Noriyuki Murai

Tokyo Medical University, Edo, Tōkyō, Japan

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Publications (16)25.66 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Secondary lymphedema occurs after trauma, cancer surgery, or obesity, and wounds in lymphedema can easily become intractable. We report positive results using lymphatico-venous anastomosis (LVA) to treat a post-traumatic lymph fistula and an intractable ulcer in a severely obese patient. A 41-year-old male (BMI 51.8), one year prior, had a traffic injury, and had an 18-cm contusion in his right leg. Six months later, lymph leakage in a 14 cm × 8 cm region and a 5 cm × 3 cm skin ulcer occurred in the center of the wound. We made a diagnosis of lymphedema resulting from obesity, accompanied with lymphorrhea and intractable ulcer. He was unable to reach his legs owing to obesity, making complex physical therapy impossible. We performed LVA under local anesthesia. The lymphorrhea healed 2 weeks after the operation and had not recurred 3 months after the operation. The leg lymphedema improved after the surgery without the compression therapy. In cases of intractable ulcers, suspected of being caused by lymphostasis, treatments indicated for lymphedema, for example LVA, may possibly allow satisfactory wound healing. © 2013 Wiley Periodicals, Inc. Microsurgery, 2013.
    Microsurgery 09/2013; · 1.62 Impact Factor
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    ABSTRACT: Objective Lymphedema is commonly viewed as difficult to treat, but lymphaticovenous anastomosis applied early after onset can be curative in some cases. Therefore, early diagnosis of cancer-related lymphedema is important. Lymphoscintigraphy is currently the most common method used for imaging diagnosis of lymphedema, but indocyanine green fluorescence lymphangiography (ICG lymphography) is also increasingly used for this purpose. The goal of this study was to compare the accuracy of these methods for diagnosis of lymphedema. Methods This was a prospective comparative study, conducted at a general hospital in Japan. The subjects were 29 consecutive patients (all female; age range, 32-79 years) with lymphedema (58 limbs, including healthy ones) after gynecologic cancer care who underwent lymphedema treatment at The University of Tokyo and Saiseikai Kawaguchi General Hospital between April 2011 and December 2011. All subjects were referred to our department for lower extremity lymphoscintigraphy and ICG lymphography. The sensitivity and specificity of lymphoscintigraphy and ICG lymphography were calculated for all limbs and for diagnosis of early lymphedema in affected limbs (International Society of Lymphology stages 0 and I). In each analysis, receiver-operating characteristic curves were prepared to compare the accuracy of the two methods. Results In receiver-operating characteristic analysis of 58 limbs, the area under the curve was 0.72642 for lymphoscintigraphy and 0.90943 for ICG lymphography. In 34 limbs with early lymphedema, the area under the curve was 0.55882 for lymphoscintigraphy and 0.81471 for ICG lymphography. Conclusions ICG lymphography was more accurate than lymphoscintigraphy for detecting lymphedema and was particularly useful for diagnosis of early lymphedema. This is clinically important since early diagnosis may permit curative treatment of lymphedema.
    Journal of Vascular Surgery: Venous and Lymphatic Disorders. 04/2013; 1(2):194–201.
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    ABSTRACT: In severe lymphedema, indocyanine green lymphography cannot be used to map lymphatic channels before lymphaticovenular anastomosis (LVA) because linear lymphatics cannot be detected in a severely affected leg. Here, we describe a new method, which we refer to as predictive lymphatic mapping, to predict the location of lymphatics for anastomosis in unilateral lymphedema, thereby improving surgical accuracy and efficiency. The approach consists of marking anatomical landmarks and joining selected landmarks with fixed lines. The distance from these fixed lines to lymphatic channels mapped by indocyanine green lymphography in the unaffected leg is then measured, scaled up based on the difference in circumference between the legs, and transposed to the affected leg. To date, we have used this method in 5 cases of unilateral or asymmetric lymphedema of the lower extremities. In no cases have we failed to find a lymphatic channel suitable for LVA within a 2-cm incision. These results suggest that predictive lymphatic mapping is a useful additional tool for surgeons performing LVA under local anesthesia, which will help to improve the accuracy of incisions and the efficiency of surgery.
