Search

Purpose: Central lymphatic obstructions are associated with anasarca and high mortality. We hypothesized that opening dilated cutaneous lymphatic channels by creating a lymphocutaneous fistula (LCF) would decompress the lymphatic circulation and improve anasarca., Methods: We reviewed all patients that had at least one LCF created between 9/2019 and 12/2022. LCF efficacy was determined by changes in weight, urine/diuresis, ventilation, and clinical status., Results: We created eleven LCFs in four infants. LCFs initially drained 108 cc/kg/d (IQR68-265 cc/kg/d). Weights significantly decreased after LCF creation (6.9 [IQR6.1-8.1] kg vs. 6.1 [IQR 4.9-7.6] kg, P = 0.042). Ventilatory support decreased significantly in all patients after at least one LCF was created, and 3/4 patients (75%) had significantly lower peak inspiratory pressures (28 [IQR 25-31] cmH 2 O vs. 22 [IQR 22-24] cmH 2 O, P = 0.005; 36 [IQR36-38] cmH 2 O vs. 33 [IQR 33-35] cmH 2 O, P = 0.002; 36 [IQR 34-47] cmH 2 O vs. 28 [28-31] cmH 2 O, P = 0.002). LCFs remained patent for 29d (IQR 16-49d). LCFs contracted over time, and 6/11 (54.5%) were eventually revised. There were no complications. Two patients died from overwhelming disease, one died from unrelated causes, and one remains alive 29 months after their initial LCF., Conclusion: LCFs provide safe and effective temporary lymphatic decompression in patients with central lymphatic obstruction. While LCFs are not a cure, they can serve as a bridge to more definitive therapies or spontaneous lymphatic remodeling., Level of Evidence: IV., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

The Fontan surgery was developed as a palliative intervention for congenital heart disease (CHD) patients with single-ventricle physiology who are not candidates for a biventricular repair. Improvements in the surgery and medical management of these patients have increased survival, yet this population remains at risk for complications and end-organ dysfunction due to Fontan failure. Lymphatic vessels maintain a fluid balance within the extracellular space, participate in fat reabsorption from the small intestine, and play an important role in the body's immune response. Altered Starling forces at the capillary level, capillary leak, and lymphatic obstruction contribute to lymphatic dysfunction in patients with Fontan physiology. These lymphatic complications include edema, pleural effusions, plastic bronchitis (PB), and protein-losing enteropathy (PLE). Over the past decade, there have been innovations in lymphatic imaging. These new imaging techniques include noncontrast magnetic resonance (MR) lymphangiography, intranodal lymphangiography (IL), dynamic contrast-enhanced magnetic resonance lymphangiography (DCMRL), and liver lymphangiography. These imaging techniques help in delineating anatomy and guiding the appropriate therapeutic approach. Lymphatic interventions then may be performed to decompress the lymphatic system or to identify and occlude abnormal lymphatic vessels and drainage pathways. The anesthesiologist should have an understanding of the effects of lymphatic disorders on the Fontan circulation and apply appropriate management techniques for the associated interventions. The Fontan surgery was developed as a palliative intervention for CHD patients with single-ventricle physiology who are not candidates for a biventricular repair. The surgery creates a series systemic and pulmonary circulation with the energy necessary to provide gradient-driven pulmonary blood flow generated by the ventricle. 1 In the past decades, improvements in the surgery and medical management of these patients have increased survival, with 30-year survival rates close to 85%. 2 Despite these improvements, this population remains at risk for complications and end-organ dysfunction due to Fontan failure, which is characterized by elevated systemic venous pressures and low cardiac output. These complications include arrhythmias, cardiac dysfunction, ascites, liver fibrosis/cirrhosis, renal dysfunction, pulmonary failure, and lymphatic complications such as edema, pleural effusions, PB, and PLE. Complications ultimately contribute to increased risk for hospitalization, death, and need for heart transplantation. 3 , 4 For this reason, there has been increasing interest in the role of abnormal lymphatic circulation in the genesis of Fontan failure. The authors characterize the lymphatic pathophysiology associated with Fontan physiology and review the imaging and interventional strategies used to treat these patients., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Significance: Primary lymphedema is a chronic condition without a cure. The lower extremities are more commonly affected than the arms or genitalia. The disease can be syndromic. Morbidity includes decreased self-esteem, infections, and reduced function of the area. Recent Advances: Several mutations can cause lymphedema, and new variants continue to be elucidated. A critical determinant that predicts the natural history and morbidity of lymphedema is the patient's body mass index (BMI). Individuals who maintain an active lifestyle with a normal BMI generally have less severe disease compared to subjects who are obese. Because other causes of lower extremity enlargement can be confused with lymphedema, definitive diagnosis requires lymphoscintigraphy. Critical Issues: Most patients with primary lymphedema are satisfactorily managed with compression regimens, exercise, and maintenance of a normal body weight. Suction-assisted lipectomy is our preferred operative intervention for symptomatic patients who have failed conservative therapy. Suction-assisted lipectomy effectively removes excess subcutaneous fibro-adipose tissue and can improve underlying lymphatic function. Future Directions: Many patients with primary lymphedema do not have an identifiable mutation and thus novel variants will be identified. The mechanisms by which mutations cause lymphedema continue to be studied. In the future, drug therapy for the disease may be developed.

