Bioelectrical Impedance Analysis of Water Reduction in Lower-Limb Lymphedema by Lymphaticovenular Anastomosis

Abstract

Background Although lymphedema is fundamentally abnormal accumulation of excess water in the extracellular space, previous studies have evaluated the efficacy of physiological bypass surgery (lymphaticovenular anastomosis [LVA]) for lymphedema without measuring water volume. This study clarified the water reductive effect of LVA using bioelectrical impedance analysis (BIA).

Methods The efficacy of LVA for unilateral lower-limb lymphedema was evaluated using BIA in a retrospective cohort. The water volume of affected and unaffected legs was measured using multifrequency BIA before and after LVA. Preoperative measurements were undertaken after compression therapy for at least 3 months. The follow-up period after LVA was a minimum of 6 months.

Results Thirty consecutive patients with unilateral lower-limb lymphedema were enrolled. The mean water volume reduction of the affected leg by LVA (ΔLBW) was 0.86 L (standard deviation [SD]: 0.86, median: 0.65) with a mean number of 3.3 anastomoses (SD: 1.7). The mean reduction rate of edema was 45.1% (SD: 36.3). Multiple linear regression analysis revealed water volume difference between the affected and unaffected legs before LVA (excess LBW) as the strongest predictor of ΔLBW (R ² = 0.759, p < 0.01; β = 0.500, p < 0.01).

Conclusion The LVA reduces the volume of accumulated body water in lower-limb lymphedema. As excess LBW most strongly predicted the amount of water volume reduction by LVA, body water volume measurement by BIA before LVA might identify patients with low excess LBW not expected to benefit from LVA, regardless of apparent differences in limb circumference.

Keywords

lymphedema - lymphaticovenular anastomosis - bioelectrical impedance analysis

Financial Disclosure

None of the authors have nothing to disclose.

Note

This study was presented in part at the 44th Annual Meeting of the Japanese Society of Reconstructive Microsurgery in Miyazaki, Japan, December 7, 2017.

