Related Terms: Lymphatic-venous anastomosis, LVA, lymphedema, Supermicrosurgery, Lymphocyst, Lymphography, Cancer, Evidence-based medicine, Lymphoscintigraphy, Inverse water volumetry, chyluria, lymphatic-venous–lymphatic-plasty, vein grafts
One particular surgical technique that actually has been around for number of years is lymphatic venous anastomosis.
This is a “micro”-surgical technique that involves the placement of a “shunt” to bypass a lymphatic blockage. In as much as I have been able to understand, there have been no serious complications from the procedure. Whether or not it has produced good results seem however to be controversial.
The technique relys on the use of supermicrosurgery to connect the lymphatic channels directly to the nearby veins. The diameter of the lymphatic channels is tiny, on the order of 0.1 mm to 0.9 mm in diameter, with most lymphatic vessels used in the procedure ranging from 0.3 mm to 0.6 mm wide. In comparison, the lead from a standard mechanical pencil is several times as broad. Specialized techniques are employed in which surgeons use superfine surgical suture and a high power microscope.
It is thought that not all of the lympaticovenous connections remain open after the surgery, which may account for the mixed results sometimes seen in the surgery. The physician seeks to make between 10 and 15 lymphatic to venous connections during a typical series of short procedures, with the goal of achieving several connections which remain open in the long term.
One report in 2009 indicated the researcher could find no convincing evidence of the success of LVA. While many others studies have indicated fair to good results.
The best results also have been with breast cancer related arm lymphedema, while success is limited with lower limb, or leg lymphedema. Besides a reduction in swelling, the procedure has reduced the number and intensity of cellulitis attacks and has generally improved the patients over all quality of life.
Italian doctor Corradino Campisis was a pioneere of LVA and in a study done in 2007, he reported improvement in 83% of the breast cancer related lymphedema patients. What was helpful in this study also, was that the average followup period was more then ten years.
So, what is the down-side?
The main downside from what I can tell is that the procedure has to be redone after a number of years, so it is not a permanent “fix.” Improved results can be expected with operations performed at earlier lymphedema stages. As a result this would not help someone with late stage two or stage three.
Also, it does seem limited in the scope of lymphedema patients that it can help. My feeling is that even if it is a limited number, at least these patients can be helped and can have the lymphedema improved.
Insurance companies believe LVA is still considered to be experimental and claim there is insufficient evidence of efficacy. See the GHC Group Insurance article below.
Patent blue-enhanced lymphaticovenular anastomosis.
Ayestaray B, Bekara F, Andreoletti JB. Source Department of Plastic and Reconstructive Surgery, Nimes University Hospital, pl Pr Robert Debré, 30000 Nimes, France; Department of Plastic and Reconstructive Surgery, Breast Institute, 15 Av. Jean Jaurès, 90000 Belfort, France. Electronic address: email@example.com.
Keywords: Lymphedema, Supermicrosurgery, Patent blue, Lymphatic vessel, Lymphaticovenular anastomosis
BACKGROUND: Lymphoedema supermicrosurgery is known to be difficult to perform. Lymphatic vessels are not easy to individualise, because of their small calibre (inferior to 1 mm) and their translucent appearance. Patent blue is an organic colourant, which is able to enhance the lymphatic network. We have evaluated the morbidity and the efficacy of patent blue lymphatic enhancement, with a view to perform lymphaticovenular anastomosis.
METHODS: From November 2010 to January 2012, 20 patients with chronic lymphoedema of the upper limb were treated by lymphaticovenular anastomosis. The mean age of the patients was 60.1 years (range, 47-78 years). The mean duration of lymphoedema was 3.2 years (range, 1-9 years). The mean volume of patent blue injected subdermally before surgery was 1.3 ml (range, 1-2 ml). The number and the calibre of enhanced lymphatic vessels at each operative site were noted. The quality of patent blue enhancement was analysed. The efficacy of surgery was assessed by quantitative measures.
RESULTS: The mean number of coloured lymphatic vessels per operative site was 2.1 (range, 1-4). The calibre of lymphatic vessels ranged from 0.3 to 0.8 mm (average, 0.57 mm). The quality of enhancement was moderate in two patients (8%), good in nine patients (36%) and excellent in 14 patients (56%). The mean number of lymphaticovenular anastomosis performed per operative site was 2.8 (range, 2-4). The mean operative time was 2.3 h (range, 2-3 h). No allergic (0%) and infectious (0%) reactions secondary to patent blue injection occurred. No secondary lymphangitis (0%) was noted. The delay of skin resorption of the blue stain ranges from 20 to 45 days (average, 30.3 days). Four patients (20%) had a remaining blue staining at the injection site. The average circumferential differential reduction rate was 13.2% (range, 4.2-27.2%) (p < 0.001). The average cross-sectional area differential reduction rate was 24.1% (range, 9.5-46.7%) (p < 0.001). The average volume differential reduction rate was 22.8% (range, 7.2-48.8%) (p < 0.001).
