End-to-End Lymphaticovenular Anastomosis Does Not Disturb the Contraction of Collecting Lymph Vessels.

Supplemental Digital Content is available in the text.

As super-micro surgical techniques and lymphangiogram have improved, lymphaticovenular anastomosis (LVA) has become the major treatment for lymphedema. To maintain the lymphatic flow, the contraction of smooth muscles play a crucial role. The vasa vasorum also plays an important role in maintaining the viability of muscle and endothelium. There are a variety of LVA techniques, and end-to-end anastomosis is the simplest one. However, dissecting the lymph vessels involve the risk of cutting the vasa vasorum; therefore, LVA can potentially disturb lymphatic contraction. Fortunately, we caught a contraction of the lymph vessels after end-to-end LVA on camera. In this article, we would like to show the video that captured the lymphatic contractility pushing the lymph through the anastomosis.

A 62-year-old woman had developed lower limb lymphedema for 5 years posthysterectomy, pelvic lymph mode dissection. Her lymphedema was International Society of Lymphedema stage II. Radio isotope lymph scintigraphy showed linear lymphatic flow in the lower leg, and dermal back flow was observed in her thigh (Fig. 1). Under general anesthesia, we performed 4 LVAs with 4 incisions. At the area where dermal back flow was observed in the RILS, LVA was performed using side-to-end technique. At the area where a linear enhanced pattern was observed, LVA was performed using end-to-end technique.

Fig. 1.

Radio isotope lymph scintigraphy image. Linear lymphatic flow in the lower leg and dermal back flow on her left thigh were observed.

In all sites, it was confirmed that the lymph flowed into the vein using an infrared camera. In the lower leg where end-to-end anastomosis was performed, contraction of the lymph vessels and pumping of the lymph into the vein was observed (see video, Supplemental digital content 1, which identifies the contraction of lymph after end-to-end LVA is performed, http://links.lww.com/PRSGO/A512).

See video, Supplemental digital content 1, which identifies the contraction of lymph after end-to-end LVA is performed. This video is available in the “Related Videos” section of the Full-Text article on PRSGlobalOpen.com or available at http://links.lww.com/PRSGO/A512.

Recent super-microsurgical techniques and near-infrared lymphatic imaging have established LVA as a common option for the treatment of obstructive lymphedema. However, previous studies revealed that normal lymph pressure is lower than venous pressure.[1] Olszewski and Engeset[2] reported that the lymphatic pressure during active contraction far exceeded the venous pressure. To maintain the lymphatic flow through the anastomosis, the intrinsic contractility of the lymph vessels is crucial. Contraction of the lymph is achieved by the pacemaker activity of the smooth muscle cells in the lymphatic wall. Smooth muscle cells receive blood supply from the vasa vasorum, whereas blood vessels can receive nourishment from the vasa vasorum and blood flowing through the lumen. There are a number of anastomosis techniques and surgeons have to choose the appropriate technique depending on the patients’ lymph dynamics. Side-to-end anastomosis is expected to collect retrograde flow.[3] However, lymph vessels have valve systems and they reduce retrograde flow naturally. Furthermore, influx of blood into the proximal side of lymph vessels is a concern. On the other hand, end-to-end anastomosis is simple and can reduce the influx of blood into the proximal side of lymph vessels. However, dissecting the lymph vessels also cuts the vasa vasorum and disturbs the lymph contraction. Our findings will support that LVA does not disturb the contraction of lymph vessels.