"Double Barrel" Lymphaticovenous Anastomosis: A Useful Addition to a Supermicrosurgeon's Repertoire.

Microsurgical amelioration of lymphedema has gained much traction in recent years and is now an established modality of treatment for this condition. Despite the development of many newer techniques, lymphaticovenous anastomosis still remains the most frequently carried out microsurgical procedure for lymphedema. One of the most common hurdles faced by lymphatic surgeons while carrying out a lymphaticovenous anastomosis is a mismatch in sizes of the vein and the lymphatic vessels. Method: This article describes a novel but simple "double barrel" technique, developed by the authors for carrying out lymphaticovenous anastomosis in cases of such lymphaticovenous mismatch. Seventeen double barrel anastomoses were carried out in 12 lymphedema patients, over a 4-year period from 2017 to 2021. Results: The overall success rate was 100%, as measured by clinical observation (venous washout, lymphatic backflow), the Acland vessel strip test, and by means of intraoperative ICG lymphography. Mild leakage was observed in four cases after release of the venous clamp and was corrected by application of additional sutures. Conclusions: The double barrel technique is a safe and effective tool that can be employed to deal with the bane of size mismatch, a persistent problem faced by lymphedema surgeons universally. Although we do not advocate it as a total replacement for other techniques, it can be a worthy addition to the present set of available options. In specific scenarios of mismatch with additional challenges, the double barrel technique has the potential to be considered as primus inter pares.

Long-term Use of Ultrasound for Locating Optimal LVA Sites: A Descriptive Data Analysis.

BACKGROUND: Preoperative mapping of lymphatic vessels for lymphovenous anastomosis (LVA) surgery is frequently performed by indocyanine green (ICG) lymphography solely; however, other imaging modalities, such as ultrasound (US), might be more efficient, particularly for Caucasian patients. We present our preoperative assessment protocol, experience, and approach of using US for locating optimal LVA sites. METHODS: Fifty-six (16 males) lymphedema patients who underwent LVA surgery were included in this study, 5 of whom received two LVA operations. In total, 61 LVA procedures with 233 dissected lymphatic vessels were evaluated. Preoperative US was performed by the author S.M. 2 days before intraoperative ICG lymphography. Fluid-predominant lymphedema regions were scanned more profoundly. Skin incisions followed preoperative US and ICG lymphography markings. Detection of lymphatic vessels was compared between ICG lymphography and the US by using the intraoperative verification under the microscope with 20 to 50x magnification as the reference standard. RESULTS: Among the dissected lymphatic vessels, 83.3% could be localized by US, and 70% were detectable exclusively by it. In all, 7.2% of US-detected lymphatic vessels could not be found and verified intraoperatively. Among the lymphatic vessels found by US, only 16% were apparent with ICG before skin incision. In total, 23.2% of the dissected lymphatic vessels could be visualized with ICG lymphography preoperatively. Only 9.9% of the lymphatic vessels could be found by ICG alone. CONCLUSION: High-frequency US mapping accurately finds functional lymphatic vessels and matching veins. It locates fluid-predominant regions for targeted LVA surgeries. It reveals 3.6 times as many lymphatic vessels as ICG lymphography. In our practice, it has an integral role in planning LVA procedures.

Exclusive use of ultrasound for locating optimal LVA sites-A descriptive data analysis.

BACKGROUND: The current standard to locate lymphatic vessels for lymphovenous anastomosis (LVA) is the use of indocyanine green (ICG)-lymphangiography. Due to fluid retention and fibrosis of tissue in patients with lymphedema, often present in Caucasian patients, vessels deeper than 0.5 cm below the dermis cannot be visualized. We present our experiences with ultrasound in locating deeper lymphatic vessels in lower extremities. MATERIALS AND METHODS: In total, 28 patients with lymphedema and positive lymphoscintigraphy were included. With ultrasound, we located 82 lymphatic vessels in lower extremities preoperatively without the use of ICG marking. Vessel diameter, depth, and exact location were examined. Using a coordinate system, a mapping of the detected lymphatic vessels was created. The ultrasound findings were confirmed under microscope and ICG intraoperatively. RESULTS: In all, we detected 28 Caucasian patients and 82 lymphatic vessels with ultrasound preoperatively. On average, we found three lymphatic vessels (range, 2-6) at each patient. Of the ultrasound-detected lymphatic vessels, 90.2% could be verified intraoperatively under a microscope. Before skin incision, lymphatic vessels could be visualized in 40% of our patients with ICG. In the mapping of the lymphatic vessels, we found no significant pattern. CONCLUSION: Ultrasound can precisely detect lymphatic vessels for efficient LVA operation without the prior use of ICG-lymphangiography.

Institutionalization of reconstructive lymphedema surgery in Austria-Single center experience.

BACKGROUND: Lymphedema surgery was not widely known in Austria before the introduction of lymphovenous anastomosis (LVA) and vascularized lymph node transfer (VLNT) in 2014. This study shares the experience and process of establishing and institutionalizing lymphedema surgery service in Austria. METHODS: The purpose of introducing reconstructive lymphedema surgery in Austria was to improve lymphedema patients' quality of life and provide them surgical therapy as an adjuvant treatment to complete decongestive therapy. To initialize reconstructive lymphedema surgery in Austria, LVA and VLNT had to be presented and introduced, in the manner of branding and advertizing a new product. Surgeries were performed with quality control by standardized documentation, pre- and postoperatively. RESULTS: Aligned with branding and marketing, presentations were given externally and internally to share knowledge and experience of lymphedema surgery. Lymphedema surgery service was introduced as a new brand in the medical service in Austria. After several communications with the Austrian Health Insurance Fund and with the final application, LVA and VLNT were listed as novel surgical therapies in its 2020 reimbursement catalog. Since 2014, more than 300 lymphedema patients were consulted, and 102 reconstructive lymphedema surgeries were performed. Circumference reduction of extremities after surgery was between 20% and 43%, postoperatively. CONCLUSION: Acceptance of surgery in lymphedema patients varies among continents, hospitals, and surgeons. Evaluation of the requirement of the surgical setup and insurance conditions for lymphedema surgery is essential to establish lymphedema surgery, providing targeted marketing and branding to spread knowledge of the novel technique and grant patients access to therapeutic treatment of their chronic disease.