LAUSR

We read with great interest the article entitled “Outcomes Following Lymphaticovenous Anastomosis (LVA) for 100 Cases of Lymphedema: Results over 24-months Follow-up” by Qiu et al. [1]. LVA performed by authors did not show a significance in reduction of circumference but resulted in improvement of quality of life (QOL). Based on our experience of LVA, LVA leads not only to significant improvement of QOL but also to significant lymphedematous volume reduction both in upper extremity and lower extremity lymphedema cases. The number of anastomoses is one of the most important factors associated with favorable results. It is essential to create appropriate anastomoses as many as possible in a LVA operating field to maximize the therapeutic efficacy [2, 3]. There are 4 basic anastomotic configurations including end-to-end (E–E), end-to-side (E–S), side-to-end (S–E) and side-to-side (S–S). E–E and E–S anastomosis can make a one-way flow, while S–E and S–S can create both antegrade and retrograde two-way flows to one recipient vein. Though S–E and S–S are efficient configurations, they require lymphotomy which is hardly applicable on lymphatic vessels complicated with severe lymphangiosclerosis [2]. Lymphangiosclerosis can be judged with temporary lymphatic expansion maneuver in which a lymphatic vessel is temporary clamped proximally and distal limb is massaged; lymphangiosclerosis is evaluated as severe when the lymphatic vessel is not expanded. For severely sclerotic lymphatic vessel, E–E or E–S anastomosis is preferred than S–E or S–S which requires lymphotomy. The major venous factor in selection of anastomotic configuration is venous reflux. If there is continuous bleeding from a venous stump after transection, there would be higher risk of anastomosis site thrombosis due to venous reflux into the anastomosis site. In such a situation with venous reflux, E–E anastomosis is the most favorable, because all lymph are forced to flow into the recipient vein. It is ideal to maximize the number of anastomoses by utilizing all the E–E, E–S, S–E and S–S techniques according to vessels’ conditions. For example, there were 2 venous branches without venous reflux and 4 lymphatic vessels, with less sclerosis in 3 and severe sclerosis in the remaining 1. The 3 less sclerotic lymphatic vessels could be anastomosed in any type of anastomotic configurations, whereas the remaining 1 severely sclerotic lymphatic vessel should be anastomosed in an E–E or E–S fashion. To anastomose all the lymphatic vessels, SS and SE anastomosis could not be performed due to the vessel distances. Based on these findings, all lymphatic vessels were transected, and all the 8 lymphatic vessels stumps were anastomosed in EE and ES fashions. After completion of the anastomoses, the recipient vein turned transparent in color fulfilled with lymph flowing from the 8 lymphatic vessel stumps (Fig. 1). Since there is a relationship between the number of LVAs and therapeutic effect, it is important to create as many anastomoses as possible. The selection of the E–E, E–S, S–E and S–S anastomosis according to the condition of the veins or lymphatic vessels is crucial. Future studies are required to confirm its efficacy in the selection of anastomotic configuration based on vessels’ conditions.