title: Sequential anastomosis for lymphatic supermicrosurgery: multiple lymphaticovenular anastomoses on 1 venule.
abstract: BACKGROUND
  Supermicrosurgical lymphaticovenular anastomosis (LVA) is becoming a treatment option for progressive lymphedema. Various types of LVA such as end-to-end, end-to-side, side-to-end, and side-to-side are performed to improve the treatment efficacy.
  
  
  METHODS
  We applied sequential anastomosis for LVA surgery, in which 2 lymphatic vessels were anastomosed to 1 venule using side-to-side and side-to-end anastomoses. Six lower extremity lymphedema (LEL) patients who underwent sequential anastomosis were included in this study. Feasibility, anastomosis patency, and treatment effect of the method were evaluated.
  
  
  RESULTS
  Six sequential anastomoses were performed on 6 lymphedematous limbs. All sequential anastomoses showed good anastomosis patency after completion of anastomoses. A significant decrease in LEL index was seen postoperatively (244.0 ± 14.6; postoperative LEL index vs 263.5 ± 19.4; preoperative LEL index, P = 0.002).
  
  
  CONCLUSIONS
  Sequential anastomosis can divert both normograde and retrograde lymph flows from 2 lymphatic vessels into 1 venule. Sequential LVA is a useful method to increase lymph flow bypasses, when there are fewer venules than lymphatic vessels.
authors.affiliation: From the Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, the University of Tokyo, Bunkyo-ku, Tokyo, Japan.
authors.forename: Takumi
authors.initials: T
authors.lastname: Yamamoto
authors.forename: Hidehiko
authors.initials: H
authors.lastname: Yoshimatsu
authors.forename: Mitsunaga
authors.initials: M
authors.lastname: Narushima
authors.forename: Nana
authors.initials: N
authors.lastname: Yamamoto
authors.forename: Timothy Weng Hoh
authors.initials: TW
authors.lastname: Shim
authors.forename: Yukio
authors.initials: Y
authors.lastname: Seki
authors.forename: Kazuki
authors.initials: K
authors.lastname: Kikuchi
authors.forename: Jun
authors.initials: J
authors.lastname: Karibe
authors.forename: Shuchi
authors.initials: S
authors.lastname: Azuma
authors.forename: Isao
authors.initials: I
authors.lastname: Koshima
mesh_terms: D000328:Adult; D000714:Anastomosis, Surgical / Q000379:methods; D005260:Female; D006801:Humans; D007044:Hysterectomy; D008197:Lymph Node Excision; D042601:Lymphatic Vessels / Q000601:surgery*; D008209:Lymphedema / Q000601:surgery*; D008866:Microsurgery; D008875:Middle Aged; D002583:Uterine Cervical Neoplasms / Q000601:surgery; D014654:Vascular Patency