Minimal Invasive Lymphaticovenular Anastomosis Under Local Anesthesia for Leg Lymphedema

Abstract

This is the first report on the effectiveness of minimal invasive lymphaticovenular anastomosis under local anesthesia for leg lymphedema. Fifty-two patients (age: 15 to 78 years old; 8 males, 44 females) were treated with lymphaticovenular anastomoses under local anesthesia and by postoperative compression using elastic stockings. The average duration of edema of these patients before treatment was 5.3 +/- 5.0 years. The average number of anastomosis in each patient was 2.1 +/- 1.2 (1-5). The patients were followed for an average of 14.5 +/- 10.2 months, and the result were considered effective (82.5%) even for the patients with stage III (progressive edema with acute lymphangitis) and IV (fibrolymphedema), but others showed no improvement. Among these cases, 17 patients showed reduction of over 4 cm in the circumference of the lower leg. The average decrease in the circumference excluding edema in bilateral legs was 41.8 +/- 31.2% of the preoperative excess length. These results indicate that minimal invasive lymphaticovenular anastomosis under a local anesthesia is valuable instead of general anesthesia.

Recent Advancement on Surgical Treatments for Lymphedema

“…Presently, we are attempting simultaneous prophylactic anastomosis of the intact as well as affected limb early after the onset, being confident about its effectiveness. 5,6) Future therapeutIc strategy: necessIty oF more eFFectIve anastomotIc surgery It is becoming clear that edema can be prevented by prophylactic anastomosis before its onset. Recently, Fujiwara (former Associate Professor at Kawasaki Medical School) reported that the incidence of edema could be reduced by a combination of the resection of uterine cancer and transfer of the greater omentum (personal correspondence).…”

“…Particularly, in patients who frequently developed cellulitis, the incidence of anastomosis-induced cellulitis was markedly reduced, and the treatment was very effective. [3][4][5][6] Since lymph is drained by compression, although not so thoroughly as in the normal limb, compression occasionally causes a decrease in the frequency of cellulitis, a marked decrease in the limb volume compared with the preoperative level, and a marked decrease in the limb girth (Fig. 4). edema not respondIng to anastomotIc surgery and Its treatment Anastomosis was ineffective in about 10% of even early cases of edema.…”

“…This technique differs from conventional microscopic LV anastomosis (O'Brien, 1977) 8) in that the cutaneous veins to be drained are anastomosed end-toend to small veins immediately below the dermis or in the superficial adipose layer. [3][4][5][6] In principle, LV anastomosis must be carried out after thorough conservative treatment by sustained compression (primarily on an outpatient basis) over at least 6 months. Compression therapy must also be continued after surgery.…”

“…Presently, cases showing marked alleviation of severe edema over 10 years or more after surgery are beginning to be reported. [3][4][5][6] This has dispelled the notion that lymphedema has no cure, and prompted the shift to early or prophylactic anastomosis or combination therapy of anastomosis and compression. In this article, treatments that we are performing now are described.…”

“…1,2) Nevertheless, a surgical technique to treat very small vessels has recently been established (super-microsurgery: anastomosis of vessels 0.8-0.5 mm in diameter) in the field of plastic and reconstructive surgery, making anastomosis of extremely small blood vessels possible. [3][4][5][6] Using this microscopic anastomosis technique, a new method for lymphaticovenular anastomosis with outcomes exceeding those of conventional gross lymphaticovenous drainage 1,2,7) or lymphaticovenous anastomosis [8][9][10] has been developed. Presently, cases showing marked alleviation of severe edema over 10 years or more after surgery are beginning to be reported.…”