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Page 2 of 6 Chen et al. Plast Aesthet Res 2021;8:36 https://dx.doi.org/10.20517/2347-9264.2021.33

Conclusion: Lymphovenular anastomosis can be performed under local anesthesia, especially in patients with high
risks of general anesthesia (ASA PS score > 3). By this way, we could achieve adequate anastomosis and effective
treatment of lymphedema in advanced cancer patients as well.

Keywords: Lymphedema, lymphovenular anastomosis, local anesthesia, complex decongestive therapy, advanced
cancer patients, ASA PS score

INTRODUCTION
The lymphovenular anastomosis (LVA) procedure was presented and described for the first time by
[1]
[2]
professor Olszewski . In 1977, O’Brien et al. developed microlymphaticovenous anastomoses for
obstructive lymphedema with a promising results. Using LVA to treat lower limb lymphedema is also well
documented in the past literature . The American Society of Anesthesiologists Physical Status (ASA PS)
[3]
classification system is a method of characterizing patient operative risk on a scale of 1-5. It can be a reliable,
[4]
independent predictor of medical complications and surgical mortalities . Local anesthetics are safe,
effective drugs that provide transient insensibility to pain in a limited area of skin . Local anesthesia allows
[5]
for low-risk surgery to occur for high-risk patients with complications, especially those with high ASA PS
[6,7]
scores. However, local anesthesia is the usual choice of anesthesia in Japan . In this study, benefits and
results were evaluated in LVA for limb lymphedema between local anesthesia and general anesthesia in the
patients at high ASA PS score.

METHODS
From January 2019 to January 2021, a total of 29 patients with lymphedema including stage III and stage IV
were treated with LVA by a single surgeon in a medical center [Figure 1]. These patients, who had been
treated with compression therapy, showed little improvement, or no change of the circumference of the
affected limbs. After surgery, the patients continued complex decongestive therapy (CDT) including a
continuous wearing of an elastic stocking and daily exercises. For an objective assessment of results, the
circumferences of the affected and opposite normal leg were measured at 15 cm above the superior border
of the patella, at 15 cm below the inferior border of the patella, at the ankle, and at the foot. Measurements
were made at admission, 2 weeks, and 3 months after LVA in our outpatient clinic. For upper limbs, the
circumferences of the affected and opposite normal arm were measured at 10 cm above the elbow, at 10 cm
below the elbow, at the wrist, and at the hand at the same time intervals [Figure 2]. To examine the
effectiveness of LVA, differences in preoperative and postoperative means were analyzed using the paired
samples t-test. Differences in proportions were analyzed using the Chi-squared test.

RESULTS
Twenty-nine patients with high ASA PS score (> 3) (age: 37-94 years old; 4 males and 25 females) were
followed after LVA and postoperative compression therapy. There were 21 patients with present oncological
therapies due to cancer recurrence. The average duration of edema of these patients before LVA was 25 ±
5.0 years. The average number of anastomosis for each patient was 6.8 ± 2.2; the methods of anesthesia had
no significant influence on these numbers. The average follow-up period was 7.8 ± 0.85 months, and the
procedure was considered effective in 26 of 29 patients (89.7%) [Table 1]. However, 3 patients showed no
improvement because of cancer progressions. Six patients showed reduction of over 4 cm in the
circumference of the lower leg. The average reduction of the circumference in affected limbs was 4.40% ±
3.67% of the preoperative excess length. Between two groups, the local anesthesia group has a higher
proportion of cancer patients (81.0% of local anesthesia vs. 62.5% of general anesthesia) and less immediate
reduction of the limb circumference in comparison to those of general anesthesia (2.03% of local anesthesia