Comparison of Outcomes between Side-to-End and End-to-End Lymphovenous Anastomoses for Early-Grade Extremity Lymphedema

Background: Lymphovenous anastomosis (LVA) is technically challenging and could be successfully performed with advanced operating microscope, super-microsurgical instruments, and indocyanine green (ICG) lymphography. This study was to compare the outcomes between side-to-end and end-to-end LVA configurations for unilateral extremity lymphedema.

Methods: Between April 2013 and June 2017, 58 patients who preoperatively had patent lymphatic ducts by ICG lymphography were indicated for LVA, including 20 upper limb lymphedema and 38 lower limb lymphedema. Either an end-to-end or a side-to-end LVA was used to anastomose the subdermal venule to lymphatic duct. The circumferential difference and episodes of cellulitis were used as outcome measurements.

Results: Twenty-three patients underwent an end-to-end LVA, and 35 patients had a side-to-end LVA. All cases had an immediate patency evaluated by ICG lymphography and patent blue assessments. All patients returned to their daily routine without the use of any compression garments. At a mean follow-up of 16.5 ± 11.5 months, the improvement of circumferential difference 3.2 ± 0.3% in side-to-end group was statistically greater than 2.2 ± 0.5% in end-to-end group (p= 0.04). The overall episodes of cellulitis were significantly reduced from 1.7 ± 2.2 to 0.7 ± 1.1 times per year (p< 0.001), but no difference was observed between the two groups.

Conclusions: Both side-to-end and end-to-end LVA configurations were effective surgical approaches for improving early-grade extremity lymphedema. Side-to-end LVA has the advantages of having a greater efficacy in terms of lymph drainage while requiring only one anastomosis and eliminating the need to use compression garments.