    Annals of plastic surgery 03/2013; · 1.29 Impact Factor
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    ABSTRACT: BACKGROUND: Secondary lymphedema is defined as swelling of the limbs caused by retention of lymph after cancer therapy. We diagnosed lymphedema using indocyanine green (ICG) fluorescent lymphography and developed a classification based on 12 regional types of edema in the lower bodies, with the goal of improved understanding of the pathology. METHODS: The subjects were 72 consecutive female patients aged 25 to 88 years (mean, 54.5 years) with secondary lymphedema of the lower extremities and abdominal area. The traditional diagnosis of lymphedema was stages 0, 1, 2, 3 and 4 in 5, 11, 19, 24, and 13 patients, respectively. All patients were examined by ICG lymphography. RESULTS: Features of dermal backflow were noted in most patients after cancer therapy, and the incidence was particularly high after radiotherapy. Regional analysis of lymphedema was classified into 12 types (A to L, definitions are given for major categories). The number of patients (number receiving radiation therapy in parentheses) in each type were A, 1 (0); B, 3 (1); C, 13 (1); D, 1 (0); E, 2 (0); F, 0 (0); G, 1 (0); H, 7 (3); I, 13 (3); J, 6 (2); K, 20 (3); and L, 5 (2). CONCLUSIONS: The ICG test permits definite diagnosis of lymphedema at a very early stage and in mild cases. The regional analysis enables establishment of policies for conservative or surgical treatment (for example, lymphaticovenous anastomosis) for individual regions, thereby facilitating more effective lymphedema treatment.
    Annals of plastic surgery 02/2013; · 1.29 Impact Factor
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    ABSTRACT: Lower limb lymphedema and an accompanying lymphatic fistula (lymphorrhea) occur as complications after gynecologic surgery to treat cancer. Herein, we report the case of a 68-year-old woman who underwent resection and radiotherapy because of uterine cervical cancer (stage 2a) 20 years previously. Left lower limb and pudendal lymphedema and continuous lymphorrhea developed soon after surgery. Conservative treatment was administered; however, the edema increased, and a pudendal lymphatic fistula and cellulitis developed repeatedly. Lymphovascular anastomosis (LVA) and lymph vessel ligation were performed after preoperative evaluation via lymphoscintigraphy and indocyanine green (ICG) lymphography. A radioisotope injected into the first interdigit pedal region flowed into the pudendal region via the inguinal lymph nodes at preoperative lymphoscintigraphy. Linear patterns were observed up to the half level of the crus, and stardust patterns occurred over the lower abdominal and pudendal regions at ICG lymphography. During surgery, ICG lymphography was also used to identify the site of the fistula. With the patient under local anesthesia, LVA was applied in the half crus and left inguinal regions, followed by ligation and division of lymph vessels flowing into the fistula. The region around the fistula was excised as a 1 × 3-cm tissue block. As of 5 months after surgery, no recurrence of lymphatic fistula or exacerbation of lymphedema has occurred. This case shows the effectiveness of preoperative ICG lymphography and lymphoscintigraphy followed by treatment via lymph vessel ligation and LVA for curative resolution of a lymphatic fistula.
    Journal of Minimally Invasive Gynecology 09/2012; 19(5):658-62. · 1.61 Impact Factor
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    ABSTRACT: In healthy people, no retrograde lymph flow occurs because of valves in collecting lymph vessels. However, in secondary lymphedema after lymph node dissection, lymph retention and lymphatic hypertension occurs and valvular dysfunction induces retrograde lymph flow. In this case reported, we focused on retrograde lymph flow and performed retrograde lymphatico-venous anastomosis (LVA) simultaneously with antegrade LVA. A 67-year-old Japanese woman had worsening edema in her right thigh and hip area for 3 years. She had previously undergone extended hysterectomy with lymph node dissection for endometrial cancer 8 years before. Indocyanine green test showed antegrade and retrograde lymph flow. Four LVAs were made in the right medial thigh and right lower abdominal area under local anesthesia. Lymphedema showed rapid improvement within 12 months and compression therapy was not required at 24 months after LVA. Retrograde LVA has a possibility of a more efficacy for secondary lymphedema. © 2012 Wiley Periodicals, Inc. Microsurgery, 2012.
    Microsurgery 08/2012; 32(7):580-4. · 1.62 Impact Factor
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    ABSTRACT: Lymphoedema can be treated conservatively or surgically. Early treatment is important, but the surgical indication and the effect of surgery on pain in lymphoedema-affected limbs have not been described. The objective of this study was to examine the effect of low-invasive scarless lymphatic venous anastomosis (LVA) for early or latent lymphoedema. LVA was performed in six patients (eight legs) with leg lymphoedema between April 2010 and March 2011. Lymphoedema was stage 0 (defined as subclinical) in three patients (five legs) and stage 1 in three patients (three legs). Subjective symptoms, circumference of the affected leg and a lymphoscintigram were evaluated before and 6 months after surgery. Preoperatively, subcutaneous lymph vessels and veins were identified non-invasively using ICG lymphoscintigraphy and non-invasive instruments for visualising subcutaneous vein, AccuVein system, through the skin. These vessels and veins were secured with vessel loops passed underneath and side-to-side anastomosed under a surgical microscope. Subjective symptoms improved after surgery in all patients. The leg circumference improved in stage 1 cases, which all had an increased circumference before surgery. Lymph retention was observed on preoperative lymphoscintigraphy in all six patients and was improved after surgery in all cases. Scarless LVA performed through a small incision improves abnormal lymph circulation and subjective symptoms in cases of early lymphoedema, in which the limb circumference has just started to increase, and latent lymphoedema, in which the circumference has not increased, but abnormal findings on lymphoscintigraphy or subjective symptoms are present.
