Deep lymphaticovenular anastomosis for refractory lymphorrhea following thigh sarcoma resection: A case report

Lymphorrhea is a common complication following wide resection of soft tissue sarcomas of the thigh. When deep lymphatic vessels are disrupted, conservative management alone may be insufficient. Lymphaticovenular anastomosis (LVA) targeting superficial lymphatic vessels has been reported as treatment for refractory lymphorrhea, while deep LVA (d-LVA) has been reported mainly for established lymphedema. Here we extend this approach to refractory postoperative lymphorrhea. We report a 53-year-old man who underwent wide resection of a left medial thigh myxoid liposarcoma with femoral artery and vein resection, followed by femoral artery reconstruction using a contralateral small saphenous vein graft and soft tissue coverage with a pedicled rectus abdominis musculocutaneous flap. He developed profuse refractory lymphorrhea and lower extremity edema. Initial LVA targeting superficial lymphatic vessels at two sites did not improve drainage, and a concurrently placed free omental graft failed and was removed. Two-compartment lymphoscintigraphy demonstrated leakage from the deep lymphatic system near the femoral canal resection margin. On postoperative day 48, additional LVA was performed at three sites, targeting deep lymphatic vessels alongside the posterior tibial vessels together with nearby superficial lymphatic vessels, and para-SSV lymphatic vessels that communicate with the deep system through the deep fascia at the popliteal fossa. Drain output decreased from approximately 200 to 19 mL/day within seven days, and lymphoscintigraphy confirmed complete resolution of leakage. No recurrence was observed within 94 days. These findings suggest that D-LVA may be effective in managing refractory lymphorrhea, and that comprehensive evaluation of the deep lymphatic system using two-compartment lymphoscintigraphy may facilitate accurate and efficient surgical planning.