Supermicrosurgical lymphaticovenous anastomosis (LVA) alleviates lymphedema by draining stagnant lymph from the lymphatic vessels into the venous system. Nevertheless, LVA is believed to be unsuitable for treating moderate-to-severe lymphedema presenting diffuse-pattern dermal backflow (DB). Dermal backflow is considered to be the sign of superficial lymphatic functional failure that renders LVA ineffective. Based on a current algorithm, a more invasive vascularized lymph node flap transfer is recommended instead of LVA. This retrospective study aimed to further investigate and possibly challenge this concept. One-hundred patients with unilateral lymphedematous lower limbs who underwent LVA were included. Patients were divided into Group I (10 patients with mild lymphedema) and Group II (90 patients with moderate-to-severe lymphedema). Demographic data and intraoperative findings were recorded. The post-LVA volume reductions by magnetic resonance volumetry were recorded and analyzed. Preoperatively, significant differences were found in BMI (20.6 vs 26.0 kg/m2, p = 0.004) and the volume gained in the lymphedematous limb (396.8 mL vs 1,056.8 mL, p = 0.005) between Groups I and II. Postoperatively, a significant median post-LVA volume reduction (-282.0 mL vs -763.5 mL, p = 0.022) was found in Group II. However, there were no differences in the percentages of post-LVA volume reduction (-43.8% vs -36.4%, p = 0.793) in Groups I and II. The use of supermicrosurgical LVA is as effective at treating moderate-to-severe lymphedema as milder lymphedema. The indication for LVA should be broadened to include such cases.

Background: Functional lymphatic vessels are essential for supermicrosurgical lymphaticovenous anastomosis. Theoretically, the larger the lymphatic vessel, the better the flow. However, large lymphatic vessels are not readily available. Since the introduction of lymphaticovenous anastomosis, no guidelines have been set as to how small a lymphatic vessel is still worthwhile for anastomosis. Methods: In this longitudinal cohort study, unilateral lower limb lymphedema patients who underwent lymphaticovenous anastomosis between March of 2016 and January of 2019 were included. Demographic data and intraoperative findings including the number and size of lymphatic vessels were recorded. The cutoff size was determined by receiver operating characteristic curve analysis, based on the functional properties of lymphatic vessels. Clinical correlation was made with post–lymphaticovenous anastomosis volume measured by magnetic resonance volumetry. Results: A total of 141 consecutive patients (124 women and 17 men) with a median age of 60.0 years (range, 56.7 to 61.2 years) were included. The cutoff size for a functional lymphatic vessel was determined to be 0.50 mm (i.e., lymphatic vessel^0.5) from a total of 1048 lymphatic vessels. Significant differences were found between the number of lymphatic vessels^0.5 anastomosed (zero to one, two to three, and greater than over equal to four lymphatic vessels^0.5), the median post–lymphaticovenous anastomosis volume reduction (in milliliters) (p < 0.001), and the median percentage volume reduction (p = 0.012). Conclusions: Lymphatic vessel^0.5 can be a valuable reference for lymphaticovenous anastomosis. Post–lymphaticovenous anastomosis outcome can be enhanced with the use of lymphatic vessel^0.5 for anastomoses. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Background: Contraction-type lymphatic vessels (LV) are considered suboptimal for lymphaticovenous anastomosis (LVA). However, despite these pathological changes, their functionality and link to outcomes have not been fully elucidated. The aim of this study was to determine the impact on outcomes when contraction-type LVs were used for LVA compared to the noncontraction-type (normal + ectatic) counterpart for treating lower limb lymphedema. Study design: Eighty-three patients with gynecologic cancer-related unilateral lower-limb lymphedema who underwent LVA as their primary treatment were enrolled in this study. The study group included 20 patients who used only contraction-type LVs. An additional 63 patients (control group) received noncontraction-type LVs only. Patients with a history of LVA, liposuction, or excisional therapy were excluded. Patient characteristics, intraoperative findings, functional parameters, and pre-LVA and post-LVA volume changes were recorded and matched using propensity scores. The primary endpoint was the volume change at 6/12 months after LVA. Results: After matching, 20 patients were included in each group. All parameters were matched, except that the study group still had a significantly inferior indocyanine green (ICG)-positive ratio, lymph flow-positive ratio, and washout-positive ratios (P<0.001, P=0.003, and P<0.001, respectively) when compared to the control group after matching. However, at 1-year follow-up, the postoperative percentage volume reduction was comparable between the groups (P=0.619). Conclusion: The use of contraction-type LVs for LVA is encouraged when no other LVs are available.