• References

• 1 International Society of Lymphology. The diagnosis and treatment of peripheral lymphedema: 2013 Consensus Document of the International Society of Lymphology. Lymphology 2013; 46 (01) 1-11
• 2 Lee KT, Park JW, Mun GH. Serial two-year follow-up after lymphaticovenular anastomosis for the treatment of lymphedema. Microsurgery 2017; 37 (07) 763-770
• 3 Sosin M, Yin C, Poysophon P, Patel KM. Understanding the concepts and physiologic principles of lymphatic microsurgery. J Reconstr Microsurg 2016; 32 (08) 571-579
• 4 Basta MN, Gao LL, Wu LC. Operative treatment of peripheral lymphedema: a systematic meta-analysis of the efficacy and safety of lymphovenous microsurgery and tissue transplantation. Plast Reconstr Surg 2014; 133 (04) 905-913
• 5 Carl HM, Walia G, Bello R. , et al. Systematic review of the surgical treatment of extremity lymphedema. J Reconstr Microsurg 2017; 33 (06) 412-425
• 6 Felmerer G, Sattler T, Lohrmann C, Tobbia D. Treatment of various secondary lymphedemas by microsurgical lymph vessel transplantation. Microsurgery 2012; 32 (03) 171-177
• 7 Huang GK, Hu RQ, Liu ZZ, Shen YL, Lan TD, Pan GP. Microlymphaticovenous anastomosis in the treatment of lower limb obstructive lymphedema: analysis of 91 cases. Plast Reconstr Surg 1985; 76 (05) 671-685
• 8 Matsubara S, Sakuda H, Nakaema M, Kuniyoshi Y. Long-term results of microscopic lymphatic vessel-isolated vein anastomosis for secondary lymphedema of the lower extremities. Surg Today 2006; 36 (10) 859-864
• 9 Yamamoto Y, Horiuchi K, Sasaki S. , et al. Follow-up study of upper limb lymphedema patients treated by microsurgical lymphaticovenous implantation (MLVI) combined with compression therapy. Microsurgery 2003; 23 (01) 21-26
• 10 Koshima I, Nanba Y, Tsutsui T, Takahashi Y, Itoh S. Long-term follow-up after lymphaticovenular anastomosis for lymphedema in the leg. J Reconstr Microsurg 2003; 19 (04) 209-215
• 11 Koshima I, Inagawa K, Urushibara K, Moriguchi T. Supermicrosurgical lymphaticovenular anastomosis for the treatment of lymphedema in the upper extremities. J Reconstr Microsurg 2000; 16 (06) 437-442
• 12 Furukawa H, Osawa M, Saito A. , et al. Microsurgical lymphaticovenous implantation targeting dermal lymphatic backflow using indocyanine green fluorescence lymphography in the treatment of postmastectomy lymphedema. Plast Reconstr Surg 2011; 127 (05) 1804-1811
• 13 Yamamoto T, Narushima M, Kikuchi K. , et al. Lambda-shaped anastomosis with intravascular stenting method for safe and effective lymphaticovenular anastomosis. Plast Reconstr Surg 2011; 127 (05) 1987-1992
• 14 Narushima M, Mihara M, Yamamoto Y, Iida T, Koshima I, Mundinger GS. The intravascular stenting method for treatment of extremity lymphedema with multiconfiguration lymphaticovenous anastomoses. Plast Reconstr Surg 2010; 125 (03) 935-943
• 15 Auba C, Marre D, Rodríguez-Losada G, Hontanilla B. Lymphaticovenular anastomoses for lymphedema treatment: 18 months postoperative outcomes. Microsurgery 2012; 32 (04) 261-268
• 16 Ipsen T, Pless J, Frederiksen PB. Experience with microlymphaticovenous anastomoses for congenital and acquired lymphoedema. Scand J Plast Reconstr Surg Hand Surg 1988; 22 (03) 233-236
• 17 Demirtas Y, Ozturk N, Yapici O, Topalan M. Comparison of primary and secondary lower-extremity lymphedema treated with supermicrosurgical lymphaticovenous anastomosis and lymphaticovenous implantation. J Reconstr Microsurg 2010; 26 (02) 137-143
• 18 O'Brien BM, Mellow CG, Khazanchi RK, Dvir E, Kumar V, Pederson WC. Long-term results after microlymphaticovenous anastomoses for the treatment of obstructive lymphedema. Plast Reconstr Surg 1990; 85 (04) 562-572
• 19 Chang DW. Lymphaticovenular bypass for lymphedema management in breast cancer patients: a prospective study. Plast Reconstr Surg 2010; 126 (03) 752-758
• 20 Baumeister RG, Siuda S. Treatment of lymphedemas by microsurgical lymphatic grafting: what is proved?. Plast Reconstr Surg 1990; 85 (01) 64-74 , discussion 75–76
• 21 Weiss M, Baumeister RG, Hahn K. Post-therapeutic lymphedema: scintigraphy before and after autologous lymph vessel transplantation: 8 years of long-term follow-up. Clin Nucl Med 2002; 27 (11) 788-792
