Restricted accessResearch articleFirst published online 2023-8
Application of indocyanine green lymphography combined with methylene blue staining in lymphaticovenular anastomosis of lower limb vessels: A prospective study
Methylene blue (MB) is a conventional lymphatic tracer. We evaluated the application of indocyanine green (ICG) lymphography combined with MB staining in lower limb lymphaticovenular anastomosis (LVA).
Methods
A total of 49 patients with lower limb lymphedema were selected as the study subjects and divided into the research (n = 27) and control groups (n = 22). The patients were treated with LVA using ICG lymphography combined with MB staining and simple ICG lymphography as the positioning method, respectively. The number of lymphatic vessels anastomosed and the operating time were compared between the groups. Lower Extremity Lymphedema Index (LEL index) and Lymphoedema Functioning, Disability and Health Questionnaire for Lower Limb Lymphoedema (Lymph-ICF-LL) were used as prognostic indices; 6 months after LVA, both groups were evaluated for the symptomatic relief of lymphedema.
Results
The number of anastomotic lymphatic vessels in the study group was higher than that in the control group (p < .05), and their procedural time was shorter than that in the control group. The two groups had no significant difference in lymphatic anastomosis time (p > .05). The LEL index and Lymph-ICF-LL of the research and control groups at 6-month follow-up after LVA were lower than those before the operation (p < .05).
Conclusion
The circumference of the affected limb is reduced after LVA in patients with lower extremity lymphedema with a favorable prognosis. ICG lymphography combined with MB staining has the advantages of real-time visualization and accurate localization.
PhillipsGSAGoreSRamsdenA, et al.Lymphaticovenular anastomosis in the treatment of secondary lymphoedema of the legs after cancer treatment. J Plast Reconstr Aesthet Surg2019; 72(7): 1184–1192.
2.
YamamotoTYamamotoNYoshimatsuH, et al.Factors associated with lymphosclerosis: an analysis on 962 lymphatic vessels. Plast Reconstr Surg2017; 140(4): 734–741.
MasiaJOlivaresLKoshimaI, et al.Barcelona consensus on supermicrosurgery. J Reconstr Microsurg2014; 30(1): 53–58.
5.
OhAKajitaHMatobaE, et al.Photoacoustic lymphangiography before and after lymphaticovenular anastomosis. Arch Plast Surg2021; 48(3): 323–328.
6.
ChaoAHSchulzSAPovoskiSP. The application of indocyanine green (ICG) and near-infrared (NIR) fluorescence imaging for assessment of the lymphatic system in reconstructive lymphaticovenular anastomosis surgery. Expert Rev Med Devices2021; 18(4): 367–374.
7.
JangSLeeCUHesleyGK, et al.Lymphatic mapping using us microbubbles before lymphaticovenous anastomosis surgery for lymphedema. Radiology2022; 304(1): 218–224.
8.
PaiMFramptonAEVirkJS, et al.Preoperative superselective mesenteric angiography and methylene blue injection for localization of obscure gastrointestinal bleeding. JAMA Surg2013; 148(7): 665–668.
9.
TummersQRVerbeekFPSchaafsmaBE, et al.Real-time intraoperative detection of breast cancer using near-infrared fluorescence imaging and methylene blue. Eur J Surg Oncol2014; 40(7): 850–858.
10.
HillarySLGuillermetSBrownNJ, et al.Use of methylene blue and near-infrared fluorescence in thyroid and parathyroid surgery. Langenbecks Arch Surg2018; 403(1): 111–118.
11.
VarghesePAbdel-RahmanATAkberaliS, et al.Methylene blue dye--a safe and effective alternative for sentinel lymph node localization. Breast J2008; 14(1): 61–67.
12.
BlessingWDStolierAJTengSC, et al.A comparison of methylene blue and lymphazurin in breast cancer sentinel node mapping. Am J Surg2002; 184(4): 341–345.
13.
MaGCuiXHanY, et al.Multipoint injection indocyanine green lymphography can reduce lymphaticovenular anastomosis surgical time and improve the surgical results for lymphedema. Plast Aesthet Res2021; 8(7): 1–8.
14.
GentileschiSServilloMAlbaneseR, et al.Lymphatic mapping of the upper limb with lymphedema before lymphatic supermicrosurgery by mirroring of the healthy limb. Microsurgery2017; 37(8): 881–889.
15.
MiharaMSekiYHaraH, et al.Predictive lymphatic mapping: a method for mapping lymphatic channels in patients with advanced unilateral lymphedema using indocyanine green lymphography. Ann Plast Surg2014; 72(6): 706–710.
16.
YamamotoTMatsudaNTodokoroT, et al.Lower extremity lymphedema index: a simple method for severity evaluation of lower extremity lymphedema. Ann Plast Surg2011; 67(6): 637–640.
17.
YamamotoTYamamotoNHayashiN, et al.Practicality of the lower extremity lymphedema index: lymphedema index versus volumetry-based evaluations for body-type-corrected lower extremity volume evaluation. Ann Plast Surg2016; 77(1): 115–118.