    Journal of Plastic Reconstructive & Aesthetic Surgery 07/2012; 65(11):1551-8. · 1.44 Impact Factor
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    ABSTRACT: We have described a procedure to minimize surgical wounds, in which lymph vessels and skin venules are identified by indocyanine green (ICG) lymphography and the AV300 noncontact visualization system (AccuVein, Cold Spring Harbor, NY), respectively. This approach allows accurate decisions regarding sites of incision for lymphatic venous anastomosis (LVA). This method was applied in a patient with right upper-limb lymphedema after breast cancer therapy. The low-invasive procedure can be used before and during surgery. The incision size is minimal, and the incision site is at the joint area. Thus, we aim to establish this approach as a standard method for identifying lymph vessels and veins that are suitable for LVA. This innovative vascular-imaging machine makes LVA less invasive and more effective without side effects.
    Journal of Reconstructive Microsurgery 04/2012; 28(5):327-32. · 1.00 Impact Factor
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    ABSTRACT: Lymphatico-venous anastomosis (LVA) is used to resolve lymph retention in lymphedema. However, the postoperative outcome of lower limb lymphedema is poorer than that for upper limb lymphedema, because of the location lower than the heart level. Improvement of the therapeutic outcome requires application of as many anastomoses as possible in a limited operation time, particularly since there is a positive correlation between the number of anastomoses and the therapeutic effect of LVA. In this case, we described a method to increase the efficiency of lymphatico-venous anastomosis for bilateral severe lower limb lymphedema through efficient identification of lymph vessels and veins suitable for anastomosis using indocyanine green (ICG) contrast imaging and AccuVein, a noncontact vein visualization system, respectively. Ten LVAs were succeeded at seven incisions, and the operation time was 3 hours and 5 minutes. Accuvein can be used for identification of subcutaneous venules with a diameter of about 0.5-1.0 mm. We used this approach in surgery for a case of bilateral lower limb lymphedema, with a resultant improvement in the surgical outcome.
    Microsurgery 01/2012; 32(3):227-30. · 1.62 Impact Factor
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    ABSTRACT: Therapeutic efficacy of lymphatic-venous anastomosis (LVA) has been shown, but expansion of the indication is desirable because LVA is a procedure with low invasiveness and is applicable over a wide area. This is the first reported case of intractable pelvic lymphocyst for which LVA was effective. LVA may be useful for pelvic lymphocyst at an early stage after cancer resection and lymph node dissection.
    Journal of Minimally Invasive Gynecology 01/2012; 19(1):125-7. · 1.61 Impact Factor
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    ABSTRACT: Secondary lymphedema causes swelling in limbs due to lymph retention following lymph node dissection in cancer therapy. Initiation of treatment soon after appearance of edema is very important, but there is no method for early diagnosis of lymphedema. In this study, we compared the utility of four diagnostic imaging methods: magnetic resonance imaging (MRI), computed tomography (CT), lymphoscintigraphy, and Indocyanine Green (ICG) lymphography. Between April 2010 and November 2011, we examined 21 female patients (42 arms) with unilateral mild upper limb lymphedema using the four methods. The mean age of the patients was 60.4 years old (35-81 years old). Biopsies of skin and collecting lymphatic vessels were performed in 7 patients who underwent lymphaticovenous anastomosis. The specificity was 1 for all four methods. The sensitivity was 1 in ICG lymphography and MRI, 0.62 in lymphoscintigraphy, and 0.33 in CT. These results show that MRI and ICG lymphography are superior to lymphoscintigraphy or CT for diagnosis of lymphedema. In some cases, biopsy findings suggested abnormalities in skin and lymphatic vessels for which lymphoscintigraphy showed no abnormal findings. ICG lymphography showed a dermal backflow pattern in these cases. Our findings suggest the importance of dual diagnosis by examination of the lymphatic system using ICG lymphography and evaluation of edema in subcutaneous fat tissue using MRI.