Background: Lymphovenous anastomosis (LVA) has become an increasingly common treatment for patients with extremity lymphedema. In this article, we present our current strategy for patient selection, preoperative planning, and a series of intraoperative clues that may help to perform a supermicrosurgical LVA. Technical considerations are presented using a systematic step-by-step method to make this procedure more reproducible and straightforward., Patients and Methods: We conducted a review of patients operated between January 2015 and June 2018 using the aforementioned approach. Data were collected prospectively, and all procedures were performed by the senior author. Preoperative assessment included lymphoscintigraphy, indocyanine green lymphography, noncontrast magnetic resonance lymphography and high-frequency ultrasonography. Lymphovenous anastomosis was decomposed into a sequential 6-step approach considering the main aspects that determine a successful anastomosis., Results: Lymphovenous anastomosis was performed in 229 patients, including 677 anastomoses. Median follow-up was 33 months (range, 13-51 months). A median of 3.1 (range, 1-7) LVA were performed on 2.7 (range, 1-6) incision sites per patient. Median time for dissection of lymphatic(s) and vein(s) was 8.7 minutes (1-18 minutes) with a median time of 27.2 minutes (range, 13-51 minutes) for a complete LVA. Lymphatic detection rate was 100% (677 of 677) and vein detection rate was 99.7% (675 of 677), with 31.0% (210 of 677) of reflux-free veins. For upper-extremity lymphedema (47 of 229; 20.6%), volume reduction was achieved in 100% (47 of 47) of the cases, with a median volume reduction rate of 67% (range, 7-93%). In lower-extremity lymphedema (182 of 229; 79.4%), volume reduction was achieved in 86.8% (158 of 182) of the cases, with a median volume reduction rate of 41% (range, 7-81%). Cellulitis episodes decreased from 2.1 to 0.2 episodes/year after LVA (P < 0.05)., Conclusions: Acceptable success rates were obtained using a sequential strategy for planning and execution of supermicrosurgical LVA for secondary extremity lymphedema. We believe including a stepwise approach may help to simplify this procedure, especially for surgeons in their early practice., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Lymphatic system is identified the second vascular system after the blood circulation in mammalian species, however the research on lymphatic system has long been hampered by the lack of comprehensive imaging modality. Nanomaterials have shown the potential to enhance the quality of lymphatic imaging due to the unparalleled advantages such as the specific passive targeting and efficient co-delivery of cocktail to peripheral lymphatic system, ease molecular engineering for precise active targeting and prolonged retention in the lymphatic system of interest. Multimodal lymphatic imaging based on nanotechnology provides a complementary means to understand the kinetics of lymphoid tissues and quantify its function. In this review, we introduce the established approaches of lymphatic imaging used in clinic and summarize their strengths and weaknesses, and list the critical influence factors on lymphatic imaging. Meanwhile, the recent developments in the field of pre-clinical lymphatic imaging are discussed to shed new lights on the design of new imaging agents, the improvement of delivery methods and imaging-guided surgery strategies., (© 2022. The Author(s).)

Background: Sarcoma surgery often requires large tissue resection to be treated safely. When the tumor is localized in the groin and/or medial thigh, lymphocele and lymphedema are common complications because of the rich lymphatic network present there. The aim of this study is to share the outcome of seven patients who received defect reconstruction in this area with combined pedicled superficial circumflex artery perforator (SCIP) flap with lymphatic tissue preservation and lymphovenous anastomosis (LVA) for prevention of lymphatic complications., Patients and Methods: Seven patients who underwent surgical resection of sarcoma in the groin and/or adductors compartment received defect reconstruction with pedicled SCIP flap combined with LVA. For a better dead space obliteration, four of them also received an additional tissue flap: two pedicled deep inferior epigastric perforator flaps and two free anterolateral thigh flaps. Indocyanine green lymphography was performed in all cases to identify the lymphatic pathway, make the preoperative marking and check the patency of the anastomoses., Results: All seven patients were successfully treated reaching a good aesthetic result and a full range of motion. No immediate nor delayed complications such as lymphocele or lymphorrhea and early extremity lymphedema were observed during the follow up (range: 6-9 months; mean: 7.3) and no secondary procedures were required., Conclusions: The combination of the pedicle SCIP lymphatic tissue transfer with LVA seems to be effective in preventing the development of lymphatic sequelae after large resections in the medial thigh., (© 2020 Wiley Periodicals LLC.)

Background: Over the past 2 decades, the surgical treatment of lymphedema has advanced considerably with lymphovenous bypass and vascularized lymph node transfer. Despite these advances, some patients can only be treated with a radical debulking procedure, commonly known as Charles procedure. However, the Charles procedure is not a commonly performed procedure and can have significant risks such as fluid shifts, blood loss and wound infections. In this article, we present our experience with Charles procedure and share pearls to perform this procedure expediently while avoiding potential pitfalls., Methods: Patients with severe lymphedema who were treated by the senior author with Charles procedure were evaluated. The medical record was queried for their pertinent medical history, including cause of lymphedema, prior treatments for the condition, medical comorbidities and preoperative and postoperative course. The surgical technique and lessons learned from each case are described., Results: Three patients were identified within the study period who underwent treatment with the Charles procedure. All patients had secondary lower extremity lymphedema. All patients had single-stage direct excision and skin grafting. One patient required postoperative ICU stay due to significant fluid shifts and blood loss, another suffered from a wound infection. All 3 patients ultimately recovered to exceed their preoperative activity levels with satisfactory outcomes., Conclusions: The Charles procedure continues to have clinical utility in modern lymphedema treatment. Despite potential risks, it can be done successfully with proper planning and careful attention to technical details; it can be life changing for patients suffering from most extreme lymphedema.

Lymphedema is a chronic debilitating disease in which impaired drainage of lymphatic fluid causes accumulation of fluid in the soft tissues resulting in a swollen heavy limb. This ultimately leads to severe fibrosis, recurrent infections, non-healing wounds, and a poorly functioning limb that negatively affects a patient's quality of life. Primary lymphedema is due to abnormal development of the lymphatic system and patients can present with lymphedema at birth or later in life. Secondary lymphedema is caused by damage to the lymphatic system from infection, surgery to treat malignancies, trauma, and obesity. In the past, the only treatment was controlling the swelling to prevent progression of the disease by lymphatic therapy and various types of compression which is still currently the first line treatment. Advances in supermicrosurgery (connecting vessels less than 0.8 mm) have made way for surgical treatment options for lymphedema, including lymphovenous bypass and vascularized lymph node transplant. These new surgical treatment options combined with lymphatic therapy and compression have led to better results and improved patient's quality of life. After reading this article, the participant should be familiar with diagnosis, imaging, and surgical treatment of lymphedema., (Copyright 2020 by the Missouri State Medical Association.)