Despite an increased incidence of secondary lower limb lymphedema (LLL) and severity of comorbidities with age, the impact of age on the effectiveness of lymphaticovenous anastomosis (LVA) in the older patients remains unclear. Methods: This retrospective cohort study enrolled older patients (age > 65 years) with secondary unilateral LLL. All patients underwent supermicrosurgical LVA. Demographic data and intraoperative findings including lymphatic vessel (LV) diameter, LV functionality (indocyanine green-enhanced and Flow positivity), and lymphosclerosis classification were recorded. Magnetic resonance volumetry was used for measuring preoperative and postoperative volume changes at 6 months and one year after LVA as primary and secondary endpoints. Results: Thirty-two patients (29 females/3 males) with a median age of 71.0 years [range, 68.0 to 76.3] were enrolled. The median duration of lymphedema was 6.4 [1.0 to 11.7] years. The median LV diameter was 0.7 [0.5 to 0.8] mm. The percentage of ICG-enhanced and Flow-positive LVs were 89.5% and 85.8%, respectively. The total percentage of suitable LVs (s0 and s1) for LVA based on lymphosclerosis classification was 75.9%. There were significant six-month and one-year post-LVA percentage volume reductions compared to pre-LVA volume (both p < 0.001). A significant reduction in cellulitis incidence was also noted after LVA (p < 0.001). No surgical or postoperative complications were found. Conclusion: Relief of secondary LLL was achievable through LVA in older patients who still possessed favorable LV characteristics, including larger LV diameters as well as a high proportion of functional LVs with a low grade of lymphosclerosis.

Introduction: Early identification of high-risk traumatic brain injury (TBI) patients is crucial for optimizing treatment strategies and improving outcomes. The C-reactive protein-to-lymphocyte ratio (CLR) reflects systemic immunology and inflammation function and serves as a new biomarker for patient stratification. This study aimed to assess the predictive value of the CLR for mortality in patients with isolated moderate to severe TBI. Methods: A retrospective analysis of trauma registry data from 2009 to 2022 was conducted, including 1641 adult patients with isolated moderate to severe TBI. Patient demographics, the CLR, injury characteristics, and outcomes were compared between deceased and surviving patients. Univariate and multivariate analyses were performed to identify mortality risk factors. The optimal CLR cut-off value for predicting mortality was determined using receiver operating characteristic (ROC) curve analysis. Results: The CLR was significantly higher in deceased patients compared to survivors (60.1 vs. 33.9, p < 0.001). The optimal CLR cut-off value for predicting mortality was 54.5, with a sensitivity of 0.328 and a specificity of 0.812. The area under the ROC curve was 0.566, indicating poor discriminative ability. In the multivariate analysis, the CLR was not a significant independent predictor of mortality (OR 1.03, p = 0.051). After propensity score matching to attenuate the difference in baseline characteristics, including sex, age, comorbidities, conscious level, and injury severity, the high-CLR group (CLR ≥ 54.5) did not have significantly higher mortality compared to the low-CLR group (CLR < 54.5). Conclusion: While the CLR was associated with mortality in TBI patients, it demonstrated poor discriminative ability as a standalone predictor. The association between a high CLR and worse outcomes may be primarily due to other baseline patient and injury characteristics, rather than the CLR itself.