CONCLUSIONS: Patent blue-enhanced lymphaticovenular anastomosis is a safe and effective technique to treat patients with secondary lymphoedema. Its ease of use, low cost and efficiency should make it used on a priority basis to perform lymphaticovenular anastomosis.
π-Shaped lymphaticovenular anastomosis for head and neck lymphoedema: A preliminary study.
Ayestaray B, Bekara F, Andreoletti JB.
Source Department of Plastic and Reconstructive Surgery, Nimes University Hospital, pl Pr Robert Debré, 30000 Nimes, France; Department of Plastic and Reconstructive Surgery, Breast Institute, 15, av Jean Jaurès, 90000 Belfort, France. Electronic address: firstname.lastname@example.org.
Head and neck lymphoedema secondary to jugular lymphadenectomy is a severe issue, without efficient solution. Successful treatment of lymphoedema of the upper and lower limbs has become possible with supermicrosurgical lymphaticovenular anastomosis. The technique based on two end-to-side anastomosis is named π-shaped lymphaticovenular anastomosis. We have evaluated this method for chronic head and neck lymphoedema.
From November 2010 to April 2011, four patients with a chronic head and neck lymphoedema were treated by π-shaped lymphaticovenular anastomosis. Three patients had a unilateral lymphoedema, and one patient had a bilateral lymphoedema. The mean age of the patients was 63.2 years (range, 46-77 years). The mean duration of the lymphoedema was 2.6 years (range, 1-5). Every patient was operated under local anaesthesia through a face-lift skin incision. One π-shaped lymphaticovenular anastomosis was performed at each operative site.
The average operative time to perform one π-shaped lymphaticovenular anastomosis was 1.9 h (range, 1.8-2.5). The calibre of lymphatic vessels used for lymphaticovenular anastomosis ranged from 0.3 to 0.7 mm (average, 0.5). A venous back-flow was found in seven lymphaticovenular anastomosis (70%). Three patients (75%) had a qualitative improvement of skin tissue and a significant circumferential reduction after surgery. The average circumferential differential reduction rate was 3.7% (range, 0.6-7.8) (p = 0.006). The average cross-sectional area differential reduction rate was 7.2% (range, 1.2-15.1) (p = 0.007). The average volume differential reduction rate was 6.9% (range, 2-14.8) (p = 0.05).
The authors present a new option to treat head and neck lymphoedema. π-Shaped lymphaticovenular anastomosis is an effective method to reduce the severity of skin tissue fibrosis and lymphoedema volume. Further studies with larger groups of patients are required to confirm the outcome of this preliminary study. EBM Level = level 4.
Classification of lymphoscintigraphy and relevance to surgical indication for lymphaticovenous anastomosis in upper limb lymphedema.
Mikami T, Hosono M, Yabuki Y, Yamamoto Y, Yasumura K, Sawada H, Shizukuishi K, Maegawa J.
Department of Plastic and Reconstructive Surgery, Yokohama City University Hospital, Yokohama, Japan. email@example.com
Upper limb lymphedema that develops after breast cancer surgery causes physical discomfort and psychological distress, and it can require both conservative and surgical treatment. Lymphaticovenous anastomosis has been reported to be an effective treatment; however the disease severity criteria that define indications for this treatment remain unclear. Here, we examined lymphoscintigraphic findings in 78 patients with secondary upper limb lymphedema and classified them into 5 major types (Type I-V) and 3 subtypes (Subtype E, L, and 0). Results revealed that this classification is related to the clinical stage scale of the International Society of Lymphology. Based on intraoperative examination findings in 20 of the 78 patients, lymphatic pressure is likely to be further elevated in Type II-V cases which are characterized by the presence of dermal back flow. Therefore, lymphaticovenous anastomosis should be considered as a treatment option for lymphedema in Type II-V cases. Furthermore, there are only limited lymph vessel sites usable for lymphaticovenous anastomosis in more severe lymphedema types [Types IV and Type V (which is characterized by dermal backflow only in the hand)]. The findings in Type IV-V cases suggest that therapeutic strategies for severe upper limb lymphedema need further consideration.