Objective: To analyze the clinical characteristics, treatment and prognosis of chyle leakage after central lymph node dissection for thyroid cancer. Methods: A retrospective analysis was made of 985 patients who underwent surgical for thyroid carcinoma plus central lymph node dissection from January 2017 to June 2018 in Renji Hospital Affiliated to Medical College of Shanghai Jiaotong University. Patients were divided into those without (group A, n= 973) and with (group B, n= 12) chyle leakage. Patients with chyle leakage who underwent left central lymph node dissection were divided into group B1 ( n= 5) and right central lymph node dissection into group B2 ( n= 7). Patients with chyle leakage were treated with fat-free diet and negative pressure drainage. SPSS 20.0 software was used to analyze the general condition, surgical pathology, postoperative drainage, hospitalization days, treatment and prognosis of patients in B1 and B2 groups. Results: The incidence of chyle leakage after central lymph node dissection for thyroid cancer was 1.2% (12/985). There were no significant differences in age, sex, size of primary lesion, number of lymph node dissection in central area and number of lymph node metastasis in central area between group A and group B (all P> 0.05). The drainage volume on the first day after operation [((51.7±26.7)) ml] and the average hospitalization days [(3.4±0.8) d] in group A were significantly lower than those in group B ([131.3±56.0)]ml, [10.4±2.6)]d). The differences were statistically significant ( t value was -5.442, -11.238, respectively, both P< 0.001). There were no significant differences in age, size of primary lesion, number of lymph node dissection, number of lymph node metastasis, drainage volume on the first day after operation and average hospitalization days between group B1 and group B2 (all P> 0.05). All chyle leakages in group B stopped after conservative management without surgical intervention. Conclusion: The occurrence of chyle leakage after central lymph node dissection is a rare complication. It can be cured by conservative treatment such as diet control, pressure bandaging and negative pressure drainage, and generally does not require secondary surgery.

This protocol provides a comprehensive reference for the evolution of the lymph fistula model, the mechanism of lipid absorption, the detailed procedure for studying lipid absorption using the lymph fistula model, the interpretation of the results, and consideration of the experimental design. The lymph fistula model is an approach to assess the concentration and rate of a range of molecules transported by the lymph by cannulating lymph duct in animals. In this protocol, mice first undergo surgery with the implantation of cannulae in the duodenum and mesenteric lymph duct and are allowed to recover overnight in Bollman restraining cages housed in a temperature-regulated environment. To study in vivo lipid absorption, a lipid emulsion is prepared with labeled tracers, including [ 3 H]-triolein and [ 14 C]-cholesterol. On the day of the experiment, mice are continuously infused with lipid emulsion via the duodenum for 6 hr, and lymph is usually collected hourly. At the end of the study, gastrointestinal segments and their luminal contents are collected separately for determination of the digestion, uptake, and transport of exogenous lipids. © 2019 by John Wiley & Sons, Inc., (© 2019 John Wiley & Sons, Inc.)

Background and Objectives: Lymphedema is caused by insufficient lymphatic drainage leading to abnormal accumulation of interstitial fluid within soft tissues. Lympho-venous anastomosis (LVA), as a surgical option for selected patients, is widely applied. Through preoperative localization of functional lymphatics with indocyanine green, real time visualization of functioning lymphatic vessels is possible. This examination is time consuming and operator dependant and is not suitable to differentiate the ratio of fat hypertrophy to liquid edema. We investigated whether MR lymphangiography is accurate for imaging functional lymphatics and adjacent veins in arms. Furthermore, we investigated the accuracy and predictability of preoperative mapping for the feasibility of performing LVA and the preoperative decision making in lymphedema surgery., Methods: A prospective study was performed in which 25 patients suffering from lymphedema of the upper extremity were examined. MR lymphography with contrast agent injection in a deep dermal plane was performed., Results: Precise localization of lymphatic vessels crossing a vein was achieved in 18 of 25 arms. In 16 of the 18 patients in whom functional lymphatics were localized with an adjacent vein on MRI an LVA was performed successfully., Conclusions: MR lymphangiography is an accurate and reproducible method for imaging and mapping of lymphatic channels in the lymphedemateous limb., (© 2018 Wiley Periodicals, Inc.)

Background/purpose: Lymphedema surgery, when integrated into a comprehensive lymphedema treatment program for patients, can provide effective and long-term improvements that non-surgical management alone cannot achieve. Such a treatment program can provide significant improvement for many issues such as recurring cellulitis infections, inability to wear clothing appropriate for the rest of their body size, loss of function of arm or leg, and desire to decrease the amount of lymphedema therapy and compression garment use., Methods: The fluid predominant portion of lymphedema may be treated effectively with surgeries that involve transplantation of lymphatic tissue, called vascularized lymph node transfer (VLNT), or involve direct connections from the lymphatic system to the veins, called lymphaticovenous anastomoses (LVA). VLNT and LVA are microsurgical procedures that can improve the patient's own physiologic drainage of the lymphatic fluid, and we have seen the complete elimination for the need of compression garments in some of our patients. These procedures tend to have better results when performed when a patient's lymphatic system has less damage. The stiff, solid-predominant swelling often found in later stages of lymphedema can be treated effectively with a surgery called suction-assisted protein lipectomy (SAPL). SAPL surgeries allow removal of lymphatic solids and fatty deposits that are otherwise poorly treated by conservative lymphedema therapy, VLNT or LVA surgeries., Conclusion: Overall, multiple effective surgical options for lymphedema exist. Surgical treatments should not be seen as a "quick fix", and should be pursued in the framework of continuing lymphedema therapy and treatment to optimize each patient's outcome. When performed by an experienced lymphedema surgeon as part of an integrated system with expert lymphedema therapy, safe, consistent and long-term improvements can be achieved.

