超显微淋巴管-静脉吻合术治疗肢体淋巴水肿: 基于临床分期与吲哚菁绿分型的疗效分析

doi:10.19723/j.issn.1671-167X.2026.02.021

摘要/Abstract

摘要：

目的: 依据国际淋巴学会(International Society of Lymphology, ISL)分期及吲哚菁绿(indocyanine green, ICG)淋巴造影Yamamoto标准分型，探讨超显微淋巴管-静脉吻合术(lymphaticovenular anastomosis, LVA)治疗肢体淋巴水肿的疗效差异，为手术适应证选择提供循证依据。方法: 回顾性分析2023年12月至2025年4月收治的32例单侧肢体淋巴水肿患者。术前按ISL标准分为Ⅰ~Ⅱ期(30例)和Ⅲ期(2例)；按照ICG造影Yamamoto标准分型分为飞溅型(6例)、星尘型(14例)、弥漫型(12例)。术后6个月肢体体积减少率(percentage reduction of limb volume, %REV)和肢体周径减少情况作为主要观察指标，吻合口通畅率、蜂窝织炎复发率、压力袜降级率、患者满意度作为次要观察指标。采用单因素方差分析和Bonferroni校正比较ISLⅠ~Ⅱ期与ICG不同分型间的% REV；效应量用Cohen’ s d值；用多元线性回归分析% REV的独立影响因素。结果: (1) ISL分期疗效：Ⅰ~Ⅱ期患者整体%REV为53%±9%，其中Ⅰ期为63%±8%，Ⅱ期为50%±7%，Ⅲ期% REV为36%±5%(描述性结果)；(2) ICG分型疗效：飞溅型%REV为63%±6%，星尘型%REV为56%±7%，弥漫型%REV为36%±4%，差异具有统计学意义(P < 0.001，d=3.5)；(3) 弥漫型与ISL Ⅲ期存在临床观察到的疗效衰减趋势；吻合口1年通畅率92.2%，蜂窝织炎复发率由28.1%降至0.0%(P=0.01)；26例(81.3%)有压力袜降级，满意度96.9%。结论: LVA疗效与ISL分期及ICG分型密切相关；ICG飞溅型/ISL Ⅱ期及以内患者% REV可>55%，应作为LVA治疗的首选适应证；ICG弥漫型/ISLⅢ期患者需联合脂肪抽吸或血管化淋巴结移植等辅助治疗以优化疗效；术前ICG淋巴造影联合ISL分期评估，可为LVA手术适应证的选择及治疗方案的制定提供可靠依据。

关键词: 淋巴水肿, 超显微外科, 淋巴管-静脉吻合, 吲哚菁绿分型, 国际淋巴学会分期

Abstract:

Objective: To investigate the differential efficacy of super-microsurgical lymphaticovenular anastomosis (LVA) for limb lymphedema stratified by International Society of Lymphology (ISL) stage and indocyanine green (ICG) lymphographic Yamamoto pattern, and to provide evidence-based guidance for patient selection. Methods: A retrospective analysis was performed on 32 patients with unilateral limb lymphedema admitted between December 2023 and April 2025. Preoperatively, the patients were classified into ISL stage Ⅰ-Ⅱ (30 cases) and stage Ⅲ (2 cases), and into ICG patterns of splash (6 cases), stardust (14 cases), and diffuse (12 cases). The primary endpoint was percentage reduction of limb volume (%REV) and limb circumferential reduction at 6 months postoperatively; secondary endpoints included anastomotic patency rate, cellulitis recurrence rate, compression garment downgrade rate, and patient satisfaction. One-way ANOVA with Bonferroni correction was used to compare %REV between ISL stages Ⅰ-Ⅱ and different ICG patterns; effect size was calculated with Cohen's d; multi-variate linear regression identified independent predictors of %REV; descriptive analysis was only performed for stage Ⅲ patients. All statistical tests were two-tailed. Results: (1) ISL stratification: the overall %REV of the patients with stages Ⅰ-Ⅱ was 53%±9%, including 63%±8% for stage Ⅰ and 50%±7% for stage Ⅱ; the %REV of the patients with stage Ⅲ was 36%±5% (descriptive result). (2) ICG stratification: %REV was 63%±6% for splash, 56%±7% for stardust, and 36%±4% for diffuse patterns (P < 0.001, d=3.5). (3) A clinically observed trend of efficacy attenuation was found between diffuse pattern and stage Ⅲ (not included in the statistical model under two-tailed test). Anastomotic patency at the end of 1 year was 92.2 %. Cellulitis recurrence decreased from 28.1 % to 0.0 % (P=0.01). Compression garment was downgraded in 26 patients (81.3%), and overall satisfaction reached 96.9%. Conclusion: LVA efficacy was significantly associated with both ISL stage and ICG pattern. The patients with splash pattern or at stage Ⅱ and below could achieve > 55% volume reduction and should be considered the primary indications for LVA. The patients with diffuse pattern or at stage Ⅲ disease might require adjunctive liposuction or vascularized lymph node transfer to improve outcomes. Preoperative evaluation combining ISL staging and ICG lymphography can provide a reliable basis for the selection of LVA surgical indications and the formulation of treatment plans.

Key words: Lymphedema, Super-microsurgery, Lymphaticovenular anastomosis, Indocyanine green pattern, International Society of Lymphology stage

中图分类号:

R622.4

武竞衡, 薛云皓, 陈山林, 郭银涛, 刘云涛, 张维. 超显微淋巴管-静脉吻合术治疗肢体淋巴水肿: 基于临床分期与吲哚菁绿分型的疗效分析[J]. 北京大学学报（医学版）, 2026, 58(2): 359-364.

