Lymphovenous anastomosis

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Lymphovenous anastomosis is a microsurgical procedure used to treat lymphedema and chylothoraces.

Contents

Overview

Lymphedema is a chronic condition characterized by the abnormal accumulation of lymph fluid in the interstitial tissues, typically occurring in the limbs. It often results from congenital abnormalities, surgical procedures (especially those involving lymph node dissection), infections, or radiation therapy. LVA aims to restore or improve lymphatic drainage by anastomosing (connecting) functioning lymphatic channels with adjacent small veins (venules). Advances in supermicrosurgical techniques—using high-powered microscopes and extremely fine sutures—have significantly enhanced the feasibility and outcomes of LVA.

Medical uses

LVA is primarily employed in the management of:

The procedure is most effective in patients with early-stage lymphedema or when there is still a measurable amount of functional lymphatic flow. It is frequently used in combination with conservative treatments such as compression therapy, manual lymphatic drainage, and exercise regimes as part of comprehensive lymphedema management.

Surgical technique

Preoperative assessment

Patients considered for LVA typically undergo detailed imaging studies. Techniques such as near-infrared fluorescence lymphography or indocyanine green (ICG) lymphography [1] help in mapping functional lymphatic vessels and identifying suitable sites for anastomosis.

Operative procedure

During the procedure, performed under general or local anesthesia, the surgeon makes small incisions in the affected area. Under high magnification, functional lymphatic vessels (often less than 0.8 mm in diameter) and nearby venules are identified. Using supermicrosurgical instruments and sutures as fine as 11-0 or 12-0 nylon, the surgeon meticulously creates one or multiple anastomoses between the lymphatic vessels and the venous channels.

Postoperative care

After the surgery, patients are usually advised to continue conservative therapies such as compression garments and physiotherapy to maximize the benefits of the procedure. Regular follow-up appointments are critical to monitor limb volume reduction, assess lymphatic function, and detect any complications early.

Outcomes and efficacy

Multiple studies have demonstrated that LVA can lead to:

The success of the procedure depends on several factors including the stage of lymphedema, the quality of the lymphatic vessels, and the surgeon's expertise. While many patients experience significant symptomatic relief and improved quality of life, outcomes may vary, and some individuals might require additional procedures or complementary treatments.

Advantages and limitations

Advantages

Limitations

History and evolution

The concept of surgically connecting lymphatic channels to the venous system dates back to 1970's. LVA has been first described by Gilbert (France) in 1976 [2] and O'Brien (Australia) in 1977. [3] It came into adoption in the 80's, when a handful of microsurgeons started applying this technique in their clinical practice. Most notably, Gong-Kang H (1981) [4] , Ho L.C.Y (Australia, 1983), [5] Yamamoto Y(Japan, 1998), [6] and Koshima I (Japan, 2000). [7]

Early attempts were hampered by technical limitations. The advent of supermicrosurgery in the 1990s and 2000s—with improvements in optical magnification, instrument design, and suture materials—marked a turning point for LVA. Today, it is an established component of the surgical armamentarium for lymphedema management in many specialized centers worldwide.

References

  1. Unno, Naoki; Inuzuka, Kazunori; Suzuki, Minoru; Yamamoto, Naoto; Sagara, Daisuke; Nishiyama, Motohiro; Konno, Hiroyuki (May 2007). "Preliminary experience with a novel fluorescence lymphography using indocyanine green in patients with secondary lymphedema". Journal of Vascular Surgery. 45 (5): 1016–1021. doi:10.1016/j.jvs.2007.01.023. PMID   17391894.
  2. Gilbert, A.; O'Brien, B.McC.; Vorrath, J.W.; Sykes, P.J. (October 1976). "Lymphaticovenous anastomosis by microvascular technique" . British Journal of Plastic Surgery. 29 (4): 355–360. doi:10.1016/0007-1226(76)90022-9. PMID   1000123.
  3. O'brien, Bernard M.; Sykes, Philip J.; Threlfall, George N.; Browning, Frank S. C. (August 1977). "Microlymphaticovenous Anastomoses for Obstructive Lymphedema" . Plastic and Reconstructive Surgery. 60 (2): 197–211. doi:10.1097/00006534-197708000-00006. ISSN   0032-1052. PMID   887661.
  4. Gong-Kang, Huang; Ru-Qi, Hu; Zong-Zhao, Liu; Yao-Liang, Shen; Tie-De, Lan; Gong-Ping, Pan (September 1981). "Microlymphaticovenous anastomosis for treating lymphedema of the extremities and external genitalia" . Microsurgery. 3 (1): 32–39. doi:10.1002/micr.1920030109. ISSN   0738-1085. PMID   7341732.
  5. Ho, L.C.Y.; Lai, M.F.; Kennedy, P.J. (July 1983). "Micro-lymphatic bypass in the treatment of obstructive lymphoedema of the arm: case report of a new technique" . British Journal of Plastic Surgery. 36 (3): 350–357. doi:10.1016/S0007-1226(83)90060-7. PMID   6860866.
  6. Yamamoto, Yuhei; Sugihara, Tsuneki (January 1998). "Microsurgical Lymphaticovenous Implantation for the Treatment of Chronic Lymphedema" . Plastic and Reconstructive Surgery. 101 (1): 157–161. doi:10.1097/00006534-199801000-00026. ISSN   0032-1052. PMID   9427930.
  7. Koshima, Isao; Inagawa, Kiichi; Urushibara, Katsuyuki; Moriguchi, Takahiko (2000). "Supermicrosurgical Lymphaticovenular Anastomosis for the Treatment of Lymphedema in the Upper Extremities" . Journal of Reconstructive Microsurgery. 16 (6): 437–442. doi:10.1055/s-2006-947150. ISSN   0743-684X. PMID   10993089.