Plastic bronchitis is a poorly understood and uncommon diagnosis, arising from multiple etiologies. Traditional treatment consists of steroids and vasodilators, with thoracic duct embolization emerging as a new procedural therapy. Herein, abnormal lymphatic vessels were noted on lymphangiography in an adult patient with debilitating plastic bronchitis, but anterograde lymphatic access was not feasible due to the patient's morbid obesity and non-visualization of retroperitoneal lymphatics. After trans-venous thoracic duct access could not be established, direct trans-cervical thoracic duct access was performed. A thoracic duct stent-graft was placed, excluding the abnormal bronchial lymphatics and maintaining physiologic anterograde flow through the central lymphatics. At three-month follow-up, the patient's condition had resolved., Competing Interests: The authors of this article and the planning committee members and staff have no relevant financial relationships with commercial interests to disclose., (Copyright by International Society of Lymphology.)

Vascularized composite allotransplantation (VCA) is an emerging treatment for significant tissue defects. However, VCAs usually consist of multiple highly antigenic skin tissues. Previous studies have shown that the lymphatic system in skin plays important roles in the initiation of immune responses during acute rejection, by transporting T cells and antigen-presenting dendritic cells to regional lymph nodes. Therefore, we designed a new surgical treatment to inhibit lymphatic drainage of skin allografts and investigated whether this approach could promote the survival of allografts and suppress immunological events after transplantation. This procedure was achieved by connecting the vascularized allografts to recipient tissues with only an annular plastic holder, allowing the minimum of allograft contact with recipients. Our results showed that the self-designed treatment for inhibiting lymphatic drainage promoted the survival of allografts, reduced the serum concentration of IL-2, and decreased the percentage of CD4CD25 and CD8CD25 from the lymphatic nodes draining the transplantation region. In conclusion, these data suggest that self-designed surgical approach is effective in inhibiting lymphatic drainage of skin allografts, and the lymphatic system may be new therapeutic targets for developing techniques or drugs against acute rejection after VCAs.

The Lymphatic Microsurgical Preventing Healing Approach (LYMPHA) procedure entails performing a lymphovenous bypass (LVB) at the time of axillary lymph node dissection to reduce lymphedema risk. The two most common fluorophores utilized in LVB are blue dye and indocyanine green. We developed a novel application of fluorescein isothiocyanate for intraoperative lymphatic mapping. Our goal is to demonstrate the safety and efficacy of fluorescein isothiocyanate for this application. We reviewed a prospectively collected database on breast cancer patients who underwent LYMPHA from March to September 2015. Fluorescein isothiocyanate was used to identify arm lymphatic channels after axillary lymph node dissection to perform an LVB between disrupted lymphatics and axillary vein tributaries. Data on preoperative and intraoperative variables were analyzed. Thirteen patients underwent LYMPHA with intraoperative fluorescein isothiocyanate lymphatic mapping from March to September 2015. Average patient age was 50 years with a mean body mass index of 28. On average, 3.4 lacerated lymphatic channels were identified at an average distance of 2.72 cm (range, 0.25-5 cm) caudal to the axillary vein. On average, 1.7 channels were bypassed per patient. Eleven anastomoses were performed to the accessory branch of the axillary vein and 1 to a lateral branch. In 1 patient, a bypass was not performed due to poor lymphatic caliber and inadequate length of the harvested vein tributary. No intraoperative adverse events were noted. Fluorescein isothiocyanate is a safe and effective method for intra-operative lymphatic mapping. Fluorescein isothiocyanate imaging allows for simultaneous dissection and lymphatic visualization, making it an ideal agent for lymphatic mapping and dissection in open surgical fields, such as in the LYMPHA procedure.

Background: Secondary lymphedema is often observed in postmalignancy treatment of the breast and the gynecologic organs, but effective therapies have not been established in chronic cases even with advanced physiologic operations. Currently, reconstructive surgery with novel approaches has been attempted., Methods: The hindlimbs of 10-week-old male C57BL/6J mice, after 30-Gy x-irradiation, surgical lymph node dissection, and 5-mm gap creation, were divided into four groups, with vascularized lymph node transfer abdominal flap and 1.0 × 10 adipose-derived stem cells. Lymphatic flow assessment, a water-displacement plethysmometer paw volumetry test, tissue quantification of lymphatic vessels, and functional analysis of lymphatic vessels and nodes were performed., Results: Photodynamic Eye images, using indocyanine green fluorescence, demonstrated immediate staining in subiliac lymph nodes, and linear pattern imaging of the proximal region was observed with the combined treatment of adipose-derived stem cells and vascularized lymph node transfer. Both percentage improvement and percentage deterioration with the combined treatment of adipose-derived stem cells and vascularized lymph node transfer were significantly better than with other treatments (p < 0.05). The numbers of lymphatic vessels with LYVE-1 immunoreactivity significantly increased in mice treated with adipose-derived stem cells (p < 0.05), and B16 melanoma cells were metastasized in groups treated with vascularized lymph node transfers by day 28., Conclusions: Adipose-derived stem cells increase the number of lymphatic vessels and vascularized lymph node transfers induce the lymphatic flow drainage to the circulatory system. Combined adipose-derived stem cell and vascularized lymph node transfer treatment in secondary lymphedema may effectively decrease edema volume and restore lymphatic function by lymphangiogenesis and the lymphatic-to-venous circulation route.

Peripheral lymphedema is a chronic progressive and debilitating disorder that results from abnormal lymphatic drainage. Advances in microsurgical techniques have led to the development of new treatment options for lymphedema that benefit from preoperative imaging to select the most appropriate surgical repair. Magnetic resonance (MR) lymphangiography is a noninvasive imaging modality capable of providing high-resolution 3D images of the lower extremities to define the severity and extent of lymphedema and depict individual lymphatic channels. The MR examination consists of 2 primary sequences. The first is a 3D heavily T2-weighted sequence to depict the severity and extent of the lymphedema. The second is a fat-suppressed 3D spoiled gradient-echo sequence performed after the intracutaneous injection of an extracellular gadolinium-based MR contrast agent. As venous enhancement almost always occurs, one of the interpretative challenges is differentiating enhancing lymphatic channels from superficial veins. MR techniques that can help with venous contamination include the addition of a contrast-enhanced MR venogram to the examination protocol, or the use of an iron-based blood-pool contrast agent to selectively suppress venous enhancement., (Copyright © 2016 Elsevier Inc. All rights reserved.)