• 22 Olszewski WL. Lymphovenous microsurgical shunts in treatment of lymphedema of lower limbs: a 45-year experience of one surgeon/one center. Eur J Vasc Endovasc Surg 2013; 45 (03) 282-290
• 23 Maegawa J, Yabuki Y, Tomoeda H, Hosono M, Yasumura K. Outcomes of lymphaticovenous side-to-end anastomosis in peripheral lymphedema. J Vasc Surg 2012; 55 (03) 753-760
• 24 Maegawa J, Mikami T, Yamamoto Y, Satake T, Kobayashi S. Types of lymphoscintigraphy and indications for lymphaticovenous anastomosis. Microsurgery 2010; 30 (06) 437-442
• 25 Mukenge SM, Catena M, Negrini D. , et al. Assessment and follow-up of patency after lymphovenous microsurgery for treatment of secondary lymphedema in external male genital organs. Eur Urol 2011; 60 (05) 1114-1119
• 26 Yamamoto Y, Sugihara T. Microsurgical lymphaticovenous implantation for the treatment of chronic lymphedema. Plast Reconstr Surg 1998; 101 (01) 157-161
• 27 Damstra RJ, Voesten HG, van Schelven WD, van der Lei B. Lymphatic venous anastomosis (LVA) for treatment of secondary arm lymphedema. A prospective study of 11 LVA procedures in 10 patients with breast cancer related lymphedema and a critical review of the literature. Breast Cancer Res Treat 2009; 113 (02) 199-206
• 28 Pereira N, Lee YH, Suh Y. , et al. Cumulative experience in lymphovenous anastomosis for lymphedema treatment: the learning curve effect on the overall outcome. J Reconstr Microsurg 2018;
• 29 Pereira De Godoy JM, Franco Brigidio PA, Salles Cunha SX, Batigália F, De Fatima Guerreiro Godoy M. Mobilization of fluids in large volumetric reductions during intensive treatment of leg lymphedema. Int Angiol 2013; 32 (05) 479-482
• 30 Yamamoto T, Narushima M, Doi K. , et al. Characteristic indocyanine green lymphography findings in lower extremity lymphedema: the generation of a novel lymphedema severity staging system using dermal backflow patterns. Plast Reconstr Surg 2011; 127 (05) 1979-1986
• 31 Yamamoto T, Matsuda N, Todokoro T. , et al. Lower extremity lymphedema index: a simple method for severity evaluation of lower extremity lymphedema. Ann Plast Surg 2011; 67 (06) 637-640
• 32 Cha K, Chertow GM, Gonzalez J, Lazarus JM, Wilmore DW. Multifrequency bioelectrical impedance estimates the distribution of body water. J Appl Physiol (1985) 1995; 79 (04) 1316-1319
• 33 Hoffer EC, Meador CK, Simpson DC. Correlation of whole-body impedance with total body water volume. J Appl Physiol 1969; 27 (04) 531-534
• 34 Sartorio A, Malavolti M, Agosti F. , et al. Body water distribution in severe obesity and its assessment from eight-polar bioelectrical impedance analysis. Eur J Clin Nutr 2005; 59 (02) 155-160
• 35 Bedogni G, Malavolti M, Severi S. , et al. Accuracy of an eight-point tactile-electrode impedance method in the assessment of total body water. Eur J Clin Nutr 2002; 56 (11) 1143-1148
• 36 Moseley A, Piller N, Carati C. Combined opto-electronic perometry and bioimpedance to measure objectively the effectiveness of a new treatment intervention for chronic secondary leg lymphedema. Lymphology 2002; 35 (04) 136-143
• 37 Garza III R, Skoracki R, Hock K, Povoski SP. A comprehensive overview on the surgical management of secondary lymphedema of the upper and lower extremities related to prior oncologic therapies. BMC Cancer 2017; 17 (01) 468
• 38 Ancukiewicz M, Russell TA, Otoole J. , et al. Standardized method for quantification of developing lymphedema in patients treated for breast cancer. Int J Radiat Oncol Biol Phys 2011; 79 (05) 1436-1443
• 39 Chang DW, Suami H, Skoracki R. A prospective analysis of 100 consecutive lymphovenous bypass cases for treatment of extremity lymphedema. Plast Reconstr Surg 2013; 132 (05) 1305-1314
• 40 Casley-Smith JR. Measuring and representing peripheral oedema and its alterations. Lymphology 1994; 27 (02) 56-70
• 41 Mihara M, Hara H, Tange S. , et al. Multisite lymphaticovenular bypass using supermicrosurgery technique for lymphedema management in lower lymphedema cases. Plast Reconstr Surg 2016; 138 (01) 262-272
• 42 Salgarello M, Mangialardi ML, Pino V, Gentileschi S, Visconti G. A prospective evaluation of health-related quality of life following lymphaticovenular anastomosis for upper and lower extremities lymphedema. J Reconstr Microsurg 2018;