks after surgery to obtain a matched weight. Outcome measures include ectopic fat deposition, expression of genes and proteins involved in fat metabolism, insulin-signaling and gluconeogenesis in liver and muscle. Despite no differences in body-weight and calorie-intake, DJB showed lower ectopic fat accumulation, improved peripheral and hepatic insulin-sensitivity, and enhanced lipid droplet degradation. In both tissues DJB increased insulin-signaling while hepatic key enzymes involved in gluconeogenesis and de novo lipogenesis were decreased. These findings suggest that DJB can reverse, independently of weight loss, ectopic fat deposition and insulin-resistance, two features of NAFLD that share a mutual pathway, in which Perilipin-2 (PLIN2) seems to be the main player, supporting further investigation into strategies that target the gut to treat metabolic liver diseases.

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