Therapeutic strategy for lower limb lymphedema and lymphatic fistula after resection of a malignant tumor in the hip joint region: A case report

Abstract

Lymphatic fistula complicating lymphedema is thought to occur due to communication between lymph vessels and the skin, which has yet to be shown objectively. The objective of this case report is to show the pathology and treatment using simultaneous lymphatic fistula resection and lymphatico-venous anastomosis (LVA). A 40-year-old woman underwent extended resection and total hip arthroplasty for primitive neuroectodermal tumor in the right proximal femur 23 years ago. Right lower limb lymphedema developed immediately after surgery and lymphatic fistula appeared in the posterior thigh. On ICG lymphography, lymph reflux toward the distal side dispersing in a fan-shape reticular pattern from the lymphatic fistula region was noted after intracutaneous injection of ICG into the foot. We performed simultaneous lymphatic fistula resection and of LVA. Pathological examination showed that the epidermis and stratum corneum of the healthy skin were lost in the lymphatic fistula region. Dilated lymph vessels were open in this region. The examinations provide the first objective evidence that the cause of lymphatic fistula may be lymph reflux from lymphatic stems to precollectors through lymphatic perforators.

A review of the postoperative lymphatic leakage

“…Meanwhile, a pilot study and a subsequent clinical trial show that the lymphatic fistula form after 48 h of continuing leakage [ 54 ]. Lymphatic fistula can form due to the increased pressure in lymph vessels or the reflux of capillary lymph vessels from the lymphatic channel leakage, which can dilate the capillary lymph vessels and destroy the normal structure of skin or tissue [ 50 ].…”

Indication of Lymphaticovenous Anastomosis for Lower Limb Primary Lymphedema

“…1,2,9,10 We usually perform lymphaticovenous anastomosis for patients with either primary or secondary lymphedema. [11][12][13][14] Lymphaticovenous anastomosis can be performed under local anesthesia, except in pediatric cases, and is minimally invasive, requiring only a small skin incision (only a few centimeters). In addition, lymphaticovenous anastomosis eliminates the possibility of donor-site lymphedema that may occur after lymph node transfer.…”

Revisiting Indocyanine Green: Effects of Serum and Physiological Temperature on Absorption and Fluorescence Characteristics

“…To date, ICG remains the only FDA-approved NIR dye for cardiocirculatory measurements, liver function tests, and ophthalmological imaging, predominantly involving choroidal circulation [3], [4]. ICG has also been investigated for sentinel lymph node (SLN) mapping and staging in cancer patients [5]- [13], in lymphography to assess lower and upper lymphedema [14]- [17], in lymphangiogenesis analysis following treatment of lymphedema by tissue replantation [18], and in assessment of anastomatic perfusion [19], [20]. Polom et al provide an excellent and further review of the utility of ICG-guided imaging for SLN detection, lymphedema evaluation, and assessment of microvascular circulation of free flaps in reconstructive surgery [21].…”