    PLoS ONE 01/2012; 7(6):e38182. · 3.73 Impact Factor
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    ABSTRACT: To date, an electron microscopy study of the collecting lymphatic vessels has not been conducted to examine the early stages of lymphedema. However, such histological studies could be useful for elucidating the mechanism of lymphedema onset. The aim of this study was to clarify the changes occurring in collecting lymphatic vessels after lymphadenectomy. The study was conducted on 114 specimens from 37 patients who developed lymphedema of the lower limbs after receiving surgical treatment for gynecologic cancers and who consulted the University of Tokyo Hospital and affiliated hospitals from April 2009 to March 2011. Lymphatic vessels that were not needed for lymphatico venous anastomosis surgery were trimmed and subsequently examined using electron microscopy and light microscopy. Based on macroscopic findings, the histochemical changes in the collecting lymphatic vessels were defined as follows: normal, ectasis, contraction, and sclerosis type (NECST). In the ectasis type, an increase in endolymphatic pressure was accompanied by a flattening of the lymphatic vessel endothelial cells. In the contraction type, smooth muscle cells were transformed into synthetic cells and promoted the growth of collagen fibers. In the sclerosis type, fibrous elements accounted for the majority of the components, the lymphatic vessels lost their transport and concentrating abilities, and the lumen was either narrowed or completely obstructed. The increase in pressure inside the collecting lymphatic vessels after lymphadenectomy was accompanied by histological changes that began before the onset of lymphedema.
    PLoS ONE 01/2012; 7(7):e41126. · 3.73 Impact Factor
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    ABSTRACT: Lymphedema is divided into primary and secondary forms. Primary lymphedema often develops in young people and may be caused by lymphvascular aplasia, hypoplasia, and hyperplasia. The most frequent cause of secondary lymphedema after lymphatic filariasis is regional lymph node dissection for treatment of a malignant tumor, and this complication occurs most frequently in middle aged or older patients. Here, we describe a relatively young patient (27 years old) in whom collecting lymph vessels in the upper limb were disrupted by repeated self-injury, with resultant lymphedema. There have been very few reports on lymphedema caused by self-induced trauma. This case report illustrates that secondary lymphedema should also be considered and evaluated appropriately when diagnosed in a relatively young patient without a history of cancer or infection.
    Lymphology 12/2011; 44(4):183-6. · 1.02 Impact Factor
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    ABSTRACT: Advances in cancer therapy have increased the importance of improvement of quality of life after cancer survival. Cancer-related lymphedema or secondary lymphedema that occurs after lymph node dissection in resection of tumors of abdominal visceral organs can impair quality of life. However, standard curative treatment for secondary lymphedema has not been established. This may be due to the lack of a method for early diagnosis of lymphedema, and because of selection of conservative treatment such as compression therapy to delay edema progression in many cases. To develop a curative approach, we have performed definite diagnosis of early-stage lymphedema using magnetic resonance imaging and an indocyanine green fluorescent lymphography, followed by surgical treatment with lymphatic-venous anastomosis using supermicrosurgery. Herein, we report the first case of secondary lymphedema in which we performed early diagnosis and surgery using these techniques and achieved an almost complete cure of lymphedema. We suggest that early diagnostic imaging and early microsurgery is the key of lymphedema treatment.
    Annals of Vascular Surgery 11/2011; 26(2):278.e1-6. · 0.99 Impact Factor
  • Journal of Plastic Reconstructive & Aesthetic Surgery 06/2011; 64(11):1544-6. · 1.44 Impact Factor
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    ABSTRACT: To evaluate the use of ultrasound elastography as a basis for determining the most appropriate sites for lymphaticovenular anastomosis (LVA) for treatment of lymphoedema. Preoperative elastography and LVA were performed in 11 patients (11 legs) with leg lymphoedema, including two cases of primary oedema and nine of secondary oedema. The mean number of LVAs applied per leg was 4.4 (range 3-7). The mean reduction in the leg circumference was 91.7%, and 10 of the 11 cases (90.0%) were improved. Hardness was reduced from a mean of 1.6 before surgery to 0.9 after surgery, and improvement was also noted in 10 cases (90.9%). The severity of oedema was determined in five regions in each leg, and was classified as elastography stage (ES) 0 in 11 regions, ES1 in 23, ES2 in 15, and ES3 in six. These results demonstrate the value of ultrasound elastography for the diagnosis of early-stage lymphoedema and determination of LVA sites. This is the first report of diagnosis of lymphoedema using elastography and the findings suggest that this procedure followed by LVA could be used as a new therapeutic method for early-stage lymphoedema.
    Clinical radiology 04/2011; 66(8):715-9. · 1.65 Impact Factor

Publication Stats

33 Citations
25.66 Total Impact Points


  • 2013
    • Tokyo Medical University
      • Department of Plastic and Reconstructive Surgery
      Edo, Tōkyō, Japan
  • 2011–2013
    • Saiseikai Kawaguchi General Hospital
      Edo, Tōkyō, Japan
  • 2012
    • The University of Tokyo
      • Faculty & Graduate School of Medicine
      Tokyo, Tokyo-to, Japan