This review summarizes current knowledge of the biology, pathology and clinical understanding of lymphatic invasion and metastasis in pancreatic cancer. We discuss the clinical and biological consequences of lymphatic invasion and metastasis, including paraneoplastic effects on immune responses and consider the possible benefit of therapies to treat tumors that are localized to lymphatics. A review of current techniques and methods to study interactions between tumors and lymphatics is presented., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Background: Axillary nodes dissection (AND) is an important risk factor for the appearance of breast cancer-related lymphedema (BCRL). The anatomy and pathophysiology leading to the development of BCRL after AND are not completely understood. Despite the existence of lymphedema models after AND, none of them were able to create lymphedemas without additional chemical inflammatory drugs or auxiliary physical techniques (radiotherapy). In this study, we aimed to describe the anatomical changes of AND on a rat's front leg before and after a new surgery technique., Methods and Results: AND was performed on seven Wistar rats with a new, posterior surgical approach. Indocyanine green mapping was done before and after surgery to detect "normal and secondary superficial lymphatic pathways" of the operated rat's front legs. Twelve months after surgery, dissections were performed. Subcutaneous blue dye injection of the hand was used to observe superficial and deep lymphatic pathways. Postsurgery, an acute edema of arm and shoulder appeared and persisted for 14-21 days. However, none of the rats showed a chronic secondary lymphedema. In two cases, seromas also appeared. All rats showed substitution functional lymphatic pathways as perforating lymph vessels around the surgical sites., Conclusion: This is the first description of perforating lymph vessels as lymphatic substitution pathways after AND on rats. These results help to understand why a chronic secondary lymphedema could not be created in rats after AND without additional chemical or physical interventions.

Unlabelled: The Mascagni lymphatic pathway comprises superficial channels along the clavicle that drain upper extremity lymph. A 65 year-old woman with recurrent left breast cancer presented with a non-functioning chemotherapy port in the right deltopectoral groove. She had undergone right mastectomy with axillary lymph node dissection (ALND). After port removal and wound closure she developed right upper extremity lymphedema. Patients who have undergone ALND may depend solely on this pathway for upper extremity lymphatic drainage., Level of Evidence: level V., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Evaluation of the lymphedema patients with appropriate staging is fundamental for further treatment. Treatment includes compressive decongestive therapy for stage 0 and 1 patients, lymphovenous anastomosis for stage 1 and 2 patients, vascularized lymph node transfer for stage 2 and above patients. Wedge resection, liposuction, and the Charles procedure are alternatives or additions to physiological procedures. The selection of donor lymph node flap and recipient site depends on the patient's lymphedema status and surgeon's expertise. J. Surg. Oncol. 2016;113:923-931. © 2016 Wiley Periodicals, Inc., (© 2016 Wiley Periodicals, Inc.)

Lymphedema is a debilitating disease that is commonly caused by cancer and it is treatments in the developed world. Surgery is an option for refractory disease. Lymphovenous bypass and vascularized lymph node transfer are newer modalities that show great promise. Further work is necessary to determine proper patient selection and ensure minimum donor site morbidity. Liposuction and direct excision still have a role, especially in advanced cases. Further investigations into prevention of iatrogenic lymphedema are underway. J. Surg. Oncol. 2016;113:932-939. © 2016 Wiley Periodicals, Inc., (© 2016 Wiley Periodicals, Inc.)

We present the clinical and radiological findings involving a mesenteric lymphatic malformation causing volvulus in a toddler presenting with acute abdominal pain, as well as its treatment options.

Catheterization of the intestinal lymph trunk in neonatal pigs is a technique allowing for the long-term collection of large quantities of intestinal (central) efferent lymph. Importantly, the collection of central lymph from the intestine enables researchers to study both the mechanisms and lipid constitutes associated with lipid metabolism, intestinal inflammation and cancer metastasis, as well as cells involved in immune function and immunosurveillance. A ventral mid-line surgical approach permits excellent surgical exposure to the cranial abdomen and relatively easy access to the intestinal lymph trunk vessel that lies near the pancreas and the right ventral segment of the portal vein underneath the visceral aspect of the right liver lobe. The vessel is meticulously dissected and released from the surrounding fascia and then dilated with sutures allowing for insertion and subsequent securing of the catheter into the vessel. The catheter is exteriorized and approximately 1 L/24 hr of lymph is collected over a 7 day period. While this technique enables the collection of large quantities of central lymph over an extended period of time, the success depends on careful surgical dissection, tissue handling and close attention to proper surgical technique. This is particularly important with surgeries in young animals as the lymph vessels can easily tear, potentially leading to surgical and experimental failure. The video demonstrates an excellent surgical technique for the collection of intestinal lymph.

Cancer-related lymphedema is a progressive, chronic condition that impairs quality of life. Its pathophysiology and the mechanisms of action of current reconstructive surgical treatments are not fully understood but lymphaticovenous communications may play a key role. We review the available literature on lymphaticovenous communications and their implications in lymphedema surgery, and propose a subclassification of lymphaticovenous communications. J. Surg. Oncol. 2016;113:374-380. © 2016 Wiley Periodicals, Inc., (© 2016 Wiley Periodicals, Inc.)