“Vein grafting in the treatment of lymphedema”
Microsurgery for treatment of peripheral lymphedema: Long-term outcome and future perspectives
Campisi C, Eretta C, Pertile D, Da Rin E, Campisi C, Macciò A, Campisi M, Accogli S, Bellini C, Bonioli E, Boccardo F. Department of Surgery, Unit of Lymphatic Surgery and Microsurgery, San Martino Hospital, University of Genoa, Genoa, Italy.
email: Corradino Campisi (firstname.lastname@example.org)
*Correspondence to Corradino Campisi, Department of Surgery, Unit of Lymphatic Surgery and Microsurgery, San Martino Hospital - University of Genoa, Largo R. Benzi 8, 16132 Genoa, Italy
Authors report over 30 years of their own clinical experience in the treatment of chronic peripheral lymphedemas by microsurgical techniques performed at the Center of Lymphatic Surgery of the University of Genoa, Italy. Over 1,500 lymphedema patients were treated with microsurgical techniques. Derivative lymphatic-venous techniques were most often used. For those cases where a venous disease was associated to lymphedema, reconstructive lymphatic microsurgery techniques were performed (lymphatic-venous-lymphatic-plasty). Objective assessment was undertaken by water volumetry and lymphoscintigraphy. Volume changes showed a significant improvement in over 83%, with an average follow-up of more than 10 years. There was an 87% reduction in the incidence of cellulitic attacks after microsurgery.
Microsurgical lymphatic-venous anastomoses have a place in the treatment of peripheral lymphedema and should be the therapy of choice in patients who are not sufficiently responsive to nonoperative treatment. Improved results can be expected with operations performed at earlier lymphedema stages.
Net Effect of Lymphaticovenous Anastomosis on Volume Reduction of Peripheral Lymphoedema after Complex Decongestive Physiotherapy.
Maegawa J, Hosono M, Tomoeda H, Tosaki A, Kobayashi S, Iwai T.
Department of Plastic and Reconstructive Surgery, Yokohama City University Hospital, 3-9 Fukuura Kanazawa-ku, Yokohama 236-0004, Japan.
OBJECTIVE: The results of reported lymphaticovenous anastomoses include some effects of complex decongestive physiotherapy (CDP). The present study aimed to determine the net effect of lymphaticovenous side-to-end anastomosis (LVSEA) in patients with lower limb lymphoedema treated by preoperative CDP.
DESIGN: Retrospective observational study.
MATERIALS: 37 LVSEAs in 31 patients.
METHODS: Volumes of the thigh and leg with oedema were compared between the time of initial examination, and before (application of CDP) and after LVSEA. The patients were divided into two groups based on the number of anastomoses and lymphoscintigraphic findings.
RESULTS: Preoperative CDP resulted in a reduction of 593 ml (both leg and thigh; p < 0.001). After CDP, LVSEA (1-8 anastomoses; average of 5) reduced the volume by 109 ml (52 ml for the thigh (p = 0.01) and 57 ml for the leg (p = 0.002)). There was no significant difference in volume reduction on lymphoscintigraphy. Volume was significantly reduced (by 55 ml in the thigh, p = 0.049; 96 ml in the leg, p = 0.006) in the group that underwent 6-8, but not 1-5 LVSEAs.
CONCLUSIONS: The net effect of LVSEA on volume reduction was confirmed, but was not particularly large. The need for CDP decreased in some patients postoperatively, and these patients should be considered for evaluation. European Society for Vascular Surgery.
Microsurgical Techniques for Lymphedema Treatment: Derivative Lymphatic-Venous Microsurgery
Corradino Campisi and Francesco Boccardo
We analyzed clinicopathologic and imaging features of chronic peripheral lymphedema to identify imaging findings indicative of its exact etiopathogenesis and to establish the optimal treatment strategy. One of the main problems of microsurgery for lymphedema is the discrepancy between the excellent technical possibilities and the subsequently insufficient reduction of the lymphedematous tissue fibrosis and sclerosis. Appropriate treatment based on pathologic studies and surgical outcome have not been adequately documented. Over the past 25 years, 676 patients with peripheral lymphedema have been treated with microsurgical lymphatic-venous anastomoses. Of these patients, 447 (66%) were available for long-term follow-up study.