18.
SowaYKodamaTNumajiriT. Can lymph transportation capacity predict treatment efficacy of lower extremity lymphedema by LVA?Plast Reconstr Surg Glob Open2021; 9(2): e3342.
19.
DevoogdtNDe GroefAHendrickxA, et al.Lymphoedema functioning, disability and health questionnaire for lower limb lymphoedema (lymph-ICF-LL): reliability and validity. Phys Ther2014; 94(5): 705–721.
20.
WangCMLeeSYHsuKF, et al.Psychometric evaluation of a Chinese version of lymphoedema functioning, disability and health questionnaire for lower limb lymphoedema in women with gynaecological cancer surgery. Eur J Cancer Care (Engl)2018; 27(6): e12940.
21.
FerreiraKRCarvalhoRBde AndradeMF, et al.Translation and cross-cultural adaptation of the lymphoedema functioning, disability and health questionnaire for lower limb lymphoedema into portuguese language. Rev Bras Ginecol Obstet2016; 38(2): 88–96.
22.
BonaAFFerreiraKRCarvalhoRBM, et al.Psychometric evaluation of a Brazilian version of the lymphedema functioning, disability and health questionnaire for lower limb lymphedema in patients after cancer treatment. Lymphat Res Biol2022; 20(1): 82–88.
23.
ŞahinoğluEErginGKaradibakD. The efficacy of change in limb volume on functional mobility, health-related quality of life, social appearance anxiety, and depression in patients with lower extremity lymphedema. Phlebology2022; 37(3): 200–205.
24.
DessourcesKAvikiELeitaoMMJr. Lower extremity lymphedema in patients with gynecologic malignancies. Int J Gynecol Cancer2020; 30(2): 252–260.
25.
FuMRRidnerSHHuSH, et al.Psychosocial impact of lymphedema: a systematic review of literature from 2004 to 2011. Psychooncology2013; 22(7): 1466–1484.
26.
BigliaNZanfagninVDanieleA, et al.Lower body lymphedema in patients with gynecologic cancer. Anticancer Res2017; 37(8): 4005–4015.
27.
OkekeAABatesDOGillattDA. Lymphoedema in urological cancer. Eur Urol2004; 45(1): 18–25.
28.
CiudadPSabbaghMDAgkoM, et al.Surgical management of lower extremity lymphedema: a comprehensive review. Indian J Plast Surg2019; 52(1): 81–92.
29.
AkitaSMitsukawaNRikihisaN, et al.Early diagnosis and risk factors for lymphedema following lymph node dissection for gynecologic cancer. Plast Reconstr Surg2013; 131(2): 283–290.
ChungJHHwangYJParkSH, et al.Preliminary outcomes of combined surgical approach for lower extremity lymphedema: supraclavicular lymph node transfer and lymphaticovenular anastomosis. J Plast Surg Hand Surg2022; 56(5): 261–269.
32.
van de PasCBBoonenRSStevensS, et al.Does tumescent liposuction damage the lymph vessels in lipoedema patients?Phlebology2020; 35(4): 231–236.
33.
LiuFLiuNFWangL, et al.Treatment of secondary lower limb lymphedema after gynecologic cancer with complex decongestive therapy. Lymphology2021; 54(3): 122–132.
34.
YamadaY. Studies on lymphatic venous anastomosis in lymphedema. Nagoya J Med Sci1969; 32: 1–21.
35.
O'BrienBMSykesPThrelfallGN, et al.Microlymphaticovenous anastomoses for obstructive lymphedema. Plast Reconstr Surg1977; 60(2): 197–211.
36.
KoshimaIInagawaKUrushibaraK, et al.Supermicrosurgical lymphaticovenular anastomosis for the treatment of lymphedema in the upper extremities. J Reconstr Microsurg2000; 16(6): 437–442.
37.
NagaseTGondaKInoueK, et al.Treatment of lymphedema with lymphaticovenular anastomoses. Int J Clin Oncol2005; 10: 304–310.
38.
ChenWFKnackstedtR. Delayed distally based prophylactic lymphaticovenular anastomosis: improved functionality, feasibility, and oncologic safety?J Reconstr Microsurg2020; 36(9): e1–e2.
39.
CwalinskiTSkokowskiJPolomW, et al.Fluorescence imaging using methylene blue sentinel lymph node biopsy in melanoma. Surg Innov2022; 29(4): 503–510.
40.
HalilbasicEIljazovicEMehmedovicZ, et al.Methylene blue as inexpensive and reliable sole sentinel lymph node mapping agent for patients with invasive ductal carcinoma. Mater Sociomed2021; 33(4): 282–287.
41.
StaniloaieDBudinCVasileD, et al.Role of methylene blue in detecting the sentinel lymph node in colorectal cancer: in vivo vs. ex vivo technique. Exp Ther Med2022; 23(1): 72.