Unlabelled: When choosing a thigh lift operation, the surgeon also chooses which complications he/she will be managing, and the most dreaded after conventional thigh lifting are those of lymphatic origin such as lymphocele or lymphedema. The authors describe avulsion thighplasty, a technique that spares lymphatics by using aggressive liposuction beneath the planned resection area, and thus minimizes lymphatic complications. The technique is outlined and complications are detailed over a 6-year period with long-term follow-up. The risk of major complications is found to be low and the procedure is found to be safe. Patients must be counseled that the risk of minor complications, such as small wound dehiscence or need for a later scar revision, is substantial., Clinical Question/level of Evidence: Therapeutic, IV.

Knowledge of the lymphatic system plays critical importance in surgical oncology. The study of the lymphatic system and its role in tumor metastasis continues to advance with new anatomical and surgical studies, and with a new study, we can gain a better understanding on how aggressive surgeons need to be with nodal dissection while balancing the complications with overly aggressive approaches. The lymphatics of the inguinal region represent a network of lymph nodes and vessels, which act as the bridge among the lower extremities, pelvis, perineum, and rest of the body. These lymph nodes are of particular importance in the metastatic spread of genitourinary and lower gastrointestinal epithelial cancer to the inguinal nodes. The aim of this article is to reveal the literature with regard to the inguinal lymph nodes and their relation in various carcinomas.

Background: We previously reported that midgut neuroendocrine tumors (NETs) often develop alternative lymphatic drainage owing to lymphatic obstructions from extensive mesenteric lymphadenopathy, making intraoperative lymphatic mapping mandatory. We hypothesize that this innovative approach needs a longer term validation., Methods: We updated our results by reviewing 303 patients who underwent cytoreduction from November 2006 to October 2011. Of these patients, 112 had lymphatic mappings and 98 were for midgut NET primaries. Among them, 77 mappings were for the initial cytoreduction and 35 were for reexploration and further cytoreduction. The operative findings, pathology reports, and long-term surgical outcomes were reviewed., Results: Lymphatic mapping changed traditional resection margins in 92% of patients. Of the 35 patients who underwent reexploration without initial mapping, 19 (54%) showed a recurrence at or near the anastomotic sites. In contrast, none of the 112 mapped patients had shown signs of recurrence in a 1- to 5-year follow-up. Additionally, 20 of 45 ileocecal valves (44.4%) were spared in patients whose tumors were at the terminal ileum that, traditionally, would call for a right hemicolectomy., Conclusion: With a longer follow-up, lymphatic mapping has proven to be a safe and effective way to prevent local recurrences and preserve the ileocecal valve for selected patients., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Metastatic breast cancer to the contralateral axilla (CAM) is defined as stage IV disease. We postulate that CAM represents an extension of local-regional disease rather than distant metastasis and may have a better outcome. A single-institution, retrospective review of breast cancer cases from January 2005 and May 2011 was performed to identify cases with CAM. Eligibility for the study included unilateral primary breast cancer at presentation with synchronous/metachronous documented CAM without a documented primary invasive breast cancer within the contralateral breast by surgery or MRI. Clinicopathologic data was recorded for these patients (pts). Thirteen pts were identified. 12/13 (92%) pts presented with a locally advanced breast tumor or an ipsilateral in-breast recurrence. 10/13 (77%) pts had documented dermal involvement of tumor either at initial presentation or local recurrence. CAM occurred synchronously with the initial primary tumor (5 pts, 38%), concomitant with a local recurrence (5 pts, 38%), metachronously with the initial tumor (1 pt, 8%), and metachronously with a local recurrence (2 pts, 15%). Three patients had other distant disease at presentation. Of the other 10 pts, seven developed distant disease with a mean follow up of 3.6 years (range 0.3-7.6 years). Three pts have no evidence of disease at a mean follow up of 5.8 years (range 1.5-8.2). CAM may have different prognostic implications than other distant metastases and may occur through dermal lymphatic spread. Further study is warranted on the prognosis and management of these challenging and rare cases., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Background: The purpose of this study was to quantify the efficacy and safety of microsurgery for lymphedema through a systematic meta-analysis, which has not been described before., Methods: A literature search was conducted to identify all articles involving microsurgical treatment of lymphedema. Studies meeting criteria for inclusion were rated on methodologic quality based on the American Society of Plastic Surgeons levels of evidence. Demographic information, cause of lymphedema, and surgical technique were recorded. Quantitative change in lymphedema and perioperative complications were noted., Results: Twenty-seven studies were included, with 24 offering level IV evidence and three offering level III evidence. Lymphovenous shunt procedures were performed in 22 studies and lymph node transplantation was performed in five. Excess circumference was reduced by 48.8 ± 6.0 percent, and absolute circumference was reduced by 3.31 ± 0.73 cm. Studies reporting change in volume demonstrated reduction in excess volume by 56.6 ± 9.1 percent, and absolute volume was reduced by 23.6 ± 2.1 percent. The incidence of no improvement in lymphedema postoperatively was 11.8 percent, and 91.2 percent of patients reported subjective improvement. Approximately 64.8 percent of patients discontinued compression garments at follow-up. Complications included operative-site infection (4.7 percent), lymphorrhea (7.7 percent), reexploration for flap congestion (2.7 percent), and additional procedures (22.6 percent)., Conclusions: Operative interventions for peripheral lymphedema appear to provide consistent quantitative improvements postoperatively, with a relatively wide safety margin. Lymph node transplantation may provide better outcomes compared with lymphovenous shunt, but well-designed head-to-head comparisons are needed to evaluate this further., Clinical Question/level of Evidence: Therapeutic, III.