Objective assessment was undertaken by water volumetry and lymphoscintigraphy. Objectively, volume changes showed a significant improvement in 561 patients (83%), with an average reduction of 67% of the excess volume. Of the 447 patients followed, 380 (85%) have been able to discontinue the use of conservative measures, with an average follow-up of more than 7 years and average reduction in excess volume of 69%. There was an 87% reduction in the incidence of cellulitis after microsurgery. Microsurgical lymphatic-venous anastomoses have a place in the treatment of peripheral lymphedema and should be the therapy of choice in patients who are not sufficiently responsive to nonsurgical treatment. Improved results can be expected with operations performed early, during the first stages of lymphedema.
Lymphatic-venous anastomosis for the radical cure of a large pelvic lymphocyst.
Mihara M, Hayashi Y, Hara H, Todokoro T, Koshima I, Murai N.
Department of Plastic Surgery and Reconstructive Surgery, The University of Tokyo, Tokyo, Japan.
Keywords: Lymphocyst, Lymphaticovenous anastomosis, LVA, Lymphedema, Supermicrosurgery
Therapeutic efficacy of lymphatic-venous anastomosis (LVA) has been shown, but expansion of the indication is desirable because LVA is a procedure with low invasiveness and is applicable over a wide area. This is the first reported case of intractable pelvic lymphocyst for which LVA was effective. LVA may be useful for pelvic lymphocyst at an early stage after cancer resection and lymph node dissection.
Using Indocyanine Green Fluorescent Lymphography and Lymphatic-Venous Anastomosis for Cancer-Related Lymphedema.
Mihara M, Murai N, Hayashi Y, Hara H, Iida T, Narushima M, Todokoro T, Uchida G, Yamamoto T, Koshima I.
Department of Plastic Surgery and Reconstructive Surgery, The University of Tokyo, Tokyo, Japan.
Advances in cancer therapy have increased the importance of improvement of quality of life after cancer survival. Cancer-related lymphedema or secondary lymphedema that occurs after lymph node dissection in resection of tumors of abdominal visceral organs can impair quality of life. However, standard curative treatment for secondary lymphedema has not been established. This may be due to the lack of a method for early diagnosis of lymphedema, and because of selection of conservative treatment such as compression therapy to delay edema progression in many cases. To develop a curative approach, we have performed definite diagnosis of early-stage lymphedema using magnetic resonance imaging and an indocyanine green fluorescent lymphography, followed by surgical treatment with lymphatic-venous anastomosis using supermicrosurgery. Herein, we report the first case of secondary lymphedema in which we performed early diagnosis and surgery using these techniques and achieved an almost complete cure of lymphedema. We suggest that early diagnostic imaging and early microsurgery is the key of lymphedema treatment.
Full Text Article:
Long-term results after lymphatic-venous anastomoses for the treatment of obstructive lymphedema.
Campisi C, Boccardo F, Zilli A, Macciò A, Napoli F.
Department of Specialistic Surgical Sciences, Anaesthesiology and Organ Transplants (DISCAT), Emergency Surgical Clinic Section, Lymphology and Microsurgery Center, S. Martino Hospital, University of Genoa, 16122 Genoa, Italy. email@example.com
Over the past 25 years, 665 patients with obstructive lymphedema have been treated with microsurgical lymphatic-venous anastomoses; of these, 446 patients were available for long-term follow-up study. Objective assessment was undertaken by water volumetry and lymphoscintigraphy. Lymphangioscintigraphy, lymphangiography (in patients with gravitational reflux pathology), and echo-Doppler were used preoperatively. Subjective improvement was noted in 578 patients (87%). Objectively, volume changes showed a significant improvement in 552 patients (83%), with an average reduction of 67% of the excess volume. Of those patients followed up, 379 patients (85%) have been able to discontinue the use of conservative measures, with an average follow-up of more than 7 years and average reduction in excess volume of 69%. There was a 87% reduction in the incidence of cellulitis after microsurgery. In those patients who improved, drainage resulted in increased softness of the limbs. Peripheral edema (hand and foot) diminished considerably in most patients.
These long-term results indicate that lymphatic-venous anastomoses have a place in the treatment of obstructive lymphedema and should be the therapy of choice in patients who are not sufficiently responsive to nonsurgical treatment. Improved results can be expected with earlier operations because patients referred earlier usually have fewer lymphatic alterations.
Lymphatic venous anastomosis (LVA) for treatment of secondary arm lymphedema. A prospective study of 11 LVA procedures in 10 patients with breast cancer related lymphedema and a critical review of the literature.
Damstra RJ, Voesten HG, van Schelven WD, van der Lei B.