Jingheng WU, Yunhao XUE, Shanlin CHEN, Yintao GUO, Yuntao LIU, Wei ZHANG. Super microsurgical lymphaticovenular anastomosis for limb lymphedema: An outcome analysis based on clinical stage and indocyanine green pattern[J]. Journal of Peking University (Health Sciences), 2026, 58(2): 359-364.

图/表 4

图1

图2

表1

图3

参考文献 15

1	Cheville AL, McLaughlin SA, Glaser GE, et al. Cancer related lymphedema[J/OL]. BMJ, 2025, 390(2025-07-03)[2025-09-10]. https://pubmed.ncbi.nlm.nih.gov/41065270.
2	Yamamoto T , Yamamoto N , Azuma S , et al. Near-infrared illumination system-integrated microscope for supermicrosurgical lymphaticovenular anastomosis[J]. Microsurgery, 2014, 34 (1): 23- 27. doi: 10.1002/micr.22115
3	Garza RM , Beederman M , Chang DW . Physical and functional outcomes of simultaneous vascularized lymph node transplant and lymphovenous bypass in the treatment of lymphedema[J]. Plast Reconstr Surg, 2022, 150 (1): 169- 180. doi: 10.1097/PRS.0000000000009247
4	Mortada H , Alhithlool AW , AlBattal NZ , et al. Lipedema: Clinical features, diagnosis, and management[J]. Arch Plast Surg, 2025, 52 (3): 185- 196. doi: 10.1055/a-2530-5875
5	Gilchrist L , Levenhagen K , Davies CC , et al. Effectiveness of complete decongestive therapy for upper extremity breast cancer-related lymphedema: A review of systematic reviews[J]. Med Oncol, 2024, 41 (11): 297. doi: 10.1007/s12032-024-02421-6
6	Cho MJ , Chratian S , Visconti G , et al. Ultra high-frequency ultrasound in lymphatic surgery: The next frontier[J]. Expert Rev Med Devices, 2024, 21 (11): 995- 998. doi: 10.1080/17434440.2024.2419476
7	Koshima I , Nanba Y , Tsutsui T , et al. Long-term follow-up after lymphaticovenular anastomosis for lymphedema in the leg[J]. J Reconstr Microsurg, 2003, 19 (4): 209- 215. doi: 10.1055/s-2003-40575
8	Campisi C , Boccardo F , Zilli A , et al. Long-term results after lymphatic-venous anastomoses for the treatment of obstructive lymphedema[J]. Microsurgery, 2001, 21 (4): 135- 139. doi: 10.1002/micr.1025
9	Mihara M , Hara H , Kikuchi K , et al. Scarless lymphatic venous anastomosis for latent and early-stage lymphoedema using indocyanine green lymphography and non-invasive instruments for visualising subcutaneous vein[J]. J Plast Reconstr Aesthet Surg, 2012, 65 (11): 1551- 1558. doi: 10.1016/j.bjps.2012.05.026
10	Mihara M , Hara H , Hayashi Y , et al. Upper-limb lymphedema treated aesthetically with lymphaticovenous anastomosis using indocyanine green lymphography and noncontact vein visualization[J]. J Reconstr Microsurg, 2012, 28 (5): 327- 332. doi: 10.1055/s-0032-1311691
11	Koshima I , Nanba Y , Tsutsui T , et al. Minimal invasive lympha-ticovenular anastomosis under local anesthesia for leg lymphedema: Is it effective for stage Ⅲ and Ⅳ?[J]. Ann Plast Surg, 2004, 53 (3): 261- 266. doi: 10.1097/01.sap.0000120319.89926.07
12	Yamamoto T , Matsuda N , Doi K , et al. The earliest finding of indocyanine green lymphography in asymptomatic limbs of lower extremity lymphedema patients secondary to cancer treatment: The modified dermal backflow stage and concept of subclinical lymphedema[J]. Plast Reconstr Surg, 2011, 128 (4): 314e- 321e. doi: 10.1097/PRS.0b013e3182268da8
13	Yamamoto T , Narushima M , Kikuchi K , et al. Lambda-shaped anastomosis with intravascular stenting method for safe and effective lymphaticovenular anastomosis[J]. Plast Reconstr Surg, 2011, 127 (5): 1987- 1992. doi: 10.1097/PRS.0b013e31820cf5c6
14	Auba C , Marre D , Rodríguez-Losada G , et al. Lymphaticovenular anastomoses for lymphedema treatment: 18 months postoperative outcomes[J]. Microsurgery, 2012, 32 (4): 261- 268. doi: 10.1002/micr.20980
15	Mihara M , Hara H , Furniss D , et al. Lymphaticovenular anastomosis to prevent cellulitis associated with lymphoedema[J]. Br J Surg, 2014, 101 (11): 1391- 1396. doi: 10.1002/bjs.9588

Metrics

Viewed

Full text

Abstract

Cited

Shared

Discussed

Groups	n	%REV	95%CI of %REV	Cohen’s d (vs. diffuse)
Splash	6	63%± 6%	59%- 67%	3.5 (large effect)
Stardust	14	56%± 7%	52%- 60%	2.4 (large effect)
Diffuse	12	36%± 4%	32%- 40%