Purpose: Many authors reported that microsurgical varicocelectomy was among the best treatment modalities for varicocele. However, the difference in intraoperative anatomic detail between macroscopic and microsurgical varicocele repair in the same spermatic cord has not been critically discussed., Methods: Between August 2010 and February 2011, 32 men with 42 sides' grade 2-3 varicocele were enrolled in this study. One surgeon firstly mimicked the modified open varicocelectomy by identifying, isolating, and marking the presumed internal spermatic veins, lymphatics, and arteries. Another surgeon then checked the same spermatic cord using operating microscope to investigate the number of missed veins, to be ligated lymphatics and arteries in the "imitative" open varicocelectomy., Results: There were significant differences in the average number of internal spermatic arteries (1.67 vs. 0.91), internal spermatic veins (6.45 vs. 4.31), and lymphatics (2.93 vs. 1.17) between microscopic and macroscopic procedure (P < 0.001, P < 0.001, P < 0.001, respectively). Meanwhile, an average of 2.14 ± 1.26 internal spermatic veins was missed; among them, 1.63 ± 1.32 internal spermatic veins adherent to the preserved testicular artery were overlooked. The number of 0.69 ± 0.84 lymphatics and 0.74 ± 0.74 arteries were to be ligated in "macroscopic varicocelectomy." A number of 1.07 ± 1.11 lymphatics were neither identified nor ligated. In addition, in 2 cases, the vasal vessels of the vas deferens were to be ligated at macroscopic procedure., Conclusions: Microsurgical varicocelectomy could preserve more internal spermatic arteries and lymphatic and ligate more veins which may interpret the superiority of microsurgical varicocele repair.

Knowledge about the mechanisms of regeneration of the lymphatic vasculature after surgical trauma is essential for the development of strategies for the prevention and therapy of lymphedema. However, little is known about the alterations of lymphatic flow directly after surgical trauma. We investigated lymphatic function in mice using near-infrared imaging for a period of 4 weeks after surgeries that mimic sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (ALND), by removal of the popliteal lymph node (LN) alone or together with the popliteal fat pad, respectively. SLNB-like surgery did not cause changes in lymphatic drainage in the majority of cases. In contrast, lymphatic drainage impairment shown by collecting vessel rupture, dermal backflow and rerouting of lymph flow via collateral vessels were observed after ALND-like surgery. All collateral vessels drained to the inguinal LN. These results indicate that less invasive surgery prevents lymphatic decompensation. They also reveal the development and maturation of collateral lymphatic vessels after extensive surgical trauma, which reroute the flow of lymph towards a different LN. These findings might be helpful for the development of strategies to prevent and/or treat post-surgical lymphedema.

Introduction: To report our preliminary techniques and experience with retroperitoneoscopic single-site renal pedicle lymphatic disconnection (RPSS-RPLD) in five patients with serious filarial chyluria., Materials and Methods: Between May 2010 and July 2011, five patients with serious filarial chyluria underwent RPSS-RPLD. In the patients, a 3 cm single incision was made between the 12th subcostal margin and posterior axillary line, and a homemade single multichannel port using a surgical glove and three conventional trocars was placed into retroperitoneal space. The lymphatic disconnection was similar to traditional open surgery., Results: All the operations were successfully completed without conversion to open surgery. The mean operative time was 116 (102-145) minutes. The mean blood loss was estimated to be 98 (60-190) mL. Chyluria disappeared in all patients after surgery and did not recur during the follow up period (3-14, mean 7.6 months)., Conclusion: RPSS-RPLD is safe and feasible, with favorable short term outcomes and aesthetic effect.

Background: Opinions about the optimal lymph node dissection (LND) template in prostate cancer differ. Drainage and dissemination patterns are not necessarily identical., Objective: To present a precise overview of the lymphatic drainage pattern and to correlate those findings with dissemination patterns. We also investigated the relationship between the number of positive lymph nodes (LN+) and resected lymph nodes (LNs) per region., Design, Setting, and Participants: Seventy-four patients with localized prostate adenocarcinoma were prospectively enrolled. Patients did not show suspect LNs on computed tomography scan and had an LN involvement risk of ≥ 10% but ≤ 35% (Partin tables) or a cT3 tumor., Intervention: After intraprostatic technetium-99m nanocolloid injection, patients underwent planar scintigraphy and single-photon emission computed tomography imaging. Then surgery was performed, starting with a sentinel node (SN) procedure and a superextended lymphadenectomy followed by radical prostatectomy., Outcome Measurements and Statistical Analysis: Distribution of scintigraphically detected SNs and removed SNs per region were registered. The number of LN+, as well as the percentage LN+ of the total number of removed LNs per region, was demonstrated in combining data of all patients. The impact of the extent of LND on N-staging and on the number of LN+ removed was calculated., Results and Limitations: A total of 470 SNs were scintigraphically detected (median: 6; interquartile range [IQR]: 3-9), of which 371 SNs were removed (median: 4; IQR: 2.25-6). In total, 91 LN+ (median: 2; IQR: 1-3) were found in 34 of 74 patients. The predominant site for LN+ was the internal iliac region. An extended LND (eLND) would have correctly staged 32 of 34 patients but would have adequately removed all LN+ in only 26 of 34 patients. When adding the presacral region, these numbers increased to 33 of 34 and 30 of 34 patients, respectively., Conclusions: Standard eLND would have correctly staged the majority of LN+ patients, but 13% of the LN+ would have been missed. Adding the presacral LNs to the template should be considered to obtain a minimal template with maximal gain. NOTE: This manuscript was invited based on the 2011 European Association of Urology meeting in Vienna., (Copyright © 2012 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Introduction: The ideal method for varicocelectomy in children remains controversial. We present our experience with dye-assisted lymphatic-sparing laparoscopic varicocelectomy (LSLV) in children, which overcomes the limitations of previously described techniques., Materials and Methods: Twenty-five consecutive LSLVs were performed on children with a mean age of 15 years over a 4-year period. Varicocele grade was 3 in 21 cases and grade 2 in 4. Indications for intervention were hypotrophy in 12, pain in 11 cases and family preference in 2. A scrotal injection of lymphatic dye was utilized to spare at least one lymphatic and the remaining spermatic vessels were divided., Results: Lymphatic sparing was accomplished in all cases. Operative time varied from 30 to 140 min (mean 85 ± 26). No perioperative complications were noted. On average follow-up of 13 months a residual varicocele was noted in 2 cases, with no hydrocele and resolution of pain. Mean testicular volume difference diminished from 33% pre to 18% postoperatively., Conclusion: This multi-surgeon experience demonstrates that dye-assisted LSLV is easily accomplished with promising results. It appears that preservation of a single spermatic lymphatic vessel is sufficient, although in some cases a second dye injection is required to visualize the lymphatics., (Copyright © 2011 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Metastasis to the regional lymph node is the most important prognostic indicator for the outcomes of patients with sold cancer. In general, it is well recognized that cancer development is genetically determined with progression from the microenvironment of the primary tumor site, oftentimes via the SLN gateway, to the distant sites. In about 20 % of the time, the cancer cells may spread directly through the blood vascular system to the distant sites. Thus, in general, cancer progression is consistent with Hellman's spectrum theory in that development of nodal and systemic metastasis from a localized cancer growth is a progressive process. Cancer proliferation within the tumor microenvironment may give rise to increased tumor heterogeneity, which is further complicated by its continuous change through its evolution within the host in a Darwinian sense. It is crucial to understand the molecular process of lymphangiogenesis and hemangiogenesis in the tumor microenvironment with respect to the initial steps of cancer cells entering into the lymphatic and vascular systems so that rational therapy can be developed to curb the process of specific routes of metastasis. This chapter elucidates the role of lymphatics, nodal metastasis and antitumor immunity. We present novel immune targets in nodal metastases, the importance of the lymph node as a pre-metastatic niche, and immune-related proteins as biomarkers of metastasis.