Department of Dermatology, Phlebology and Lymphology, Nij Smellinghe Hospital, Compagnonsplein 1, 9202 NN, Drachten, The Netherlands. firstname.lastname@example.org
Keywords Lympho-venous anastomosis (LVA) - Microsurgery - Evidence-based medicine - Lymphoscintigraphy - Inverse water volumetry - Review - Breast cancer related lymphedema
The incidence of breast cancer related lymphedema (BCRL) varies between 7-35% depending on the combination of treatment modalities. Early detection of BCRL is crucial in order to start an effective non-operative treatment program. Because of the lack of prospective research on this topic, this study was undertaken to prospectively determine the effect of Lympho Venous Anastomosis (LVA) on BCRL and to review the current literature.
STUDY DESIGN AND METHODS: Ten patients who were previously treated for breast cancer by surgery, radiotherapy, and chemotherapy, and were unresponsive to 12-weeks of non-operative treatment, underwent an LVA procedure (Degni-Cordeiro). Objective measurements were gathered for circumferential measurement and water volumetry, and quality of life. Various types of lymphoscintigraphy were carried out pre-operatively and post-operatively at 3 and 12 months. Treatment was embedded in a multidisciplinary setting.
RESULTS: Post-operative volume measurements initially showed a 4.8% reduction of lymphedema at 3 months and a 2% reduction after one year. Various scintigraphic parameters showed some improvement. Quality of life questionnaires reported minimal improvement. Reviewing the literature, only retrospective studies were found; these reported varying results for LVA procedures. The selection of patients, classification of lymphedema, indications and types of LVA, and additional therapeutic options were heterogeneous, not comparable, and lacked a validated method of effect-assessment.
CONCLUSIONS: Our results showed a minimal reduction in volume of lymphedema following LVA; in the literature, there was no convincing evidence of the success of LVA. Non-operative treatment and elastic stockings are still preferred by most patients with lymphedema, especially in early stages with few irreversible changes.
Reconstructive microsurgery of lymph vessels: the personal method of lymphatic-venous-lymphatic (LVL) interpositioned grafted shunt.
Campisi C, Boccardo F, Tacchella M.
Department of Emergency Surgery, University of Genoa, Italy.
Our clinical observations in 64 patients affected by chronic obstructive lymphedema (either arm or leg) undergoing interposition autologous lymphatic-venous-lymphatic (LVL) anastomoses are reported. This microsurgical technique is an alternative to other lymphatic shunting methods, especially when venous dysfunction coexists in the same limb and, therefore, when direct lymphatic-venous anastomosis is accordingly inadequate. Preoperative diagnostic evaluation (including lymphatic and venous isotopic scintigraphy, Doppler venous flowmetrics, and pressure manometry) plays an essential role in assessing the conditions of both the lymphatic and venous systems and in establishing which microsurgical procedure, if any, is indicated. Our microsurgical technique consists of inserting suitably large and lengthy autologous venous grafts between lymphatic collectors above and below the site of obstruction to lymph flow. The data show that, using this technique, both limb function and edema improved, and in all patients followed up for over 5 years edema regression was permanent.
Lymphatic Venous Anastomosis (LVA) for the Treatment of Post-Breast Cancer Lymphedem GroupHealth Article
Traumatic injury of the thoracic duct. “Microsurgical lymphatic repair or lymphatic-venous anastomosis”
Lymphatic vessel-to-isolated-vein anastomosis for secondary lymphedema in a canine model.
Chyluria treated with inguinal lymphangiovenous and lymph node-venous anastomosis: a case report.
Keywords: chyluria, lymphatic-venous anastomosis, microsurgery
Long-term results of microscopic lymphatic vessel-isolated vein anastomosis for secondary lymphedema of the lower extremities. 2006
Treatment of lymphedema with lymphaticovenular anastomoses. Oct 2005
Key words: Lymphedema - Lymphaticovenular anastomosis - Supermicrosurgery - Lymphangiogenesis
Microsurgical techniques for lymphedema treatment: derivative lymphatic-venous microsurgery June 2004
Vein graft interposition in treating peripheral lymphedema.
Key words: Reconstructive microsurgery - vein grafts - lymphoedemas - lymphatic-venous-lymphatic plasty - long-term results
Microsurgical lympho-venous anastomosis in the treatment of secondary lymphoedema of the upper extremity July 2003
Surgical Management of Lymphedema Dr. Reid's Corner
Lymph Edema Surgery “Pictoral of the surgery”
Inclusion of these pages does not consitute an acceptance of the treatment modality. The pages are for patient information and education. In situations where I feel the treatments are either ineffective, dangerous or just plain bogus I have added my personal commentary.