Lymphedema of the lower limb can occur as a result of lymphatic obstruction secondary to malignancy or to lymphatic filariasis in endemic countries. Resistant lymphedema can be treated with microsurgical lymphovenous anastomosis, thus creating a lymphovenous shunt. Patency of these anastomoses cannot be assessed with conventional imaging modalities (lymphangiogram). Lymphoscintigraphy is useful for this purpose. Early visualization of liver and blood pool activity indirectly confirms presence of a patent lymphovenous shunt. We demonstrate the patency of lymphovenous shunt in a 48-year-old woman who underwent microsurgical lymphovenous anastomosis for severe lymphedema of the left lower limb.

Background: Intestinal ischemia and reperfusion (I/R) is a documented cause of acute lung injury (ALI) and systemic inflammation. We previously reported that obstruction of thoracic lymphatic flow during intestinal I/R blunts pulmonary neutrophil recruitment and microvascular injury and decreases the systemic levels of tumor necrosis factor. Here, we consider the existence of a gut-lung axis promoting the induction of systemic inflammation, whereby drained intestinal lymph stimulates lung expression of adhesion molecules and matrix components and generation of inflammatory mediators., Material and Methods: Upon administration of anesthesia, male Wistar rats were subjected to occlusion of the superior mesenteric artery for 45 min, followed by 2 h of intestinal reperfusion (I/R); groups of rats were subjected to I/R with or without thoracic lymphatic duct ligation immediately before the procedure. The non-manipulated rats were used to investigate basal parameters., Results: Obstruction of thoracic lymphatic flow before intestinal I/R decreased the ability of cultured lung tissue explants to release IL-1β, IL-10, and VEGF. In contrast, lymphatic obstruction normalized the elevated lung expression of PECAM-1 caused by intestinal I/R. On the other hand, lung E-selectin expression was significantly reduced, whereas fibronectin expression and collagen synthesis were not affected. Lymph levels of LTB(4) and TXB(2) were found to be significantly increased., Conclusions: These data suggest that lymph factors drained from the intestine during ischemic trauma stimulate the lung to generate inflammatory mediators and alter the expression of adhesion molecules. Disturbances in lung homeostasis mediated by lymph might contribute to the spread of inflammatory processes, thereby accounting for the systemic inflammation induced by intestinal I/R., (Copyright © 2012 Elsevier Inc. All rights reserved.)

A wide clinical experience in General Surgery has brought about a remarkable knowledge about lymphatic disorders both primary and secondary ones. Diagnostic and histopathological studies of lymphatic diseases allowed to better understand etiological aspects and pathophysiological mechanisms responsible of complex clinical features correlated to lymphatic dysfunctions. Translational lymphologic basic and clinical researches permitted to improve therapeutical approaches both from the medical and surgical point of view. Thus, strategies of treatment were proposed to prevent lymphatic injuries, to avoid lymphatic complications and to treat lymphatic diseases early in order to be able even to cure these pathologies.

Objective: To evaluate postoperative lymphatic compensation in the upper limb after mastectomy with axillary dissection., Subjects and Methods: Twenty-three patients who underwent lymphoscintigraphy before and 60 days after surgery were enrolled from September 2006 to June 2007, in Campinas, Brazil. Protocol examination consisted in static imaging of each upper limb in semi-flexion and thoracic imaging after 10 min and 1 and 2 hr after subcutaneous injection of 1 mCi (37 MBq) of 99mTc dextran into the dorsum of the hand. A comparative analysis was made of hepatic uptake of the radiopharmaceutical, velocity of axillary lymph node visualization (I, visible at 10 min; II, at 1 hr; III, at 2 hr; IV, not visible) and degree (intensity) of uptake (a, marked; b, moderate; c, mild; d, absent) before and 60 days after surgery., Results: In the preoperative period, 3 (13%) patients were considered to have an optimal pattern (Ia) and 2 (9%) showed total involvement (IVd). Compared to velocity in the postoperative period, 9 (39%) patients showed no difference, 5 (22%) improved, 9 (39%) became worse, and one was considerably worse. Regarding the degree, 10 (43%) patients showed no difference, 9 (39%) became worse, and 4 (17%) improved. Regarding classification, 2 (9%) patients had an optimal lymphatic pattern (Ia) and 3 (13%) had total involvement (IVd). No patient presented decreased hepatic uptake after surgical treatment., Conclusions: The study found relevant changes in preoperative and postoperative lymphoscintigraphy, demonstrating the existence of functional differences in the lymphatic system of the upper limb. Alterations in lymphatic drainage pattern may already be perceived 60 days postoperatively, as can signs of lymphovenous anastomoses.